Dermatology & Skin Care

Biography

Biography: Dr. Danni Fu

Abstract

Introduction: Subtherapeutic anticoagulation (AC) of mechanical aortic valves (MAV) can lead to thrombosis causing obstruction. Hyperdynamic left ventricular (LV) systolic function, elevated LV outflow tract velocity, and aortic insufficiency (AI) can be seen on echocardiogram (TTE) due to changes in transvalvular gradient. Thrombolytics (tPA) are used in high-risk candidates while surgery is done in low/moderate risk candidates and those with large clots. Our case shows a high-risk candidate treated with a novel tPA protocol that resulted in the resolution of aortic valve obstruction. Case Description: 54 yo female with MAV underwent abdominal surgery where AC was held now presenting with cardiogenic shock. TTE showed new severe aortic stenosis (AS) due to leaflet restriction from a large thrombus along with new AI, which precluded mechanical circulatory support. She was a poor surgical candidate and was given 50mg of alteplase at a rate of 8.3 mg/dl along with low intensity IV heparin. After 2 hours, TTE showed resolution of AI and significant improvement of AS. Unfortunately she experienced cardiac arrest due to other reasons and failed to respond to multiple rounds of resuscitation. Hemoglobin checked during the code blue was stable, ruling out hemorrhage as the cause of death. Discussion: tPA infusion for AV thrombosis is generally recommended at an ultraslow rate of 25mg over 25 hours followed by IV heparin 6 hours post infusion. Given the instability of our patient, we administered 50mg of tPA over 6 hours, simultaneously with heparin, which led to the resolution of AI and improved transvalvular gradients. Observational studies indicate lower complication rates with the ultraslow protocol, but it can fail in those with severe symptoms or larger thrombus burden. Our case demonstrates a new protocol that can be considered in patients with hemodynamically unstable AV thrombosis.