Thrombosed Mechanical Aortic Valve Treated with Low-Dose Ultraslow Alteplase Infusion
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors
I have read and reviewed the report carefully. It is very clearly written and reports the difficulties we experience in choosing treatment for prosthetic valve thrombosis.I congratulate you for your treatment and case report.
The decision to treat this issue is still controversial today and the cardiac team needs to make a decision on a patient-by-patient basis. As mentioned in the article, ultra-slow use has actually started to be widely used because a high rate of complications is observed with fibrinolytics that are loaded in a short time. However, since the reports are generally at the level of case reports, there is no clear guideline recommendation regarding dose and infusion time yet. Surgical treatment is of course more risky. However, since a biological valve will usually be installed, the risk of VKA-related bleeding and retrombosis will decrease considerably in the subsequent follow-up periods. Therefore, it is a valuable article as a report, but I would like to state that it has shortcomings such as reporting a single patient result and not having a follow-up process that shows whether there is a development of retrombosis.I suggest that additions be made regarding why coronary angiography is not performed and why surgery is not considered.
Author Response
I suggest that additions be made regarding why coronary angiography is not performed and why surgery is not considered.
- We have updated the manuscript to discuss why fibrinolytic therapy was preferred as opposed to surgery and also discuss that patient had declined coronary angiography despite the risk of embolization resulting in myocardial infarct.
Reviewer 2 Report
Comments and Suggestions for Authors
This case report is a highly interesting and clinically relevant contribution, offering a detailed demonstration of the successful management of a thrombosed mechanical aortic valve with low-dose, ultraslow alteplase infusion. The authors effectively highlight the complexity of managing prosthetic valve thrombosis, a challenging clinical scenario where both surgical and fibrinolytic treatments come with inherent risks and benefits. The use of this low-dose, prolonged infusion approach expands the therapeutic armamentarium and can provide valuable guidance to clinicians facing similar cases—especially in contexts where surgical expertise may be limited or patients prefer to avoid operative intervention.
The reported case is meticulously described, with clear baseline imaging parameters and subsequent hemodynamic improvements following therapy. The discussion thoroughly situates this therapeutic approach within the existing literature, acknowledging the need for further evidence to establish standardized guidelines.
Minor Recommendations:
To further strengthen the manuscript’s clinical utility, I recommend including additional echocardiographic parameters as suggested by the latest guidelines on prosthetic valve evaluation (Journal of the American Society of Echocardiography, 2024; 37(1): 2–63). Echo parameter metrics such as acceleration time (AT) and jet contour characteristics will align the case report with evolving guidelines. I would also recommend simplifying the reporting of numerical values for echo parameters (such as 494 cm/sec instead of 493.5 in line 71), which would enhance readability.
Author Response
To further strengthen the manuscript’s clinical utility, I recommend including additional echocardiographic parameters as suggested by the latest guidelines on prosthetic valve evaluation (Journal of the American Society of Echocardiography, 2024; 37(1): 2–63). Echo parameter metrics such as acceleration time (AT) and jet contour characteristics will align the case report with evolving guidelines.
- Echo parameter metrics such as acceleration time and jet contour characteristics are now described in our manuscript.
I would also recommend simplifying the reporting of numerical values for echo parameters (such as 494 cm/sec instead of 493.5 in line 71), which would enhance readability.
- All numerical values pertaining to echo parameters have been simplified and rounded to the nearest whole number.
