Article

Treatment strategies for prosthetic valve thrombosis in pregnant patients

852 Correspondence / American Journal of Emergency Medicine 33 (2015) 834855

References

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  2. Ozkan M, Kaymaz C, Kirma C, Sonmez K, Ozdemir N, Balkanay M, et al. Intravenous Thrombolytic treatment of mechanical prosthetic valve thrombosis: a study using se- rial transesophageal echocardiography. J Am Coll Cardiol 2000;35:1881-9.
  3. Ozkan M, Gunduz S, Biteker M, Astarcioglu MA, Cevik C, Kaynak E, et al. Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: the TROIA Trial. JACC Cardiovasc Imaging 2013;6:206-16.
  4. Ozkan M, Cakal B, Karakoyun S, Gursoy OM, Cevik C, Kalcik M, et al. Thrombolytic therapy for the treatment of prosthetic heart valve thrombosis in pregnancy with low-dose, slow infusion of tissue-type plasminogen activator. Circulation 2013;128:532-40.
  5. Kalcik M, Gursoy MO, Karakoyun S, Ozkan M. Thrombus attached to suture materials successfully thrombolysed with low-dose tissue plasminogen activator. Turk Kardiyol Dern Ars 2014;42(1):61-3.
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    Treatment strategies for prosthetic valve thrombosis in pregnant patients

    thrombotic occlusion of prosthetic valve during pregnancy is un- common but one of the dreadful complication with unclear manage- ment strategies. In general, conservative approach, re-replacement surgery, thrombectomy, and thrombolytic therapy are the accepted treatment modalities for prosthetic valve thrombosis (PVT) with their own pros and cons. Treatment modalities should be customized based upon clinical status, valve location, comorbidities, and informed deci- sion [1]. Conservative approach is suitable for stable patients or when there is any contraindication for surgery or thrombolytic therapy. As per available recommendations [2], outside pregnancy surgery remains preferred modality, and thrombolysis is reserved as rescue treatment in critically ill or patients with high surgical risk (according to the 2007 European Society of Cardiology and the 2008 American College of Cardi- ology/American Heart Association. However, review of published re- ports on thrombolytic therapy has concluded that success rate ranging from 75% to 88% can be achieved with this modality in PVT and has lower mortality for all New York Heart Association classes as compared with redo surgery [3-5]. There is no available evidence regarding safety of thrombolytic therapy in pregnancy [6]; and fear of teratogenicity, risk of abortion, and bleeding have hesitated clinicians to use this interven- tion. Nonetheless, for the past few years, use of thrombolysis in preg- nancy has shown promising results, and complication rates do not seem to be higher than that of nonpregnant patient except when administered intrapartum or with concomitant use of anticoagulants.

    Various agents with numerous Treatment protocols used for throm-

    bolytic therapy are streptokinase, urokinase, and tissue plasminogen ac- tivator (t-PA). All of them have similar efficacy, and the choice of agent is influenced by various factors like cost, half-life, and hemorrhagic com- plications. Streptokinase is favored because it is cheaper and has lower rate of cerebral hemorrhage. In contrast, t-PA is costly and has fastest re- version rate with shortest half-life [7]. So far, there is no agreement on the ideal thrombolytic agent and treatment protocol, but most experi- ence has accumulated with streptokinase. Class 1 recommendation for PVT in pregnancy is lacking in pregnancy due to the lack of randomized controlled trials, and management guidelines are similar to that of non- pregnant women [2,8]. Roudaut et al [9], in the largest nonrandomized retrospective study, indicated that patients treated with streptokinase have better success rate compared with that of urokinase and t-PA

    (86%, 68%, and 59%, respectively) and advocated thrombolysis as first- line therapy in critically ill patients. In a review by Aniteye et al [10], streptokinase as first-line thrombolytic agent in management of PVT is relatively safe and cheaper option. In another study by Gupta et al [11], 108 patients of PVT of 110 were treated with streptokinase, and complete Hemodynamic response was seen in 81.8%, partial in 10%, and no response in 8.2%. The overall response rate of 53.5% was found after thrombolysis with streptokinase in 86 patients of left-sided throm- bosis [12], which is closer to other Indian study of Karthikeyan et al [13] with reported success of 59%. However, over recent era, thrombolytic therapy under the guidance of transesophgeal echocardiography (TEE) has shown high success rate with fewer complications. Thrombolysis with t-PA is an approved therapy for stroke, myocardial infarction, and thrombosis. The transesophageal echocardiography guided throm- bolytic regimens for prosthetic valve thrombosis trial consisting of larg- est cohort of 182 consecutive patients with PVT, thrombolytic success rate was 83.2% with complication rate of 18.6% in whole series. The suc- cess rate did not differ among groups, that is, either t-PA or streptoki- nase using various Treatment regimens, and it was concluded that slow infusion regimen of t-PA without bolus seems to be the practicable and safest thrombolytic regimen [14] The subgroup analysis of 24 preg- nant women in this trial with PVT, and low-dose slow infusion of t-PA showed complete lysis in all patients with lower maternal and fetal adverse events. All procedures were done under TEE guidance, and consensus statement is that this protocol seems better than surgical or other medical therapy [15]. However, although this research included remarkable number of patients including pregnant women, its applica- bility may be questioned because of nonrandomized, single-centered observational study; uneven numbers in few groups; and due to high- cost factor of t-PA. Furthermore, almost half of the patients had smaller, recent nonobstructive thrombi, and they in general have better progno- sis. So, streptokinase still remains sustainable option mainly in develop- ing countries, until we have good randomized, prospective studies with t-PA.

    Detailed clinical examination along with transthoracic echocardiog-

    raphy (TTE) is an initial and essential part of diagnostic assessment [16]. Transthoracic echocardiography provides direct visualization of pros– thesis and accurately quantifies transvalvular gradient. Artifacts of pros- thesis, quality of acoustic window, and nonobstructive thrombosis are few limitations of TTE; and it may be normal in case of low cardiac out- put despite valvular obstruction (silent Doppler PVT). Hence, in these situations, TEE holds fundamental role as not only assess exact size and location of thrombus but also helps in making Treatment decisions and can differentiate thrombus from vegetation or pannus [17]. So, we do agree that TEE is superior to TTE.

    Bharti Joshi, MBBS, MD, DNB Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research Chandigarh, India Corresponding author. Department of Obstetrics and Gynecology Old Nehru hospital, 3rd Floor PGIMER Chandigarh, India

    Tel.: +919915166210

    E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.03.056

    References

    Roudaut R, Serri K, Lafitte S. Thrombosis of prosthetic heart valves: diagnosis and Therapeutic considerations. Heart 2007;93:137-42.

  9. Bonow RO, Carabello BA, Chatterjee K, de Leon Jr AC, Faxon DP, Freed MD, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of thoracic surgeons. J Am Coll Cardiol 2008;52:e1-142.

    Correspondence / American Journal of Emergency Medicine 33 (2015) 834855 853

    Vidne H, Sagie A. Repeated thrombolysis in multiple episodes of obstructive throm- bosis in prosthetic heart valves: a report of three cases and review of the literature. J Heart Valve Dis 2000;9(l):146-9.

  10. Gupta D, Kothara SS, Bahl VK, et al. Thrombolytic therapy for prosthetic valve throm- bosis: short- and long term results. Am Heart 2000;140:906-16.
  11. Ozkan C, Kaymaz C, Kirma K. Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: a study using serial transesophageal echocardiography. Am Coll Cardiol 2000;35(7):1881-9.
  12. Sahnoun-Trabelsi I, Jimenez M, Choussat A, Roudaut R. Prosthetic valve thrombosis in pregnancy. A single-center study of 12 cases. Arch Mal Coeur Vaiss 2004;97:305-10.
  13. Caceres-Loriga FM, Perez-Lopez H, Santos-Gracia J, Morlans- Hernandez K. Prosthetic heart valve thrombosis: pathogenesis, diagnosis and management. Int J Cardiol 2006;110:1-6.
  14. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery. Eur Heart J 2012;33:2451-96.
  15. Roudaut R, Lafitte S, Roudaut MF, Courtault C, Perron JM, Jais C, et al. Fibrinolysis of mechanical prosthetic valve thrombosis: a single-center study of 127 cases. J Am Coll Cardiol 2003;41:653-8.
  16. Aniteye EA, Tettey M, Sereboe L, Kotei D, Edwin F, Tamatey M, et al. Thrombolysis for prosthetic valve thrombosis: a report of 6 cases and review of the literature. Ann Afr Chir Thorac Cardiovasc 2007;2(1):38-41.
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  18. Singh AK, Agarwal S, Satyarthi S, Kunal, Satsangi DK. Comparison of thrombolytic therapy for prosthetic valve thrombosis at the mitral and aortic position. Indian J Thorac Cardiovasc Surg 2011;27(3):114-8.
  19. Karthikeyan G, Math Ravi S, Mathew Navin, Shankar Bhima, Kalaivani Mani, Singh Sandeep. Accelerated infusion of streptokinase for the treatment of left- sided prosthetic valve thrombosis a randomized controlled trial. Circulation 2009;120:1108-14.
  20. Ozkan M, Gursoy OM, Astarcioglu MA, Gunduz S, Cakal B, Karakoyun S, et al.

    Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: the TROIA Trial. JACC Cardiovasc Imaging 2013;6:206-16.

    Ozkan M, Gunduz S, Biteker M, Karakoyun S, Gursoy OM, Cevik C. Thrombolytic therapy for the treatment of prosthetic heart valve thrombosis in pregnancy with low-dose, slow infusion of tissue-type plasminogen activator. Circulation 2013; 128:532-40.

  21. Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommenda- tions for evaluation of prosthetic valves with echocardiography and Doppler ultra- sound. J Am Soc Echocardiogr 2009;22:975-1014.
  22. Muratori M, Montorsi P, Teruzzi G, Celeste F, Doria E, Alamanni F, et al. Feasibility and diagnostic accuracy of quantitative assessment of mechanical prostheses leaflet motion by transthoracic and transesophageal echocardiog- raphy in suspected prosthetic valve dysfunction. Am J Cardiol 2006;97: 94-100.

    A survey of emergency medicine residents’ perspectives of the choosing wisely campaign

    Many initiatives have been proposed to reduce health care expendi- tures in the United States because of the continued rise in medical care costs. The Choosing Wisely campaign has been developed by physicians and for physicians; and its primary aim is to provide care that is “supported by evidence, not duplicative of other tests or procedures al- ready received, free from harm, and truly necessary” [1]. Through guide- lines, it is the hope that Choosing Wisely will reduce unnecessary testing and treatment, thereby reducing wasteful spending and potential harm to patients.

    The American College of Emergency Physicians (ACEP) announced in February 2013 that the organization is joining the Choosing Wisely cam- paign. The president of ACEP, Dr Andrew Sama, in his announcement of ACEP joining Choosing Wisely, acknowledged that ACEP initially declined involvement because of “the unique nature of emergency medicine, liabil- ity concerns, and a potential harm to physician reimbursement” [2]. Other confounders contributing to health care overuse in the emergency depart- ment include “the Emergency Medical and Active Labor Act mandate, var- iation in patient severity, lack of access to follow-up care, the requests of referring physicians, consultants or admitting physicians, and patient preferences” [3]. However, Choosing Wisely is in alignment with ACEP’s “commitment to cost-effective care and a high-value health care system” [2], and thus, the organization joined the initiative.

    Current emergency medicine residents are at a unique position within health care. Residents may learn appropriate medical care throughout their training. However, what is medically appropriate is not always efficient, patient centered, or defensible in a court of law. Residents have a debt burden higher than previous generations of phy- sicians, face reimbursement cuts, and are subject to increasing scrutiny of quality and appropriateness of care delivered, while continuously threatened with Malpractice litigation, in a medical system that it overwhelmed, understaffed, and metric focused, with incomplete infor- mation, while providing unfunded, unprotected, mandated medical care. It remains unknown as to whether residents are willing to adopt the principles of Choosing Wisely into their practice because of barriers of implementation and the unique situation into which residents will begin their medical practice.

    The authors created a 45-question survey to determine the barriers of implementation of the first 5 of ACEP’s Choosing Wisely recommen- dations as perceived by emergency medicine residents. Refer to Exhibit 1 for the Survey. The survey was distributed to all emergency medicine programs on the CORD listserv. A total of 228 residents responded to the survey.

    The vast majority of respondents support the Choosing Wisely cam- paign (98.1%) and feel that ACEP should continue to provide more re- commendations (97.6%). Residents identified barriers to implementing the recommendations regarding Head computed tomograms, engaging palliative care, and using oral rehydration. Specifically regarding head computed tomograms, barriers included fear of litigation (68.9%) and patient expectations (66.7%). The primary reported barrier to en- gaging palliative care was a lack of resources (73.7%). Finally, the major barrier identified to using oral rehydration was patient expecta- tions (52.4%). No major barriers were identified regarding urinary cath- eters or the use of antibiotics and wound cultures. The majority of respondents (73.6%) reported that medical liability and a lack of tort re- form are major barriers to implementation of the Choosing Wisely recommendations.

    Question #44 revealed that 81.3% of participants feel that “It is the job of the emergency physician to provide evidence-based, cost-conscious care that is truly necessary and with minimal harm to all patients.” Con- versely, 18.8% of respondents feel that “It is the job of the emergency physician to rule out all potentially life- or limb-threatening emergencies regardless of the cost, resources used, or risk to the patient.” This ques- tion highlights the dichotomy that exists amongst not only emergency medicine but medicine in general: are physicians to direct all possible resources to the individual patient, or rather be a steward in directing resources across a community? Although both may be possible in concept, in reality, this can be a challenging task, and the 2 ideologies are often at odds. Further clarification is necessary not only from the medical community but also from legislators, payers, government, the courts, and health care administrators to determine if the emergency physician’s role is to do everything possible for an individual patient or to appropriately allocate resources across a community.

    In summary, emergency medicine residents overwhelmingly sup- port ACEP’s participation in the Choosing Wisely campaign. Unfortu- nately, barriers to implementation are perceived to exist, including fear of litigation, patient expectations, lack of resources, and most nota- bly medical liability and lack of tort reform. With systemic changes to address the significant barriers identified, emergency medicine resi- dents may be better able to provide cost-conscious, patient-centered care. In addition, there is a dichotomy that exists with regard to the fun- damental delivery of health care amongst emergency medicine resi- dents. Further clarification and coordination are necessary amongst all stakeholders to determine the standard to which emergency physicians are held accountable.

    Exhibit 1: Survey

    Avoid computed tomography (CT) scans of the head in emergency department patients with Minor head injury who are at low risk based on validated decision rules.

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