Management of prosthetic valve thrombosis concomitant with coronary embolism

We have recently read with great interest the article by Olcay (1) published in Anatol J Cardiol 2018; 20: 365-7. We appreciate the author for his report describing the concomitant left main coronary artery and mitral prosthetic valve thrombosis (PVT) treatment. On the other hand, we believe that there are several major drawbacks that need to be addressed. Coronary embolism (CE) is a rare cause of acute coronary syndrome (ACS) in patients with prosthetic heart valves. Information regarding ACS in patients with prosthetic heart valves is scarce and based mainly on case reports and limited number of clinical trials (2, 3). We agree with the authors that thrombolytic therapy (TT) provides the advantage of widespread availability and easier administration than surgery (4). However, low-dose and ultraslow fibrinolytic therapy (25 mg/25 h) in a patient with cardiogenic shock may not be an effective option for urgent treatment (5). Recently, Yesin et al. (3) reported that TT with low-dose and slow infusion of tissue plasminogen activator (tPA) (25 mg/6 h) has proven its efficacy and safety in patients with concomitant CE and PVT. In such cases, low-dose and slow infusion TT may be preferred to ultraslow infusion as a bailout treatment strategy when surgical support is insufficient