Severe complications following thrombolytic therapy of an acute thrombosis of a prosthetic mitral valve

Abstract

Thrombosis of prosthetic cardiac valves is a rare but potentially lethal complication. As emergency surgical intervention of thrombotic prosthetic cardiac valves is correlated with high mortality, fibrinolytic therapy has been recently recommended as a therapy with high efficacy and no severe side effects. We report on a patient with thrombosis of a prosthetic mitral valve who developed severe embolic complications following the administration of the thrombolytic agent. On admission the patient showed signs of incipient cardiogenic shock. The diagnosis of thrombotic obstruction of the prosthetic mitral valve was confirmed by transesophageal echocardiography. The effective valve area was 0.41 cm². Pulmonary arterial blood pressure and wedge pressure were significantly elevated. A fibrinolytic therapy with recombinant tissue-type plasminogen activator according to the Neuhaus scheme was attempted. Within 60 min after start of treatment the effective valve area increased (1.41 cm²), and the pulmonary capillary wedge pressure decreased. However, peripheral and cerebral embolism occurred. Occlusion of the right brachial and right femoral artery was ascertained by Doppler ultrasound. Embolism into the right leg made an embolectomy with a Fogarty catheter necessary. Computed tomography revealed two lesions located in the occipital and left temporal area of the brain. Correlated with the lesions evaluated in computed tomography, right hemiplegia and complete aphasia was observed. The neurological status of the patient has only slightly improved to the present. To our knowledge no severe persistent neurological deficits following thrombolytic therapy have been reported. We therefore assume that the risk of severe neurological complications is underestimated. It is suggested that fibrinolytic therapy is a reasonable alternative in severely compromized patients with thrombotic prosthetic cardiac valves, but the final value of this treatment cannot be ascertained due to the small number of patients and the underestimation of severe embolic complications.