Low-dose, slow-infusion tPA is the treatment of choice for left-sided PVT

This commentary refers to ‘Urgent surgery vs fibrinolytic therapy for left-sided prosthetic valve thrombosis: a randomized trial’, by G. Karthikeyan et al., https://doi.org/10.1093/eurheartj/ehaf391 and the discussion piece ‘Left-sided prosthetic valve thrombosis in low-income settings: why one size does not fit all—heart valve prosthesis in Africa fit all’, by V. Manuel, https://doi.org/10.1093/eurheartj/ehaf907. We thank Dr Manuel for their interest in our trial. We showed that among patients who present with recent onset (2 weeks or less) of valve dysfunction, a strategy of urgent surgery did not result in better outcomes compared with a strategy of low-dose, slow-infusion tissue plasminogen activator (tPA), and was associated with a higher risk of complications including death.1 The high mortality risk due to urgent surgery observed in our trial is consistent with that reported by others, both in middle-income (19%)2 and high-income settings (24%) in patients in New York Heart Association (NYHA) IV).3 These high-mortality figures (ours included) are from experienced surgical teams operating at high-volume centres. However, Dr Manuel believes that urgent surgery should remain the treatment of choice in patients who are off anticoagulation for ‘prolonged periods of time’ and present with ‘organized’ thrombus causing valve dysfunction. The collective experience worldwide suggests that prosthetic valve thrombosis (PVT) occurs in close temporal proximity to suboptimal anticoagulation, and these patients often present acutely (within 2 weeks of symptom onset). Chronic valve dysfunction developing over longer periods of time (as described by Dr Manuel) may be due to the accumulation of pannus, which is often indistinguishable from thrombus on echocardiography. Valve dysfunction due to pannus is best treated surgically. Therefore, the cumulative published evidence favours the use of low-dose, slow-infusion tPA for the treatment of left-sided PVT, primarily because of a higher rate of serious complications associated with urgent surgery. Among the patients with residual valve dysfunction following fibrinolytic therapy, about half have spontaneous restoration of valve function on follow-up, and those with persistent valve dysfunction may undergo lower-risk elective surgery.4