Dual mechanical valve thrombosis resolution through thrombolytics: a case series

Colin McGuire; Michael Yang; Alexander Papolos; Toby Rogers; Benjamin Kenigsberg

doi:10.1093/ehjcr/ytad399

Dual mechanical valve thrombosis resolution through thrombolytics: a case series

Eur Heart J Case Rep. 2023 Aug 19;7(9):ytad399. doi: 10.1093/ehjcr/ytad399. eCollection 2023 Sep.

Authors

Colin McGuire¹, Michael Yang², Alexander Papolos^{2

3}, Toby Rogers^{4

5}, Benjamin Kenigsberg^{2

3}

Affiliations

¹ Department of Medicine, Georgetown University Hospital, Washington, DC, USA.
² Division of Cardiology, Medstar Washington Hospital Center, 110 Irving St., NW, Washington, DC, USA.
³ Department of Critical Care Medicine, Medstar Washington Hospital Center, 110 Irving St., NW, Washington, DC, USA.
⁴ Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
⁵ Cardiovascular Intervention Program, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.

Abstract

Background: Prosthetic valve thrombosis (PVT) is a severe complication of mechanical valve replacement. Simultaneous thrombosis of multiple prosthetic valves is rare and is associated with worse outcomes. Treatment options include anticoagulation, thrombolysis, and redo operative valve replacement, with rare reports of adjunctive balloon valvuloplasty. There is limited evidence to guide therapeutic selection, specifically dosing, timing, and duration of thrombolysis. The following case series highlights the importance of successful thrombolytic management in dual PVT with high bleeding risk defined as a coagulopathy with an elevated international normalized ratio greater than 3 and New York Heart Association (NYHA) Class III and IV heart failure.

Case summary: We describe two patients with concomitant aortic and mitral PVT. Both patients presented in NYHA Class III and IV heart failure with different challenges to surgical treatments including high bleeding risk from coagulopathy and history of multiple prior sternotomies. After multi-disciplinary discussions, both patients underwent a combination of low-dose, slow, or ultra-slow infusion of tissue plasminogen activator, with a resolution of their dual PVT seen on cine-fluoroscopy imaging as freely moving mechanical leaflets and improvement of heart failure symptoms back to baseline NYHA Class II or lower.

Discussion: Prosthetic valve thrombosis is a complex medical condition requiring a multi-disciplinary team to evaluate the best course of treatment. A trial of pharmacologic thrombolysis is often the first attempted treatment for obstructive PVT, although surgery is recommended for patients with NYHA IV symptoms, or with contraindications to thrombolysis, including high bleeding risk. However, in patients with high bleeding risk and NYHA Class III and IV heart failure, especially with surgical contraindications, low-dose thrombolytics, with slow or ultra-slow infusions, may still be safe and effective treatment strategies for multi-valve PVT. Further research is needed to guide thrombolysis in multi-valve PVT.

Keywords: Case reports; Heart valve prosthesis; Thrombolytic therapy; Thrombosis; Valvular heart Disease.

Publication types

Case Reports