1132 JACC April 5, 2016 Volume 67, Issue 13
FIT Clinical Decision Making ACUTE PROSTHETIC MECHANICAL MITRAL VALVE THROMBOSIS: NEEDLE OR SCALPEL? Poster Contributions Poster Area, South Hall A1 Saturday, April 02, 2016, 3:45 p.m.-4:30 p.m. Session Title: FIT Clinical Decision Making: Congenital Heart Disease, Valvular Heart Disease, Pulmonary Hypertension Abstract Category: Valvular Heart Disease Presentation Number: 1152-322 Authors: Nishi Shah, Yogita Rochlani, Naga Venkata Pothineni, Aatish Garg, Sabha Bhatti, University of Arkansas for Medical Sciences, Little Rock, AR, USA
Background: Surgery is the treatment of choice for prosthetic mechanical mitral valve thrombosis (PMVT) with heart failure. We present a case where two-dose thrombolysis was successful in PMVT. Case: A 35-year-old woman with history of mechanical mitral valve for rheumatic mitral stenosis presented with dyspnea, orthopnea, and inaudible prosthetic valve click for two days. Her warfarin dose was held for 2 days for a urological procedure and resumed with no bridging. On exam, patient was tachycardic, tachypneic, normotensive and had bilateral lung crackles. There was no audible valve click. Chest Xray showed pulmonary edema. INR was 1.8. Echocardiography (ECHO) revealed restricted mobility of mitral valve leaflets with a mean gradient of 24.6 mmHg. Cine fluoroscopy revealed completely stuck anterior leaflet and severely restricted mobility of posterior leaflet.
Decision Making: Cardiac surgery was consulted and we decided to attempt thrombolysis. 10 mg bolus of alteplase (t-PA) followed by 90 mgs over 3 hours was administered. Repeat ECHO 24 hours later showed a decrease in trans-mitral mean gradient to 7 mm Hg. Repeat cine showed normal mobility of posterior valve but anterior leaflet remained immobile. t-PA was repeated. Cine on day 3 showed normal posterior leaflet mobility and mild limitation of anterior leaflet excursion. Conclusions: Two dose thrombolysis regimen was successfully used to treat PMVT, hence avoiding re-do valve surgery.