Successful Low-Dose tPA for Mechanical Mitral Valve Thrombosis in a Patient with Postinfarction Contained Left Ventricular Free Wall Rupture.

James Livesay,Raj Baljepally,Hassan Tahir,Emmanuel Isang,Francesco Nappi

doi:10.1155/2021/5532728

James Livesay, Raj Baljepally + Show 3 more

Open Access

https://doi.org/10.1155/2021/5532728

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Abstract

Prosthetic valve thrombosis is a potentially life-threatening complication diagnosed by a combination of clinical features and imaging modalities, but the optimal management in high bleeding risk patients remains controversial. Current treatment options for prosthetic valve thrombosis included surgery, thrombolytic therapy, and anticoagulation. We present a very unusual case of a patient with a recent ST-elevation myocardial infarction complicated by contained left ventricle free wall rupture and mechanical mitral valve thrombosis. Deemed a high surgical risk candidate, low-dose tissue plasminogen activator was used despite significant bleeding risk from contained left ventricle free wall rupture, which resulted in resolution of the thrombus. To the best of our knowledge, this is the first report of successful thrombolytic therapy for prosthetic mechanical mitral valve thrombosis in a patient with recent postmyocardial infarction contained left ventricular free wall rupture.

Highlights

The most common complications after native valve replacement include prosthetic valve thrombosis (PVT), pannus formation, embolic events, bleeding, and infective endocarditis [1]
Any patient with a known mechanical valve that presents with clinical signs of valve obstruction such as a new murmur, subdued clicks, symptoms or signs of heart failure, thromboembolic events, or elevated transvalvular gradients should be evaluated for PVT
Thrombolytic therapy for right-sided PVT is considered if clot persists despite intravenous heparin

Summary

Introduction

The most common complications after native valve replacement include prosthetic valve thrombosis (PVT), pannus formation, embolic events, bleeding, and infective endocarditis [1]. The rate of PVT is higher in patients with mechanical valves versus those with bioprosthetic valves, with an annual rate up to 5.7% in the mechanical valve group [2]. Any patient with a known mechanical valve that presents with clinical signs of valve obstruction such as a new murmur, subdued clicks, symptoms or signs of heart failure, thromboembolic events, or elevated transvalvular gradients should be evaluated for PVT. Prosthetic valve mean gradients increased by 50% from the baseline in the setting of acute presenting symptoms, and subtherapeutic anticoagulation is consistent with PVT [4]. The current management strategies for PVT include surgical intervention, thrombolytic therapy, and anticoagulation [2]. The best treatment option depends on many factors, including right versus left-sided valve involvement, thrombus burden, surgical risk, and patient preference

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