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Successful Thrombolysis of an Obstructive Prosthetic Mitral Valve Thrombosis Using Alteplase
Govindaraj Varadaraj1, Kiran Maribashetti2, R Ananthakrishnan3
1Assistant Professor, Department of General Medicine, Air Force Central Medical Establishment, Delhi, India, Corresponding Author.
Insights
This case study shows successful thrombolysis with Alteplase for prosthetic mitral valve thrombosis in a hemodynamically unstable patient. This approach offers an alternative when surgery is unavailable, restoring valve function and relieving symptoms.
Area of Science:
- Cardiology
- Interventional Cardiology
- Pharmacology
Background:
- Rheumatic heart disease (RHD) and prior ischemic stroke necessitate anticoagulation for mitral valve replacement (MVR) patients.
- Prosthetic valve thrombosis (PVT) is a serious complication, often requiring surgical intervention.
- Defaulting oral anticoagulant (OAC) therapy significantly increases the risk of PVT.
Observation:
- A 48-year-old male with MVR for RHD presented with acute angina and hemodynamic instability.
- Physical examination revealed atrial fibrillation with severe hypotension and hypoxia.
- Transthoracic echocardiogram and fluoroscopy confirmed obstructive prosthetic mitral valve thrombosis.
Findings:
- Despite hemodynamic instability, the patient was treated with a 'long fibrinolytic protocol' using Alteplase (recombinant tissue plasminogen activator, rtPA) due to unavailability of surgical facilities.
- Post-thrombolysis echocardiography demonstrated a reduced mean gradient and improved valve motion, indicating successful clot lysis.
- The patient experienced rapid symptomatic relief and was subsequently managed with OAC therapy under strict compliance.
Implications:
- Pharmacological thrombolysis with rtPA can be a viable alternative to surgery for prosthetic mitral valve thrombosis, even in initially unstable patients, when surgical intervention is not feasible.
- This case highlights the importance of OAC adherence in patients with mechanical heart valves to prevent life-threatening PVT.
- Successful thrombolysis can restore valve function, improve hemodynamics, and lead to favorable clinical outcomes, underscoring the potential of pharmacotherapy in managing PVT.
Abstract:
A 48-year-old man with a history of mitral valve replacement (MVR) in March 2019 for rheumatic heart disease (RHD) and ischemic stroke in August 2019 presented with a history of sudden onset angina of 6 hours duration. He admits to defaulting oral anticoagulant (OAC) intake for the last 50 days. On arrival, he had atrial fibrillation with hemodynamic instability [blood pressure (BP) 70/40 mm Hg, saturation of peripheral oxygen (SpO2) 80% at room air and heart rate approx 140/minute], which was managed with intravenous diltiazem and hemodynamic stability achieved (BP 116/72 mm Hg, heart rate 86/minute). Urgent transthoracic echocardiogram (TTE) and fluoroscopy confirmed obstructive prosthetic mitral valve thrombosis. Though available recommendations suggest surgical intervention for the left-sided valve involvement in a stable patient, in view of the nonavailability of a surgical facility, the patient was thrombolyzed with Alteplase, a recombinant tissue plasminogen activator (rtPA). Since the patient was stable, a "long fibrinolytic protocol" of Alteplase 10 mg bolus, 50 mg during the 1st hour, and 20 mg each during the 2nd and 3rd hour (total of 100 mg) was given. Subsequent TTE revealed a mean gradient of 5 mm Hg, and cine fluoroscopy showed improved mitral valve motion, thereby indicating successful thrombolysis. The patient felt symptomatically relieved within 6 hours and is presently on OAC therapy with strict drug compliance.
