Case presentation:
A 45-year-old woman presented to our clinic with Severe TR and
degenerative Bioprosthetic TV leaflets following surgical VSD closure
and Mechanical TVR 22 years before, Redo TVR with mechanical valve 17
years later, and 3do Bioprosthetic TVR after ten months due to TV
malfunction. The patient underwent successful TV valve in valve
implantation (Edward Sapien 3, size 29, MG: 3 mmHg) under TEE guidance
with optimal results (Mg: 2mmHg, PHT:125 msec) and no complications. She
was discharged on a dual antiplatelet regimen consisting of ASA and
clopidogrel. She presented to the emergency department three weeks
following the procedure with new onset of dyspnea and palpitation. TTE
and TEE were performed and revealed: Normal LV size with mild systolic
dysfunction, EF:45%, Moderate RV enlargement with severe systolic
dysfunction, diffuse thickening of all three leaflets (thickness=7 mm)
with reduced motion, significantly increased transvalvular gradients and
PHT (MG: 13 mmHg, PHT:300 msec) with no transvalvular or paravalvular
leakage (Figure 1).
Intensive anticoagulation with unfractionated heparin was initiated, and
the Mean gradient dropped to 8 mmHg after two days of achieving
therapeutic PTT. Nonetheless, the patient remained symptomatic, and no
further improvements were made in the following days. After consultation
with the heart team (Cardiac surgeon, peripheral interventionist, and
echocardiologist), the decision to administer fibrinolysis was taken. 25
mg alteplase mg was infused over 25 hours using the ultra-slow regimen.
Following that, unfractionated heparin was administered with the bolus
of 70 units/kg and 16 units/kg/hr for 6 hours. The next day, TTE and TEE
revealed a considerable decrease in transvalvular gradient and PHT (MG:
4 mmHg, PHT:200 msec), as well as relief of leaflet thickening and
improved mobility (Figure 2 and 3). No complications occurred, and the
patient was discharged on warfarin.