High-Risk Mechanical Aortic Valve Thrombosis Managed with Transseptal Catheter Directed Tissue Plasminogen Activator
Presenter
Kari Gorder, MD, The Christ Hospital Health Network, Cincinnati, OH
Kari Gorder, MD1, Jacob Henderson, DO1 and Timothy D. Smith, M.D., FSCAI2, (1)The Christ Hospital Health Network, Cincinnati, OH, (2)Sanger Heart & Vascular Institute, Cincinnati, OH
Title
High-Risk Mechanical Aortic Valve Thrombosis Managed with Transseptal Catheter Directed Tissue Plasminogen Activator Introduction
Prosthetic valve complications include prosthetic valve thrombosis (PVT), cardioembolic events, and valve regurgitation. Management in high-risk patients remains controversial but includes surgical repair, thrombolytic therapy with tissue plasminogen activator (tPA), and systemic anticoagulation. We present a case of mechanical aortic valve (AV) thrombosis successfully treated with localized thrombolysis using a catheter-directed transseptal approach.
Clinical Case
A 59-year-old woman with a history of bicuspid AV status-post mechanical AV replacement on chronic anticoagulation with warfarin, chronic kidney disease and diabetes presented with critical limb ischemia. She had a subtherapeutic INR of 1.3 and ultrasound revealed acute femoral artery thrombosis. Vascular surgery performed an emergent iliofemoral thrombectomy. Transthoracic echocardiogram (TTE) revealed a dysfunctional AV and posterior mechanical leaflet fixation with stenosis and regurgitation. There was a mean transvalvular gradient of 20mmHg and a peak gradient of 30mmHg. Transesophageal echocardiogram (TEE) revealed thrombosis of the mechanical AV which was confirmed with fluoroscopy. She was deemed high risk for redo surgery and systemic anticoagulation was insufficient given her thromboembolism and aortic regurgitation. After a multidisciplinary discussion, she was treated with a catheter-directed tPA infusion via transseptal puncture for a total of 48 mg of tPA over 24 hours’ duration. This resulted in a significant reduction of the mean AV transvalvular gradient to 10mmHg and a normally functioning valve on fluoroscopy. The patient experienced no significant complications and was discharged home.
Discussion
This case illustrates the complex management of PVT. Factors in this case favoring fibrinolysis were high surgical risk, ischemic events, and aortic insufficiency. Catheter directed fibrinolysis via transseptal infusion of tPA is a safe, non-surgical option for certain high-risk patients with PVT and may offer an advantage over a systemic thrombolytic infusion by allowing for successful thrombolysis using a lower dose of fibrinolytic medication.