Fighting Fire with Fire: tPA for Thrombosed Mitral Valve Presenting with Alveolar Hemorrhage
AAPA ePoster library. Sharp M. 05/17/17; 180558; 236
Michael Sharp
Michael Sharp
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Abstract
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Introduction Mechanical mitral valve placement is a common surgery for mitral regurgitation and mitral stenosis. A 2001 study reported a thrombosis rate of 0.2% per patient-year with the St. Jude mechanical valve[1]. Severe mitral stenosis caused by prosthetic valve thrombosis can cause acute heart failure, pulmonary edema, and diffuse alveolar hemorrhage secondary to pulmonary vascular congestion. Case A 53-year-old female with a history of mitral valve regurgitation status-post mitral valve replacement with St. Jude mechanical valve was admitted to an outside hospital for acute hypoxic respiratory failure. On bronchoscopy, she was found to have diffuse alveolar hemorrhage and was placed on high-dose methylprednisolone. She required multiple blood transfusions and ultimately was transferred to our institution for continued treatment. A repeat bronchoscopy showed significant pulmonary vascular congestion, and a transthoracic echocardiogram (TTE) revealed a diastolic mean gradient of 23 mmHg (heart rate 92 bpm) across the mitral valve prosthesis. A subsequent transesophageal echocardiogram (TEE) showed a mitral valve diastolic mean gradient of 13 mmHg (heart rate 100 bpm) across the mitral valve prosthesis with restriction of the lateral and medial leaflets. This was suggestive of an occlusive thrombus versus vegetation. The prosthetic orifice area was calculated to be 1.4 cm^2 (normal orifice area >1.5 cm^2). It was felt that one leaflet of the St. Jude valve was immobile and non-functional. She was deemed not to be a surgical candidate due to her poor baseline functional status and multiple co-morbidities; therefore systemic tissue plasminogen activator (tPA) was proposed for mitral valve thrombolysis. The risks and benefits of this treatment were discussed with the patient and her husband, and they consented. Given her diffuse alveolar hemorrhage and pulmonary varicosities, she was electively intubated prior to thrombolytic administration. Following intubation, 25 mg of tPA was administered via IV infusion over 6 hours. A limited TEE the following day revealed a normal mitral prosthetic bileaflet occluder disc motion throughout the cardiac cycle. Lateral and medial disc motion had improved, and there was no evidence of persistent mitral prosthetic vegetation or thrombosis. Fortunately, she did not have recurrent alveolar hemorrhage, and she was successfully extubated the following day. Discussion Many different pathologies can lead to acute hyp...
Introduction Mechanical mitral valve placement is a common surgery for mitral regurgitation and mitral stenosis. A 2001 study reported a thrombosis rate of 0.2% per patient-year with the St. Jude mechanical valve[1]. Severe mitral stenosis caused by prosthetic valve thrombosis can cause acute heart failure, pulmonary edema, and diffuse alveolar hemorrhage secondary to pulmonary vascular congestion. Case A 53-year-old female with a history of mitral valve regurgitation status-post mitral valve replacement with St. Jude mechanical valve was admitted to an outside hospital for acute hypoxic respiratory failure. On bronchoscopy, she was found to have diffuse alveolar hemorrhage and was placed on high-dose methylprednisolone. She required multiple blood transfusions and ultimately was transferred to our institution for continued treatment. A repeat bronchoscopy showed significant pulmonary vascular congestion, and a transthoracic echocardiogram (TTE) revealed a diastolic mean gradient of 23 mmHg (heart rate 92 bpm) across the mitral valve prosthesis. A subsequent transesophageal echocardiogram (TEE) showed a mitral valve diastolic mean gradient of 13 mmHg (heart rate 100 bpm) across the mitral valve prosthesis with restriction of the lateral and medial leaflets. This was suggestive of an occlusive thrombus versus vegetation. The prosthetic orifice area was calculated to be 1.4 cm^2 (normal orifice area >1.5 cm^2). It was felt that one leaflet of the St. Jude valve was immobile and non-functional. She was deemed not to be a surgical candidate due to her poor baseline functional status and multiple co-morbidities; therefore systemic tissue plasminogen activator (tPA) was proposed for mitral valve thrombolysis. The risks and benefits of this treatment were discussed with the patient and her husband, and they consented. Given her diffuse alveolar hemorrhage and pulmonary varicosities, she was electively intubated prior to thrombolytic administration. Following intubation, 25 mg of tPA was administered via IV infusion over 6 hours. A limited TEE the following day revealed a normal mitral prosthetic bileaflet occluder disc motion throughout the cardiac cycle. Lateral and medial disc motion had improved, and there was no evidence of persistent mitral prosthetic vegetation or thrombosis. Fortunately, she did not have recurrent alveolar hemorrhage, and she was successfully extubated the following day. Discussion Many different pathologies can lead to acute hyp...
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