Prosthetic Mitral Valve Thrombosis Treated With Two Consecutive Courses of Fibrinolysis

We present the case of a 57-year-old woman who 14 months earlier underwent a double aortic and mitral valve replacement with a bileaflet mechanical prosthesis. Discharged after a slow postoperative, she had remained asymptomatic for more than 1 year until recently beginning with dyspnoea and progressive systemic congestion. She did not exhibit fever or infectious symptoms. The thoracic radiography showed a bilateral alveolar interstitial oedema pattern, and the analysis and haemostasis were normal, with INR =0.99. Interestingly, anticoagulant treatment had been discontinued 4 months earlier due to an episode of mild haemoptysis. The patient was admitted to the coronary unit, and conventional treatment for heart failure began paired with intravenous heparin sodium. The urgent echocardiography study (Figure) absolute lack of opening of one of the mitral prosthesis’ leaflets and a reduced opening of the other one, which resulted in a total effective area of 0.8 cm2 and an mean gradient of 24 mm Hg. There was thrombotic occupancy on the left appendix and spontaneous echo contrast on the left atrium, although thrombotic material was not observed in the mitral prosthesis. The aortic mechanical prosthesis functioned adequately, and left ventricular systolic function was normal. Still without locating thrombus in the mitral prosthesis, antecedents of interrupted anticoagulation, the thrombus in the left appendix, and the echo contrast established thrombosis of the prosthesis as the most probable diagnosis. Considering the previously complicated postoperative, initiation of fibrinolytic treatment with rt-PA (10 mg of intravenous bolus followed by another 90 mg in continuous perfusion for 90 min) was chosen. This obtained favourable but insufficient results, with improved opening of the partially immobilized leaflet and persistence of the other leaflet being closed and fixed (effective area, 1.36 cm2; mean gradient, 8.5 mm Hg) (Figure). The patient also improved symptomatically. echo-Doppler, computerized tomography, magnetic resonance, or angiography. Angiography is an essential tool for planning treatment.2 Therapeutic procedure includes antibiotic treatment for infectious endocarditis, according to individual case, and exeresis of the aneurysm with rebuilding of flow with a bypass. As a minimally invasive alternative, successful cases of repair with endovascular prosthesis with fewer incidences of lesions to structures next to the aneurysm compared to surgery, have been described.2,4