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.