CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 6, November/December 2011
342
AFRICA
and in those with large clots. Thrombolysis remains an alterna-
tive therapy for patients with a high surgical risk or contraindica-
tion to surgery, or if surgery is not available.
8,9
The individual experience of several authors has led to the
decision to recommend thrombolysis as first-line therapy in
PVT.
3,10-17
Accordingly, in the recent PVT guidelines of the
Society of Heart Valve Disease, thrombolysis was recommended
as first-line therapy in all patients with PVT and a thrombus
diameter
≥
5 mm, regardless of the obstruction and NYHA
functional class. Surgery is reserved only for cases with failed
thrombolytic therapy or where there was a contraindication to
thrombolysis (evidence B).
3,18
Nagy
et al
.,
19
in a study with the objective of analysing the
predictors of the outcome of thrombolytic therapy in 62 events
of prosthetic mitral valve thrombosis, showed that, based on
previous data and the present findings, thrombolysis may be
considered a first-line treatment in all patients with PVT, since
the complication and success rates of thrombolysis are independ-
ent of valve type, NYHA functional class, and thrombus size.
In a recent systematic review on the role of thrombolysis
in the treatment in left-sided PVT, Reyes
et al
.
20
reported on
904 patients treated between January 1970 and January 2007.
Clinical improvement was observed in 86% of the patients and
failure in 14%. The peripheral and cerebral embolism rate was
5 and 4%, respectively. Major bleeding was 4% and intracranial
haemorrhage was 1%.
Shapira
et al
.,
21
in a current review, affirms that thrombus size
is probably the most important determinant of complications.
If small, thrombolysis is probably advised across all degrees of
functional class, as suggested by the American College of Chest
Physicians.
Taljaard and Doubell
22
report the results of a case series of
a total of 32 patients presented on 34 occasions with prosthetic
valve obstruction at Tygerberg Hospital between January 1991
and February 2001. Valve replacement was performed on 20
patients, six received thrombolysis and the remaining eight
patients did not receive any treatment. The conclusion of this
study was that, given the extremely high mortality rate with
current management, the treatment of prosthetic valve obstruc-
tion with thrombolysis in selected patients deserves considera-
tion in a prospective study.
We chose thrombolysis as first-line therapy in our patient.
This is another case where the benefits and safety of thromboly-
sis in the treatment of PVT are evident.
Conclusion
In the absence of randomised, controlled trial data, thrombolysis
appears to be an effective treatment. It should be considered in
all patients, even when a surgical strategy is readily available.
In the absence of on-site cardiothoracic surgical support, it is
reasonable to consider this first-line treatment in appropriate
patients.
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