Balloon inflation for a mechanical tricuspid valve thrombosis: case report

Mechanical valve thrombosis (MVT) is rare but life-threatening complication. While the clinical guideline suggests that thrombolysis for high-risk surgical candidates should be considered, the European guideline does not differentiate between left- and right-sided MVTs while the American guideline only made specific recommendations for left-sided MVT. Furthermore, the American guideline suggests that percutaneous intervention for left-sided MVT may be considered. Both clinical guidelines did not refer to percutaneous intervention for right-sided MVT.

A 52-year-old woman with three mechanical valve replacements for rheumatic heart disease presented with subacute onset of symptoms of right-sided heart failure. Transthoracic echocardiogram (TTE) demonstrated a high transvalvular gradient across the tricuspid mechanical valve which is new from TTE 3 years prior. Further imaging confirmed thrombosis of the anterior leaflet of the tricuspid mechanical valve. Four cycles of ultra-low-dose thrombolysis and one standard-dose thrombolysis failed to restore normal valve function. Surgery was considered prohibitively high-risk, and the patient was left with either palliation or percutaneous intervention. Percutaneous mechanical valve balloon inflation was undertaken with subsequent improvement in transvalvular gradient and leaflet motion.

There is limited data on percutaneous intervention for right-sided MVT with only one other case reported to date. In patients with prohibitively high surgical risk, thrombolysis should be considered as per the clinical guidelines. However, in ∼1 in 10 patients, thrombolysis fails to restore normal valve function. Percutaneous intervention may be an alternative option.