TO LYSE OR NOT TO LYSE: MECHANICAL AORTIC VALVE THROMBOSIS

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Prosthetic valve thrombosis remains a rare but serious complication of a valve replacement. Due to the significant morbidity and mortality associated with this complication, it requires quick diagnostic evaluation. However, diagnosis of a prosthetic valve thrombosis is difficult due to various clinical presentations and overlap with other complications. Through this case presentation, we discuss how valvular thrombosis should be considered in patients with mechanical valves as one of the many complications that can arise and cause symptoms similar to other common diseases such as COPD exacerbation and heart failure exacerbation. Furthermore, while fibrinolysis of thrombosed mechanical valves are not well studied, it still should be considered in patients that are suboptimal surgical candidates already on long-term anticoagulation. CASE PRESENTATION: A 56-year-old man with an extensive past medical history including systolic heart failure and aortic insufficiency status post mechanical aortic valve presented with shortness of breath and productive cough. He was initially treated for chronic obstructive pulmonary disease exacerbation, however, throughout his hospital course, his symptoms worsened. He developed flash pulmonary edema and acute hypoxic respiratory failure and was subsequently intubated in the cardiac care unit. Further work up revealed a decreased ejection fraction of 15-20% and significantly increased aortic valvular peak velocity and mean gradient compared with a previous echocardiogram. He underwent fluoroscopy which displayed a fixed mechanical valve leaflet, suggestive of thrombosis. This patient was not an ideal surgical candidate due to extensive comorbidities, so after further consideration, 10 mg slow infusion of alteplase was administered. The days following the procedure, the patient’s symptoms improved, and vital signs normalized. Repeat echocardiogram showed interval improvement of aortic valve gradient. DISCUSSION: Prosthesis-related complications include valve obstruction, embolic events, bleeding, prosthetic heart valve regurgitation, infective endocarditis, and prosthetic valve-related hemolysis. Prosthetic valve thrombosis is a serious complication occurring in 0.5-8% of mechanical valves in the mitral and aortic valve replacements. Common treatment options include valve surgery and a trial of anticoagulant therapy. However, fibrinolysis is another option in severe obstructed left sided bio prosthetic valve thrombosis that is not as well studied. This patient represents a case of a severely symptomatic mechanical aortic valve thrombosis that responded well to direct thrombolysis with alteplase. CONCLUSIONS: Prosthetic valve thrombosis is a rare yet serious complication after a valve replacement. Due to this, it requires swift diagnosis and in patients that are not optimal surgical candidates, fibrinolysis remains a viable, yet not well-studied, option. Reference #1: Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e576S-e600S. doi:10.1378/chest.11-2305 Reference #2: Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in J Am Coll Cardiol. 2014 Jun 10;63(22):2489. Dosage error in article text]. J Am Coll Cardiol. 2014;63(22):e57-e185. doi:10.1016/j.jacc.2014.02.536 Reference #3: Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739-2791. doi:10.1093/eurheartj/ehx391 DISCLOSURES: No relevant relationships by Akash Patel, source=Web Response No relevant relationships by Sagar Patel, source=Web Response