Prolonged Infusions of Low-Dose Thrombolytics in Elderly Patients With Prosthetic Heart Valve Thrombosis

• Published in: Clinical and applied thrombosis/hemostasis 2017-04, Vol.23 (3), p.241-247
• Main Authors: Gündüz, Sabahattin, Özkan, Mehmet, Yesin, Mahmut, Kalçık, Macit, Gürsoy, Mustafa Ozan, Karakoyun, Süleyman, Astarcıoğlu, Mehmet Ali, Aykan, Ahmet Çağrı, Gökdeniz, Tayyar, Biteker, Murat, Duran, Nilüfer Ekşi, Yıldız, Mustafa
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Blood clots; Dose-Response Relationship, Drug; Drug Evaluation; Female; Fibrinolytic Agents - administration & dosage; Fibrinolytic Agents - adverse effects; Heart Valve Prosthesis - adverse effects; Humans; Male; Predictive Value of Tests; Prostheses; Streptokinase - administration & dosage; Thrombolytic Therapy - adverse effects; Thrombolytic Therapy - methods; Thrombosis; Thrombosis - drug therapy; Thrombosis - etiology; Thrombosis - pathology; Tissue Plasminogen Activator - administration & dosage
• ISSN: 1076-0296; 1938-2723
• DOI: 10.1177/1076029615609698

Background: The outcomes of thrombolytic therapy (TT) in elderly patients with prosthetic valve thrombosis (PVT) have not been evaluated previously. We investigated the outcomes of low-dose and slow infusion TT strategies in elderly patients with PVT. Methods: Twenty-seven (19 female) patients aged ≥65 years (median: 70 years, range: 65-82 years) were treated with repeated TT agents for PVT. The TT regimens included 24-hour infusion of 1.5 million units of streptokinase in 2 patients, 6-hour infusion of 25 mg recombinant tissue plasminogen activator (t-PA) in 12 patients, and 25-hour infusion of 25 mg t-PA in 13 patients. Treatment success and adverse event rates were assessed. Results: The initial and cumulative success rates were 40.7% and 85.2%, respectively. Adverse events occurred in 6 (22.2%) patients including 4 (14.8%) major (1 death, 1 rethrombosis, and 2 failed TT) and 2 (7.4%) minor (1 transient ischemic attack and 1 access site hematoma) events. Higher thrombus burden (thrombus area ≥1.1 cm2 by receiver operating characteristics analysis, sensitivity: 83.3%, specificity: 85%, area under the curve: 0.86, P = .008) and New York Heart Association class (0% vs 15.4% vs 25% vs 100% for classes I-IV, respectively, P = .02) predicted adverse events. By multiple variable analysis, thrombus area was the only independent predictor of adverse events (odds ratio: 13.8, 95% confidence interval: 1.02-185, P = .04). Conclusion: Slow infusion of low doses of TT agents (mostly t-PA) with repetition is successful and safe in elderly patients with PVT. However, excessive thrombus burden may predict adverse events.