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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 244-246

Prosthetic valve thrombosis management in a patient with deranged coagulation parameters


1 Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication11-Jan-2019

Correspondence Address:
Dr. Nitin Kumar Parashar
Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_42_18

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  Abstract 

Appropriate guidelines are not available at present for the management of patient with acute prosthetic heart valve thrombosis presenting with New York Heart Association Class IV symptoms and having deranged coagulation profile. Here, we thrombolyzed one such patient with tissue plasminogen activator (alteplase) using very slow infusion (25 mg over 24 h) which resulted in rapid improvement in symptoms and subsequent resolution of pulmonary edema with simultaneous improvement of echocardiographic gradient and fluoroscopic movement of leaflets.

Keywords: Deranged coagulation parameters, prosthetic heart valve thrombosis, thrombolysis


How to cite this article:
Parashar NK, Sinha M, Krishnan S, Seth S. Prosthetic valve thrombosis management in a patient with deranged coagulation parameters. J Pract Cardiovasc Sci 2018;4:244-6

How to cite this URL:
Parashar NK, Sinha M, Krishnan S, Seth S. Prosthetic valve thrombosis management in a patient with deranged coagulation parameters. J Pract Cardiovasc Sci [serial online] 2018 [cited 2019 Aug 23];4:244-6. Available from: http://www.j-pcs.org/text.asp?2018/4/3/244/249931


  Introduction Top


Prosthetic heart valve thrombosis (PHVT) is a frequent complication of mechanical prosthetic heart valves. It is managed with either replacement of prosthetic valve or with intravenous thrombolysis.[1] However, these patients are on anticoagulation for prevention of thrombosis of prosthetic valves. At presentation, some of these patients have high value of prothrombin time (PT) and international normalized ratio (INR). This deranged coagulation profile poses a specific challenge in the management of these patients. Elevated INR is a relative contraindication to thrombolysis, and there is high risk of bleeding during major surgery also. Here, we report one such case with high-INR value who presented to us in THE New York Heart Association (NYHA) Class IV dyspnea.


  Case Report Top


A known case of rheumatic heart disease, 18-year-old female, who underwent mitral valve replacement with subtotal chordal preservation in December 2017, presented early after surgery in March 2018 with rapidly worsening shortness of breath for 5 days associated with mild chest discomfort. Initially, she was in NYHA Class III which worsened to NYHA Class IV for the last 1 day. She also gave a history of loss of previously audible prosthetic valve click. On examination, she had bilateral crepitations in chest suggestive of pulmonary edema. Electrocardiogram showed sinus tachycardia, and chest X-ray was suggestive of pulmonary venous hypertension. Urgent cinefluoroscopy was done which revealed that one of the prosthetic valve leaflet was completely stuck in closed position and other leaflet also showed moderate restriction of movement. Bedside echocardiography revealed turbulence and increased flow gradient across mitral valve (mean diastolic gradient [MDG]-26 mmHg). Her total leukocyte count, and renal function tests were normal. However, she had deranged coagulogram (PT-39 sec, INR-4.1, activated partial thromboplastin time-32). She was started on injection furosemide; and noninvasive ventilatory support was also initiated. We took surgical consultation, and as a heart team approach, she was considered having very high risk for open heart surgery due to poor general condition and deranged coagulation profile. Hence, we planned for intravenous thrombolysis. Injection alteplase with regimen of 25 mg over 24 h was started after taking consent from the caregivers. She began to show symptomatic improvement within 3 h of starting alteplase and after 6 h her noninvasive ventilation support was removed. There was fall in MDG, and improvement was seen on fluoroscopy also [Table 1]. After that, she was given another dose of tissue plasminogen activator (TPA) (25 mg over 48 h). We chose very prolonged infusion of TPA because her INR had further worsened (INR-5.9). Exact cause of deranged coagulation parameters could not be ascertained but was partially contributed by oral anticoagulation therapy (warfarin) which she was taking before presentation. She received a total of 50 mg TPA and her MDG decreased to 4 mmHg. Repeat fluoroscopy at the end of infusion showed normal movement of both the leaflets of mitral valve [Table 1].
Table 1: Echocardiography, fluoroscopy result, and improvement in symptoms at various time frames after starting thrombolysis

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  Discussion Top


Thrombolysis is a well-established therapy for prosthetic heart valve thrombosis. In resource-constrained developing countries, it is more frequently used than surgery as surgery is not immediately available.[2] For the patients with deranged coagulation profile, direct guidelines are not available; however, the usual policy is to correct the coagulation profile by giving prothrombin complex concentrate (PCC) followed by surgery. However, because of difficulty in obtaining PCC in time, fresh-frozen plasma can be used; however, it is required in large quantities and may cause volume overload in class IV patients. Thrombolysis becomes a relative contraindication in case of deranged coagulation profile. Acute PHVT in NYHA class IV respiratory distress with elevated PT and INR is a difficult situation to manage.

Different regimens have been in used in various trials. thrombolytic regimens for prosthetic valve thrombosis trial showed that low-dose slow infusion of TPA (25 mg over 6 h without bolus dose) had better outcomes than other regimens and thrombolytic agents.[3] The ultra-slow prosthetic mechanical valve thrombosis and the predictors of outcome trial showed that ultraslow, low-dose regimen of TPA (25 mg over 25 h without bolus dose) had least complications regarding major bleed, embolism, and deaths.[4] Hence, we decided to initially use slow infusion of TPA (25 mg of TPA over 24 h regimen) to start with. The patient started showing improvement in her symptoms within 3 h of initiation of infusion. Then, she received another 25 mg of TPA over 48 h. Fluoroscopy and echocardiography were done after 50 mg of TPA showed normal movement of both leaflets of mitral valve with normalization of MDG across mitral valve. The success of thrombolysis in our case is also related to recent surgery (less chances of pannus formation) and short duration of symptoms (less chances of organization of thrombus).

Overall, risk of major bleeding complications during thrombolysis in PHVT patients has been estimated up to 7%,[5],[6] which would be even higher in presence of other risk factors. Deranged coagulation profile at the time of thrombolysis is a definite risk factor for bleeding in patients undergoing thrombolysis. Other factors which increase the risk of bleeding in these patients include low body weight, older age group, previous history of stroke or bleeding, receiving concomitant antiplatelets and anticoagulants, uncontrolled hypertension, deranged renal and liver functions. Here, our patient had none of these risk factors (other than deranged coagulation parameters), and hence, it could be one of the reasons that she did not develop any bleeding complications with TPA. Various risk scores, such as hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol, outcomes registry for better informed treatment, anticoagulation and risk factors in atrial fibrillation and hepatic or renal disease, ethanol abuse, malignancy, older (age >75 years), reduced platelet count or function, hypertension (uncontrolled), anemia, genetic factors, excessive fall risk, and stroke predict bleeding risk in patients with atrial fibrillation on long-term anticoagulation.[7],[8],[9],[10] These risk scores have not been validated in patients undergoing thrombolysis, hence they cannot be applied for the same until further studies are performed. The data on number of PHVT patients presenting with deranged coagulation profile are not available. However, if the patient is not in NYHA Class IV and are not deteriorating rapidly, we usually wait until INR becomes <1.7 before thrombolysis. In present case, we could not wait for normalization of INR as she was having NYHA class IV symptoms and was in pulmonary edema.

Computed tomography of the head should be performed before thrombolysis to rule out intracranial lesion or previous stroke in high-risk but hemodynamically stable patients. Slow infusion regimen of thrombolytic agents has been suggested in high-risk PHVT patients to decrease the complications.[3],[4] During thrombolysis, continuous monitoring of the patient for systemic symptoms suggestive of bleeding or embolism is of paramount importance for early detection of complications. Onset of any new symptom should be considered as potential complication of thrombolysis and should be immediately and thoroughly evaluated. Frequent evaluation with two-dimensional echocardiography and cinefluoroscopy is indicated during thrombolysis as per the institution's feasibility for termination of thrombolysis in case of successful opening of thrombosed prosthetic valves. Unnecessary continuation of thrombolysis will increase bleeding risk. Every institution should form its own protocol for PHVT patients undergoing thrombolysis to minimize complications.


  Conclusion Top


Low-dose very slow infusion of TPA is a therapeutically effective method for the management of patients of PHVT in NYHA Class IV symptoms and with deranged coagulation parameter. In these types of patients, both open heart surgery for redo valve replacement and high-dose rapid infusion of TPA pose very high risk for bleeding complications. This therapy decreased the symptoms rapidly in our case. However, further large randomized controlled trials of this regimen will be required to assess the outcomes in these patients regarding success rates and complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Huang G, Schaff HV, Sundt TM, Rahimtoola SH. Treatment of obstructive thrombosed prosthetic heart valve. J Am Coll Cardiol 2013;62:1731-6.  Back to cited text no. 1
    
2.
Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, Alfieri O, Andreotti F, Antunes MJ, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-96.  Back to cited text no. 2
    
3.
Özkan M, Gündüz S, Biteker M, Astarcioglu MA, Çevik C, Kaynak E, et al. Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: The TROIA trial. JACC Cardiovasc Imaging 2013;6:206-16.  Back to cited text no. 3
    
4.
Özkan M, Gündüz S, Gürsoy OM, Karakoyun S, Astarcıoğlu MA, Kalçık M, et al. Ultraslow thrombolytic therapy: A novel strategy in the management of PROsthetic MEchanical valve thrombosis and the prEdictors of outcomE: The ultra-slow PROMETEE trial. Am Heart J 2015;170:409-18.  Back to cited text no. 4
    
5.
Karthikeyan G, Senguttuvan NB, Joseph J, Devasenapathy N, Bahl VK, Airan B, et al. Urgent surgery compared with fibrinolytic therapy for the treatment of left-sided prosthetic heart valve thrombosis: A systematic review and meta-analysis of observational studies. Eur Heart J 2013;34:1557-66.  Back to cited text no. 5
    
6.
Castilho FM, De Sousa MR, Mendonça AL, Ribeiro AL, Cáceres-Lóriga FM. Thrombolytic therapy or surgery for valve prosthesis thrombosis: Systematic review and meta-analysis. J Thromb Haemost 2014;12:1218-28.  Back to cited text no. 6
    
7.
Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY, et al. Anovel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: The euro heart survey. Chest 2010;138:1093-100.  Back to cited text no. 7
    
8.
O'Brien EC, Simon DN, Thomas LE, Hylek EM, Gersh BJ, Ansell JE, et al. The ORBIT bleeding score: A simple bedside score to assess bleeding risk in atrial fibrillation. Eur Heart J 2015;36:3258-64.  Back to cited text no. 8
    
9.
Fang MC, Go AS, Chang Y, Borowsky LH, Pomernacki NK, Udaltsova N, et al. Anew risk scheme to predict warfarin-associated hemorrhage: The ATRIA (Anticoagulation and risk factors in atrial fibrillation) study. J Am Coll Cardiol 2011;58:395-401.  Back to cited text no. 9
    
10.
Gage BF, Yan Y, Milligan PE, Waterman AD, Culverhouse R, Rich MW, et al. Clinical classification schemes for predicting hemorrhage: Results from the national registry of atrial fibrillation (NRAF). Am Heart J 2006;151:713-9.  Back to cited text no. 10
    



 
 
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