A case of recurrent obstructive thrombosed mechanical mitral valve and the role of thrombolytic therapy
Mawri S, Ly N, Shah R, Parikh S, Eng M, O'Neill WW. A case of recurrent obstructive thrombosed mechanical mitral valve and the role of thrombolytic therapy. J Am Coll Cardiol. 2018;71(11)
J Am Coll Cardiol
Background: Early recognition of obstructive thrombosedprosthetic heart valves (OTPHV) is crucial to prevent delays in treatment and avoid signifcant morbidity and mortality. Choice between surgery, thrombolysis and escalation ofanticoagulation can be a challenge. Case: A 69 year-old man with history of liver transplant, subdural hematoma (1 year ago), and St. Jude bileafet mechanical mitral and aortic valve replacements (9 years ago) for severe MR and AR presented to an outside hospital with worsening progressive dyspnea for four months. Initially, his symptoms were attributed to angina and he underwent coronary angiogram and received 1 DES to his LAD. However, 2 weeks later he returned with persistent symptoms, and was treated with antibiotics for presumed pneumonia, given his immunosuppressed state. Due to persistent symptoms, he was transferred to our institution. TTE showed prosthetic mitral valve obstruction with a mean gradient of 18.8 MMHG. TEE revealed a fxed occluder with atrial-side echodensities consistent with thrombus. This was likely due to interruptions in warfarin for prior outpatient procedures. Decision-making: We performed thrombolysis based on the Ultraslow PROMETEE trial, which involves intermittent infusions of 25 mg of tPA over 25 hours with Doppler echocardiography between cycles to document reductions in transvalvular gradients. After initial infusion, his transmitral gradient fell to 7 MMHG; however, he continued to have persistently frozen occlude despite total of 65 mg of tPA; though with dramatic symptomatic improvement. One year later, he presented with recurrentsymptoms. TTE showed mitral valve obstruction with amean gradient of 28 MMHG, with frozen anterior leafet on cinefuroscopy. A higher dose of tPA (50mg over 12 hours) was delivered, with complete resolution of his gradients and which freed his mitral mechanical prosthesis on fuoroscopy. He was discharged with a higher INR goal of3.5-4.5 and continues to do well. Conclusion: OTPHV is a life-threatening complication that requires a high index ofsuspicion to make the correct diagnosis. Recent studies show that thrombolysis is noninferior to surgery, even in patients with a history of stroke.