Use of glycoprotein IIb/IIIa receptor antagonist in prosthetic valve thrombosis

To the Editor

Since the seminal publication by Lengyel more than a decade ago, sufficient evidence has been accrued to endorse the preference of thrombolytic therapy over a surgical approach for the thrombosis of cardiac valve replacements [1].

In 2004, the first report was published demonstrating the successful treatment of a patient with thrombosed mitral and aortic valve replacements, cardiogenic shock and acute pulmonary edema with glycoprotein IIb/IIIa receptor antagonist (Abciximab) [2].

Six years later, M. Yuce et al. [3] described the successful treatment of a thrombosed mitral valve replacement with Tirofiban in a young patient who was hemodynamically stable. The exact dose administered is not mentioned in this publication, and therefore the cost of this therapy cannot be estimated.

Prosthetic valve thrombosis is a accumulate of fibrin and thrombocytes. GP IIb/IIIa platelet receptor antagonist in addition contain peptides which compete with fibrinogen and von Willebrand factor, this makes the difference between platelet antagonists like aspirin, thienopyridins and GP IIb/IIIa antagonists.

At present, thrombolyis and surgery each have specific indications and complement each other. However, in our opinion thrombolytic therapy should be used initially, except in non-obstructive thrombosis with a large clot, cerebral thromboembolism and with obstructive thrombosis and clot in the left atrium [4].

The use of GP IIb/IIIa antagonists, albeit a tempting pharmacological alternative, would be an option when there are contraindications to surgery according to Rahman [2], or when there is a high risk of bleeding and the hemodynamic state allows it, according to Yuce [3]. The number of published cases is limited and this topic deserves more powerful studies.

Another consideration to take into account in the worldwide context is economic. Restricted availability and the high cost of GP IIb/IIIa receptor antagonists limit their use in developing countries. The relatively easy and safe use of trombolytic therapy remains the treatment of choice [5].