Low-dose slow infusion thrombolysis in the treatment of prosthetic heart valve thrombosis: a clinical case

Agnė Kraujelytė1, Indrė Justina Ignatavičiūtė1, Vilius Janušauskas2, Aleksėjus Zorinas2, Jurij Šabliauskas3, Donata Ringaitienė3

1Vilnius University, Faculty of medicine, Vilnius, Lithuania.

2Heart and Chest Surgery Center, Cardiac Surgery department – Vilnius University Hospital Santaros Clinics

3Institute of Clinical Medicine- Vilnius University- Faculty of Medicine, Clinic of Anesthesiology and Reanimatology- Vilnius University Hospital Santaros Clinics – Centre of Anaesthesiology- Intensive Therapy and Pain Management, Vilnius, Lithuania.

Background and Aims. Describe and present a clinical case of a patient treated with low-dose slow infusion thrombolysis after prosthetic valve thrombosis.

Methods. The patient is a 75 year old women treated with low–dose slow infusion thrombolysis in the Resuscitation and Intensive Care Unit II of Vilnius University Hospital. Data was monitored since 2017 till 2020. A detailed analysis of the patient’s life and medical history was made. The course and dynamics of examinations and treatment procedures / medications prescribed to the patient were analyzed in a structured way. The literature on the selected topic is examined in detail in order to compare the efficacy and outcome of low-dose slow infusion thrombolysis with the results of previous studies and in the case we presented. Permission to use patient data has been obtained with the consent of the personal data protection specialist. Patient confidentiality was guaranteed – name, surname, address and other personal data were not collected. The results of the study are published only in a summary form.

Results.  A 75-year-old patient had a prosthetic mitral mechanical valve in 2009 St. Jude 29 MJ. In 2015, the valve was replaced due to high thrombosis. Since 2016 the woman was hospitalized 4 times (once a year) in December for recurrent mitral valve thrombosis for a low-dose slow infusion thrombolysis procedure. Overall of 12 thrombolysis were performed. Actilyse 25 mg / 6 h was infused with heparin after each thrombolysis for aPTT 50-80 sec. The efficacy of thrombolysis was evaluated by repeated transesophageal ultrasound examinations. The mean pressure gradient dynamics was decreasing (24mmHg 4.3mmHg). A geneticist and hematologist were consulted for suspected thrombophilia that had not been diagnosed, but hyperhomocysteinemia had been identified. 2020 she was hospitalized in July for suspected recurrent MV prosthetic thrombosis, but there were insufficient data on thrombosis, so the patient was admitted to outpatient treatment, recommending a Level III cardiologist consultation twice a year.

Conclusions.  Low-dose, slow-infusion thrombolytic therapy is currently increasingly being used in patients with prosthetic valve thrombosis. This is because it has safety, efficacy, and a lower incidence of complications. However, this clinical case demonstrates that such treatment does not always prevent recurrence of thrombosis.

Keywords: Actilyse, low – dose, slow infusion thrombolysis, prosthetic valve thrombosis.