Key words:
Mushroom thrombus, post TMVR, 3D TEE
Case :
A 53-year-old lady follow up case of rheumatic heart disease, post MVR;
bioprosthetic valve (Epic #25) implanted 6 years ago. She developed
progressive breathlessness for last 3 months NYHA class III.
Transthoracic as well as transesophageal echocardiography (TEE)
suggested dysfunction prosthetic valve with flail leaflet leading to
severe MR (Fig A).
Patients with contraindication or high risk for surgical treatment and
failed surgical bioprosthesis or annuloplasty; Transcatheter mitral
valve replacement (TMVR) is a good therapeutic option [1,2]
She was implanted 23 mm bioprosthetic Meril’s My valve (valve in valve)
via percutaneous transcatheter technique right femoral vein under 3D TEE
guidance (Fig B). Result was satisfactory (Mean pressure gradient 3
mmHg) with no residual mitral regurgitation.
After 1 month follow up, she had some breathing difficulty for which
transthoracic echocardiography,& 2DTEE were done which showed a mobile
hyperechogenic mass hanging over prosthetic valve (Fig C) with
significant gradients across mitral inflow, mean gradients were 18 mmHg
(Fig D) 3D transesophageal echocardiography from left atrial side view
showed a unique mushroom like mobile mass hanging over prosthetic valve
, measuring ~20X30 mm (fig E).
In view of significant gradients and obstruction of color flow across
valve; thrombolysis was done with streptokinase bolus followed by
intravenous continuous infusion. After 24 hours, echocardiography
reviewed showed significant reduction in gradients (MPG 6 mmHg) and
disappearance of mass. 3D trans
thoracic echocardiography revealed normal functioning of valve with no
mass as seen previously (Fig F)
On review of literature, the incidence of prosthetic valve thrombosis
post TMVR remains largely unknown. Although it may occur more frequently
than after transcatheter aortic valve replacement, only isolated cases
have been reported up to now [3,4]. This unique large mushroom
thrombus post TMVR case is first of its kind reported ever.