RESULT OF SLOW INFUSION OF STREPTOKINASE THERAPY IN LEFT SIDED PROSTHETIC VALVE THROMBOTIC OCCLUSION- A CASE SERIES FROM A TERTIARY CARE HOSPITAL IN EASTERN INDIA

Abstract

Prosthetic valve thrombosis (PVT) is a life threatening complication seen after heart valve replacement and is associated with high mortality and morbidity. Surgical approach or brinolysis and heparin therapy are considered as treatments of choice according to the clinical status of the patient. Thrombolytic therapy has been tried in cases with acute prosthetic valve thrombosis as an alternative to emergency operation with variable results. But fear of peripheral embolism has limited its use in left-sided valve occlusions. The incidence of complications decreases with low dose and slow infusion of brinolytic therapy. In this study we are presenting our experience of thrombolytic therapy with streptokinase in 40 patients who had presented with acute or subacute left-sided prosthetic valve thrombosis. In this study the mean age was 40.9 years (SD-11.2, range-19 to 64 year) with majority (77.5%) were below 50 year of age. Duration of valve replacement was 2.95 ± 1.74 years (1 to 7 years). Average time of presentation since onset of symptoms was 4.75 ± 2.77 days (1 to 12 days). Majority was presented with NYHA class IV symptoms (22/40) and 50% patients presented with cardiogenic shock. 85% patients had atrial brillation and the anticoagulation status was inadequate in 62.5% cases. Overall aortic valve involvement was 37.5% (15 patients) and mitral valve involvement was 62.5% (25 patients). Average mean gradient for aortic valve was 64.5 ±4.2 mm of Hg and that in case of mitral valve was 23.4±3.7 mm of Hg. Duration of thrombolytic therapy was individualized. Average total dose of streptokinase per patient was 25,25000 ± 8,69350 U (ranging from 20,00000 to 50,00000 U) with majority (28/40) had received a total 20,00000U of streptokinase. Patients were re-evaluated after thrombolysis with clinical, echocardiographic, and cine-uoroscopic evaluation. Total complications (both major and minor bleeding) occurred in 8 patients. Most of them were minor like injection site hematoma, gum bleeding transient GI bleed (hematemesis), hemoptysis and those were resolved spontaneously with conservative management/observational care. Thrombolysis was unsuccessful in 2 patients and death due to massive hemorrhagic CVA occurred in 2 patients. Overall success rate was 90% (36/40). In conclusion, the present study demonstrates the feasibility of thrombolytic therapy for left-sided prosthetic valve occlusion.