Case report of successful low-dose, ultra-slow infusion thro
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An increase in the transvalvular pressure gradient of the prosthetic valve should always raise suspicion for obstructive valve thrombosis. A multimodality diagnostic approach including transthoracic echocardiography, transoesophageal echocardiography (TOE), cinefluoroscopy, or computed tomography (CT) is necessary for a prompt diagnosis. The management of mechanical prosthetic valve thrombosis (PVT) is a high risk in any therapeutic option taken. Emergency valve replacement is recommended for critically ill patients. Fibrinolysis is an alternative for patients with contraindication to surgery or if surgery is not immediately available.

A 52-year-old woman presented with symptoms and signs of cardiac congestion. In the laboratory, brain natriuretic peptide was elevated and the international normalized ratio (INR) was in the subtherapeutic range. She underwent a mitral valve replacement with mechanical prosthesis 7 months before, because of a significant residual regurgitation after repair on the same year. TOE revealed severe stenosis of the prosthesis with the immobile anterior disc but there was no mass present. CT revealed a minor lesion at the hinge points of the prosthesis without the involvement of the ring, suggestive for thrombus. The initial fruitless management with intravenous (i.v) heparin in high therapeutic range was followed by a successful ‘low-dose, ultra-slow’ fibrinolysis.

It can be understood that CT may help differentiate thrombus vs. pannus. The acute onset of symptoms, inadequate anticoagulation, and restricted leaflet motion increased the suspicion for PVT. The current European guidelines propose a normal dose of fibrinolysis. Doctors performed ‘low-dose, ultra-slow’ fibrinolysis due to lower bleeding risk with successful results. The low dose should be considered as an alternative to normal dose fibrinolysis or urgent surgery.