Thrombolysis Versus Redo-Surgery for Treatment of Mechanical Prosthetic Mitral Valve Thrombosis in Young Adult Patients

Abstract

Abstract Objectives To evaluate and compare outcome of redo-surgery and thrombolysis for treatment of mitral PVT following mechanical valve replacement for rheumatic etiology in young adult patients (<50 years old). Methods and Results This retrospective study included 42 young adult patients who had PVT after mechanical valve replacement for rheumatic mitral valve disease, between January 2014 and June 2019. Eighteen patients underwent redo-surgery and 24 patients underwent thrombolysis (Streptokinase 100,000 U/h for at least 24 hours). The approach of treatment was based on proposed criteria considering hemodynamic status, NYHA functional class, and thrombus size. Complete response to thrombolysis was defined by normal clinical and echocardiographic parameters. Primary outcome included response to thrombolysis, complications, mortality, and recurrence. The median follow-up period was 24 months. The thrombus size was significantly larger in redo-surgery group (9.88±2.44 mm2 vs 5.87±1.26 mm2, P < 0.001). The response to thrombolysis was complete recovery (70.8%), partial recovery (16.7%), or failure (12.5%). There was no significant difference in the incidence of major complications. Mortality was significantly higher in redo-surgery group (27.8% vs 4.2%, P = 0.03), with cumulative survival of 72.2% for redo-surgery versus 95.8% for thrombolysis (Log-rank P-value = 0.04). The reduced cumulative survival with redo-surgery was more evident in patients with delayed presentation (> 1 week). Recurrent thrombosis occurred only with thrombolysis (8.3% vs 0%, P = 0.20). Cumulative proportions for freedom from thrombosis were 100% for surgery versus 78.1% for thrombolysis (Log-rank P-value = 0.17). Conclusions Proper patient selection may improve outcome after treatment of mitral PVT using thrombolysis or redo-surgery in young adults. Redo-surgery has advantages over thrombolysis regarding mid-term recurrence of thrombosis; however, thrombolysis has significantly lower mortality than redo-surgery. Further evaluation of the proper treatment for delayed presentation of PVT is recommended.