Dual mechanical valve thrombosis resolution through thrombolytics: a case series

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 elevated international normalized ratio (INR) greater than 3 and New York Heart Association Class (NYHA) III-IV heart failure. Case Summary We describe two patients with concomitant aortic and mitral PVT. Both patients presented in NYHA Class III-IV heart failure with different challenges to surgical treatments including high bleeding risk from coagulopathy, and history of multiple prior sternotomies. After multidisciplinary discussions, both patients underwent a combination of low-dose, slow or ultra-slow infusion of tissue plasminogen activator (tPA), with 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 PVT is a complex medical condition requiring a multidisciplinary 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-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.