Abstract

Introduction: Prosthetic valve thrombosis (PVT) may be life-threatening if left untreated. History (recent change in symptoms including dyspnea), physical examination (recent change in prosthetic heart sounds), and different available imaging modalities including transthoracic (TTE) and transesophageal echocardiography (TEE) and fluoroscopy could lead to the diagnosis. Depending on prosthetic valve position, thrombosis size and patient’s symptoms, a range of therapeutic options including an intensification of anticoagulation, fibrinolytic therapy, and surgical intervention exist.
Case presentation: A 51-year-old woman with a history of aortic valve replacement (AVR) 9years ago was admitted with refractory pulmonary edema and function class IV dyspnea. TTE showed severe left ventricular systolic dysfunction with an ejection fraction of 10-15% and a mean transvalvular aortic valve (AV) gradient of about 20mmHg. Fluoroscopy revealed prosthetic valve malfunction with one leaflet being fixed. TEE confirmed the etiology with a 0.9cm2 thrombosis. Due to high surgical risk and refusal of surgery by both patient and surgeon, fibrinolytic therapy with streptokinase was started. Improved patient's symptoms, decreased mean AV gradient to 7mm Hg and improved valvular motion in fluoroscopy were documented after the treatment, with severe abdominal pain as a presumed complication.
Discussion: In spite of current guideline recommendation for surgical treatment in patients with left-sided PVT who are in function class III and IV or who have large clot burden, still fibrinolytic therapy could be considered as a possible treatment option in extremely high-risk patients.

Keywords

aortic valve replacement, prosthetic valve thrombosis, fibrinolytic therapy, anticoagulation