Abstract
Dear Editor,
Prosthetic heart valve thrombosis is a serious and urgent complication and related to the type and position of valve, the management of mechanical prosthetic valve thrombosis is high risk. Fibrinolysis is considered when surgery is not available or is very high risk or for thrombosis of right-sided prostheses.
A 60-year-old woman was admitted to our intensive cardiac care unit with symptoms of acute global heart failure. Four months prior to admission, she underwent an implantation of a mechanical bileaflet mitral valve due to severe rheumatic valve stenosis. She had left ventricular dysfunction with a left ventricular ejection fraction of 40%, probably rheumatic (preoperative coronary angiography was normal). Her physical examination showed regular rhythm, decrease of the prosthetic click, and lung congestion with signs of jugular venous distention and extremities edema. Her heart rate was noticed 90 beat per min and arterial blood pressure evaluated at 140/60 mm Hg. Routine blood investigations were normal (especially infectious assessment was normal). The international normalized ratio was subtherapeutic at 1.9. Transthoracic echocardiography and transesophageal echocardiography showed a 3×5 mm diameter thrombus on the prosthetic valve with immobilized bileaflet and transvalvular peak and mean gradient of 19 and 14 mmHg in endotracheal tube and 34 and 22 mm Hg in transesophageal echocardiography (ETO), respectively. We treated the heart failure with a loop diuretic and started unfractionated heparin combined with a low dose of aspirin and intravenous bolus of Tenecteplase. Twenty-four hours later, the control of the transprosthetic peak and mean gradients decreased significantly to 10 and 3 mmHg, respectively.
A number of factors can contribute to thrombotic dysfunction of a prosthetic heart valve and inadequate anticoagulation can play a major role in this.1, 2 The management of mechanical prosthetic valve thrombosis is high risk, whatever the option taken. Surgery is high risk because it is most often performed under emergency conditions and is a reintervention. On the other hand, fibrinolysis carries risks of bleeding, systemic embolism, and recurrent thrombosis that are higher than after surgery. According to the European Society of Cardiology (ESC) guidelines at 2021: emergency valve replacement is recommended for obstructive prosthetic valve thrombosis in critically ill patients without a contraindication to surgery. Fibrinolysis may be considered if surgery is at high risk but carries a risk of bleeding and thromboembolism. 3 According to the American College of Cardiology/American Heart Association guidelines (ACC/AHA) 2020: urgent initial treatment with either slow-infusion low-dose fibrinolytic therapy or emergency surgery is recommended for patients with a thrombosed left-sided mechanical prosthetic heart valve presenting with symptoms of valve obstruction. 4 The decision for emergency surgery vs. fibrinolytic therapy should be based on multiple factors (the valve location and presence or absence of valve obstruction), including the individual patient characteristic, the availability of surgical expertise, and the clinical experience with both treatments. 5
Obstructive prosthetic valve thrombotic can be successfully and more conveniently treated with Tenecteplase. More experience of its use might establish its role as a thrombolytic agent of choice in management of prosthetic valve thrombosis (PVT).
