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Case report of successful low-dose, ultra-slow infusion thrombolysis of prosthetic mitral valve thrombosis in a high risk patient after redo-mitral valve replacement.
Eur Heart J Case Rep. 2020 Jun; 4(3):1-5.EH

Abstract

Background

An increase in transvalvular pressure gradient of prosthetic valve should always raise suspicion for obstructive valve thrombosis. A multimodality diagnostic approach including transthoracic echocardiography, transoesophageal echocardiography (TOE), cinefluoroscopy, or computed tomography (CT) is necessary for a prompt diagnosis. The management of mechanical prosthetic valve thrombosis (PVT) is high risk in any therapeutic option taken. Emergency valve replacement is recommended for critically ill patients. Fibrinolysis is an alternative for patients with contraindication to surgery or if surgery is not immediately available.

Case summary

A 52-year-old woman presented with symptoms and signs of cardiac congestion. On laboratory, brain natriuretic peptide was elevated and international normalized ratio (INR) was in subtherapeutic range. She underwent a mitral valve replacement with mechanical prosthesis 7 months before, because of a significant residual regurgitation after repair on the same year. TOE revealed severe stenosis of the prosthesis with immobile anterior disc but there was no mass present. CT revealed a minor lesion at the hinge points of the prosthesis without involvement of the ring, suggestive for thrombus. The initial fruitless management with intravenous (i.v) heparin in high therapeutic range was followed by a successful 'low-dose, ultra-slow' fibrinolysis.

Discussion

CT may help differentiate thrombus vs. pannus. The acute onset of symptoms, inadequate anticoagulation, and restricted leaflet motion increased the suspicion for PVT. The current European guidelines propose normal dose fibrinolysis. We performed 'low-dose, ultra-slow' fibrinolysis due to lower bleeding risk with successful results. Low dose should be considered as alternative to normal dose fibrinolysis or urgent surgery.

Authors+Show Affiliations

Department of Cardiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.Department of Cardiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland. Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.Department of Cardiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.

Pub Type(s)

Case Reports

Language

eng

PubMed ID

32617496

Citation

Kapos, Ioannis, et al. "Case Report of Successful Low-dose, Ultra-slow Infusion Thrombolysis of Prosthetic Mitral Valve Thrombosis in a High Risk Patient After Redo-mitral Valve Replacement." European Heart Journal. Case Reports, vol. 4, no. 3, 2020, pp. 1-5.
Kapos I, Fuchs T, Tanner FC. Case report of successful low-dose, ultra-slow infusion thrombolysis of prosthetic mitral valve thrombosis in a high risk patient after redo-mitral valve replacement. Eur Heart J Case Rep. 2020;4(3):1-5.
Kapos, I., Fuchs, T., & Tanner, F. C. (2020). Case report of successful low-dose, ultra-slow infusion thrombolysis of prosthetic mitral valve thrombosis in a high risk patient after redo-mitral valve replacement. European Heart Journal. Case Reports, 4(3), 1-5. https://doi.org/10.1093/ehjcr/ytaa053
Kapos I, Fuchs T, Tanner FC. Case Report of Successful Low-dose, Ultra-slow Infusion Thrombolysis of Prosthetic Mitral Valve Thrombosis in a High Risk Patient After Redo-mitral Valve Replacement. Eur Heart J Case Rep. 2020;4(3):1-5. PubMed PMID: 32617496.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Case report of successful low-dose, ultra-slow infusion thrombolysis of prosthetic mitral valve thrombosis in a high risk patient after redo-mitral valve replacement. AU - Kapos,Ioannis, AU - Fuchs,Tobias, AU - Tanner,Felix C, Y1 - 2020/03/16/ PY - 2019/12/09/received PY - 2019/12/21/revised PY - 2020/02/12/accepted PY - 2020/7/4/entrez PY - 2020/7/4/pubmed PY - 2020/7/4/medline KW - Case report KW - Computed tomography KW - Echocardiography KW - Mechanical prosthesis KW - Thrombolysis KW - Valve disease SP - 1 EP - 5 JF - European heart journal. Case reports JO - Eur Heart J Case Rep VL - 4 IS - 3 N2 - Background: An increase in transvalvular pressure gradient of prosthetic valve should always raise suspicion for obstructive valve thrombosis. A multimodality diagnostic approach including transthoracic echocardiography, transoesophageal echocardiography (TOE), cinefluoroscopy, or computed tomography (CT) is necessary for a prompt diagnosis. The management of mechanical prosthetic valve thrombosis (PVT) is high risk in any therapeutic option taken. Emergency valve replacement is recommended for critically ill patients. Fibrinolysis is an alternative for patients with contraindication to surgery or if surgery is not immediately available. Case summary: A 52-year-old woman presented with symptoms and signs of cardiac congestion. On laboratory, brain natriuretic peptide was elevated and international normalized ratio (INR) was in subtherapeutic range. She underwent a mitral valve replacement with mechanical prosthesis 7 months before, because of a significant residual regurgitation after repair on the same year. TOE revealed severe stenosis of the prosthesis with immobile anterior disc but there was no mass present. CT revealed a minor lesion at the hinge points of the prosthesis without involvement of the ring, suggestive for thrombus. The initial fruitless management with intravenous (i.v) heparin in high therapeutic range was followed by a successful 'low-dose, ultra-slow' fibrinolysis. Discussion: CT may help differentiate thrombus vs. pannus. The acute onset of symptoms, inadequate anticoagulation, and restricted leaflet motion increased the suspicion for PVT. The current European guidelines propose normal dose fibrinolysis. We performed 'low-dose, ultra-slow' fibrinolysis due to lower bleeding risk with successful results. Low dose should be considered as alternative to normal dose fibrinolysis or urgent surgery. SN - 2514-2119 UR - https://www.unboundmedicine.com/medline/citation/32617496/Case_report_of_successful_low-dose,_ultra-slow_infusion_thrombolysis_of_prosthetic_mitral_valve_thrombosis_in_a_high_risk_patient_after_redo-mitral_valve_replacement DB - PRIME DP - Unbound Medicine ER -
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