A case of thrombolytic therapy with recombinant tissue plasminogen activator for mechanical valve thrombosis at 9 weeks of pregnancy in a Japanese woman

Abstract

A 29-year-old woman was admitted to our hospital due to diagnosis of pregnancy at 5 weeks and a day. She underwent valve replacement with mechanical heart valve (MHV: SJM valve) for congenital mitral valve regurgitation, when 11 years old. Warfarin 4 mg was used for anticoagulation. After admission, warfarin was replaced by unfractionated heparin (UFH). She developed exertional dyspnea at 8 weeks of pregnancy. Echocardiogram and fluoroscopy showed an immobile leaflet in the closed position. She was diagnosed with mechanical valve thrombosis. Cardiac surgery or thrombolytic therapy (TT) were treatment options. TT is not established, but is reported to be safer than cardiac surgery. Recently, lowdose, slow infusion of recombinant tissue plasminogen activator (rt-PA) therapy showed acceptable results. About 2.5 h after an intravenous injection of rt-PA, diastolic rumble improved to the normal range of leaflet. Thereafter, warfarin was restarted and there was no recurrence of symptoms and no abortion. She was readmitted for the scheduled Caesarean section (CS) at 32 weeks of pregnancy, and warfarin was replaced with UFH. At 34 weeks of pregnancy, a baby was delivered by CS. She suffered hemostasis after surgery under the anticoagulation. Postoperative day 31, both mother and a child were healthy and left the hospital. <Learning objective: The coagulation status is activated and the fibrinolytic activity is reduced during pregnancy. Prosthetic valve thrombosis during pregnancy is known as a life-threatening event for mother and fetus. The treatment strategy for this complication is not well established. Low-dose, slow infusion of recombinant tissue plasminogen activator (rt-PA) therapy showed acceptable results. This case report shows that rt-PA therapy for the prosthetic valve thrombosis in a Japanese pregnancy woman could be an alternative treatment strategy to surgery.>

Author’s reply to “Anticoagulation strategy and management of patients with mechanical prosthetic heart valves during pregnancy”

“…We are thankful for your insightful and thorough comment on our article [1]. In particular, we completely agree with your concern regarding the optimal anticoagulation strategy in the first trimester of pregnancy.…”

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Letter to the Editor Author's reply to "Anticoagulation strategy and management of patients with mechanical prosthetic heart valves during pregnancy"We are thankful for your insightful and thorough comment on our article [1]. In particular, we completely agree with your concern regarding the optimal anticoagulation strategy in the first trimester of pregnancy.

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Anticoagulation strategy and management of patients with mechanical prosthetic heart valves during pregnancy

“…For the reasons described above, European Society of Cardiology/European Association for Cardiothoracic Surgery guidelines regarding the management of cardiovascular diseases during pregnancy recommend the use of low-dose warfarin in women who are able to maintain therapeutic international normalized ratios (Class IIa) over the use of either low molecular weight heparin or UFH in the first trimester (Class IIb) [3]. In the present case reported by Komatsu et al [1], it was debatable that UFH was used as anticoagulation therapy in the first trimester in a patient needing low-dose warfarin (4 mg/day) for anticoagulation. Furthermore, continuous intravenous infusion made the patient prone to additional risks such as catheter-associated bacteremia.…”

“…We have read with great interest the article by Komatsu et al entitled "A case of thrombolytic therapy with recombinant tissue plasminogen activator for mechanical valve thrombosis at 9 weeks of pregnancy in a Japanese woman" [1]. The authors have reported the management of a pregnant patient with mechanical prosthetic valve thrombosis in mitral position.…”