Thrombolysis of a tricuspid prosthetic valve

A 25-year-old Caucasian woman presented to our hospital in April 2005, complaining of exertional dyspnoea, palpitations and fatigue since three weeks. She underwent a mitral and tricuspid valve replacement with two mechanical prostheses in 1999 in Serbia for rheumatic mitral and tricuspid stenosis and was reoperated in 2003 for a subacute tricuspid prosthesis obstruction with implantation of a 31 mm bi-leaflet St. Jude valve. On physical examination she was an alert young woman without clinical signs of left or right heart failure. Cardiac auscultation revealed a large splitting of S1 associated to a /6 holosystolic murmur and /6 diastolic rumble on the left parasternal and apical regions. A transthoracic echocardiography (TTE) was performed and showed a normal left ventricular systolic function with a mild post-operative septal hypokinesia, a mildly dilated left atrium and a normally functioning mitral prosthetic valve. The right atrium was dilated and assumed a round shape with bulging of the interatrial septum to the left. There was a dilatation of the inferior vena cava and the sub-hepatic veins. The right ventricle was mildly dilated with a normal right ventricular systolic function. The posterior leaflet of the tricuspid prosthetis was jammed in a close position and there was an incomplete excursion of the anterior leaflet with a significant valvular leak. The mean transprosthetic gradient varied between 7 and 9 mm Hg (fig. 1–3). Adiagnosis of a subacute thrombosis of the tricuspid St. Jude valve was made and an intravenous thrombolysis was started. We administered a recombinant tissue plasminogen activator (rt-PA; Actilyse®, Boehringer Ingelheim, Germany) with a loading dose of 10 mg IV, followed by 90 mg IV for 90 min. Heparin 5000 U bolus IV was administered 2 hours after the loading dose, followed with 30000 U/ 24 h IV. One hour after the end of the thrombolysis, the diastolic rumble had disappeared. A transthoracic examination, 6 hours after the beginning of the fibrinolysis, showed a complete excursion of the two leaflets with a mean transprosthetic gradient of 2 mm Hg (fig. 1–3).