title: Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: the TROIA trial.
abstract: OBJECTIVE
  The aim of this prospective study was to identify the most effective and safest regimen among different thrombolytic treatment strategies.
  
  
  BACKGROUND
  The best treatment strategies for prosthetic valve thrombosis have been controversial.
  
  
  METHODS
  Transesophageal echocardiography-guided thrombolytic treatment was administered to 182 consecutive patients with prosthetic valve thrombosis in 220 different episodes (156 women; mean age, 43.2 ± 13.06 years) between 1993 and 2009 at a single center. These regimens chronologically included rapid (Group I), slow (Group II) streptokinase, high-dose (100 mg) tissue plasminogen activator (t-PA) (Group III), a half-dose (50 mg) and slow infusion (6 h) of t-PA without bolus (Group IV), and a low dose (25 mg) and slow infusion (6 h) of t-PA without bolus (Group V). The endpoints were thrombolytic success, in-hospital mortality, and nonfatal complication rates.
  
  
  RESULTS
  The overall success rate in the whole series was 83.2%; it did not differ significantly among Groups I through V (68.8%, 85.4%, 75%, 81.5%, and 85.5%, respectively; p = 0.46). The overall complication rate in the whole series was 18.6%. Although the overall complication rate was similar among Groups I through IV (37.5%, 24.4 %, 33.3%, and 29.6%, respectively; p > 0.05 for each comparison), it was significantly lower in Group V (10.5%, p < 0.05 for each). The combined rates of mortality and nonfatal major complications were also lower in Group V than in the other groups, with all differences significant except for comparison of Groups IV and V. By multivariate analysis, the predictors of combined mortality plus nonfatal major complications were any thrombolytic therapy regimen other than Group V (odds ratios for Groups I through IV: 8.2, 3.8, 8.1, and 4.1, respectively; p < 0.05 for each) and a history of stroke/transient ischemic attack (odds ratio: 3.5, p = 0.011). In addition, there was no mortality in Group V.
  
  
  CONCLUSIONS
  Low-dose slow infusion of t-PA repeated as needed without a bolus provides effective and safe thrombolysis in patients with prosthetic valve thrombosis. (Comparison of Different TRansesophageal Echocardiography Guided thrOmbolytic Regimens for prosthetIc vAlve Thrombosis; NCT01451320).
authors.affiliation: Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey. memoozkan1@gmail.com
authors.forename: Mehmet
authors.initials: M
authors.lastname: Özkan
authors.forename: Sabahattin
authors.initials: S
authors.lastname: Gündüz
authors.forename: Murat
authors.initials: M
authors.lastname: Biteker
authors.forename: Mehmet Ali
authors.initials: MA
authors.lastname: Astarcioglu
authors.forename: Cihan
authors.initials: C
authors.lastname: Çevik
authors.forename: Evren
authors.initials: E
authors.lastname: Kaynak
authors.forename: Mustafa
authors.initials: M
authors.lastname: Yıldız
authors.forename: Emrah
authors.initials: E
authors.lastname: Oğuz
authors.forename: Ahmet Çağrı
authors.initials: AÇ
authors.lastname: Aykan
authors.forename: Emre
authors.initials: E
authors.lastname: Ertürk
authors.forename: Yusuf
authors.initials: Y
authors.lastname: Karavelioğlu
authors.forename: Tayyar
authors.initials: T
authors.lastname: Gökdeniz
authors.forename: Hasan
authors.initials: H
authors.lastname: Kaya
authors.forename: Ozan Mustafa
authors.initials: OM
authors.lastname: Gürsoy
authors.forename: Beytullah
authors.initials: B
authors.lastname: Çakal
authors.forename: Süleyman
authors.initials: S
authors.lastname: Karakoyun
authors.forename: Nilüfer
authors.initials: N
authors.lastname: Duran
authors.forename: Nihal
authors.initials: N
authors.lastname: Özdemir
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D004334:Drug Administration Schedule; D017548:Echocardiography, Transesophageal; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D017052:Hospital Mortality; D006801:Humans; D007263:Infusions, Parenteral; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012307:Risk Factors; D013300:Streptokinase / Q000008:administration & dosage* / Q000009:adverse effects; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D016896:Treatment Outcome; D014421:Turkey; D055815:Young Adult
chemical_list: D005343:Fibrinolytic Agents; D013300:Streptokinase; D010959:Tissue Plasminogen Activator