Between a Rock and a Hard Place: Systemic Thrombolysis for Obstructive Mechanical Valve Thrombosis

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Between a Rock and a Hard Place: Systemic Thrombolysis for Obstructive Mechanical Valve Thrombosis

Editorials
Published: February 13, 2026

Sub-editor: Dr Michael Campbell

Take home messages

Obstructive mechanical valve thrombosis (MVT) is associated with high morbidity and mortality and the role of thrombolytic therapy (TLT) in treating MVT is debated
Contemporary observational and randomised evidence demonstrate low-dose, slow, image guided TLT achieves high rates or valve re-opening and low complication rates
These data support TLT as a reasonable first line alternative to surgery in selected patients with obstructive MVT
Larger, multi-centre studies with long term follow up are required before TLT and surgery are regarded as equivalent treatment strategies

Whilst obstructive mechanical valve dysfunction has a wide differential diagnosis encompassing pannus formation, valve degeneration and endocarditis, clinicians must maintain a high index of suspicion for mechanical valve thrombosis (MVT), particularly in acute presentations. Management options for MVT include optimisation of anticoagulation, thrombolytic therapy (TLT), transcatheter therapies (TCT) and surgery. (1)

In patients presenting with symptoms or signs of heart failure in the presence of obstructive MVT (see figure 1), optimisation of anti-coagulation alone is not recommended. (2,3)

Mortality with surgical therapies is high (10-15%) and increasing evidence suggests that TLT is a safe and efficacious treatment option. (2) The focus of this review is the approach to TLT in patients with obstructive MVT.

Author

Sub-editor: Dr Michael Campbell

Dr Michael Campbell obtained his primary medical degree at the University of Bristol and holds an intercalated degree in Clinical Cardiovascular Sciences from the University of Glasgow. He completed his post graduate certificate in medical education with Queen’s University Belfast with whom he is a sub deanery teaching fellow. He is currently a Cardiology Specialty Resident Doctor Registrar (ST5) in the Northern Ireland deanery. His subspecialty interest is in interventional cardiology. His previous research interests include haemostasis and cardiac biomarkers.