A case of unusual looking prosthetic mitral valve thrombosis treated with low dose slow infusion tPA

Abstract

AS was of rheumatic cause, with commisural fusion and little calcification. The aortic annulus and sinuses of Valsalva diameters were 22 and 30 mm, respectively. Systolic pulmonary artery pressure was 60 mm Hg. Coronary angiography showed normal epicardial coronary arteries, the calculated logistic EuroSCORE was 21. She was declined for surgery on the basis of prior cardiac surgery and poor left ventricular function.The technique was similar to that described by the previous case. During deployment, accelerated right ventricular pacing with 140 bpm and an oversized (29 mm) CoreValve prothesis were used. Only one attempt was necessary to achieve the optimal result without any technical issues (Video 5, 6. See correspondening video/movie images at www.anakarder.com). Follow-up echocardiography showed a well functioning prosthesis, with a mean gradient of 8 mm Hg, respectively. Mild paravalvular leak was present. The patient was clinically stable at 30 days follow up after the procedure. DiscussionThe use of TAVI is considered a relative contraindication in noncalcified valves (5). Calcium seems mandotory for anchoring the stentvalve and prevent pop-out, dislocation and migration of the prosthesis. In rheumatic AS, there is little or no calcification. However, our cases show that TAVI could be safe, feasible and effective treatment in patients with rheumatic AS.The concept of TAVI is based on crushing the usually heavily calcified native valve leaflets against the aortic wall by implanting a metallic stent-frame. Since calcification of the native valve leaflets is presumably essential for fixation of the stent-frame, TAVI is indicated in patients with calcified AS. Indeed, TAVI in patients with only marginal annular calcifications may lead to dislocation of the bioprosthesis into the left ventricle (2, 4). The unique pathological features of rheumatic AS, with lack of calcium, commissural fusion and pliable leaflets, can make it unsuitable to TAVI.The CoreValve prosthesis might anchor solidly even in the absence of calcification when oversized due to engineering properties (2), and may offer treatment for rheumatic AS without dislocation and migration of the prosthesis. During deployment, to prevent pop-out, embolization and migration of the prosthesis we performed accelerated right ventricular pacing between 140-180 bpm. In addition, oversized, selfexpandable (CoreValve) valves were selected.

Concomitant LMCA and Prosthetic Mitral Valve Thrombosis Treatment

“…Coronary embolisation is also seen in PVT, and generally, acute coronary syndrome is considered due to PVT-related embolism ( 3 ). Thrombolytic therapy may be considered for both coronary and valve thrombosis in hemodynamically stable patients ( 4 ). The superiority of surgery or thrombolytics is not clear due to the head-to-head randomized controlled trial; however, low-dose slow infusion of tPA repeated as needed without a bolus provides effective and safe thrombolysis in patients with prosthetic valve thrombosis ( 2 , 5 ).…”