Extended-duration low-dose rt-PA thrombolysis successfully resolved bioprosthetic valve thrombosis in all 5 episodes among 3 patients following transcatheter tricuspid valve replacement.
Observational (n=11)
No
Does prolonged low-dose rt-PA thrombolysis safely resolve bioprosthetic valve thrombosis in patients following transcatheter tricuspid valve replacement?
A standardized imaging protocol frequently detects HALT/PVT after TTVR, and prolonged low-dose rt-PA safely and effectively resolves clinically significant PVT.
Abstract Background Recently, the first catheter-based orthotopic tricuspid valve replacement (TTVR) device became available. Hypoattenuated leaflet thickening (HALT) and bioprosthetic valve thrombosis (PVT) are known complications following prosthetic valve replacement, including TTVR, with potential impact on valve function and patient outcomes. Purpose Effective clinical management of PVT (and likely also HALT) is essential for both short- and long-term patient outcomes. However, data on the detection and treatment of these complications in TTVR is limited. The current study evaluates the use of a standardized imaging protocol as a diagnostic and a prolonged low-dowse lysis as a treatment approach. Methods Between March and October 2024, patients undergoing TTVR at our center were enrolled in a standardized follow-up protocol, including echocardiography and multidetector computed tomography (MDCT) at four weeks and three months post-TTVR with a focus on HALT/PVT detection. Patients with CT-confirmed and clinically significant HALT/PVT, defined by symptoms and an elevated transvalvular mean pressure gradient (TVpmean), received a standardized treatment protocol, starting with prolonged low-dose thrombolysis (rt-PA 25 mg over 25 hours, repeated up to three times). Results A total of 11 patients underwent TTVR for severe (n=2), massive (n=8) and or torrential (n=1) tricuspid regurgitation (TR). Discharge echocardiograms (1-3 days post-TTVR) confirmed TR reduction to grade ≤1 in all patients, with a median TVpmean of 3 mmHg (IQR 2-3 mmHg). While no HALT/PVL was observed during initial hospitalization, follow-up MDCT screening identified subclinical HALT in 5 patients (45%) with varying severity. Clinically significant PVT was detected 5 times in three patients, presenting with new-onset dyspnea (NYHA class III-IV) and a TVpmean increase from 2 to 7 mmHg, 3 to 5 mmHg and 3 to 9 mmHg, respectively. Thrombolysis using an extended-duration low-dose rt-PA regimen successfully resolved PVT in all cases without bleeding complications. Conclusion In our 11 patient case series HALT/PVT was frequently observed, highlighting the need for standardized diagnostic and therapeutic protocols. Early detection is critical, as an extended-duration low-dose rt-PA thrombolysis regimen safely and effectively resolved PVT in all patients.
Kriechbaum et al. (2025) conducted an observational in Severe, massive, or torrential tricuspid regurgitation undergoing transcatheter tricuspid valve replacement (TTVR) (n=11). Prolonged low-dose thrombolysis (rt-PA) was evaluated on Resolution of bioprosthetic valve thrombosis (PVT) without bleeding complications. Extended-duration low-dose rt-PA thrombolysis successfully resolved bioprosthetic valve thrombosis in all 5 episodes among 3 patients following transcatheter tricuspid valve replacement.