Düşük Doz Doku Plazminojen Aktivatörünün Yavaş İnfüzyonu ile

Düşük Doz Doku Plazminojen Aktivatörünün Yavaş İnfüzyonu ile Başarılı Şekilde Tedavi Edilen Dev Mitral Protez
Kapak Trombüsünün Gösterilmesi
Delineation Of A Giant Thrombus On A Prostethic Mitral Valve Which Was Succesfully Thrombolysed With Low Dose
Slow Infusion Of Tissue Plasminogen Activator
Asistant Mahmut Yesin İSTANBUL KARTAL KOŞUYOLU YÜKSEK İHTİSAS EĞİTİM VE ARAŞTIRMA HASTANESİ
TURKEY
Asistant Macit Kalçık İSTANBUL KARTAL KOŞUYOLU YÜKSEK İHTİSAS EĞİTİM VE ARAŞTIRMA HASTANESİ
TURKEY
MD Mustafa Ozan Gürsoy İSTANBUL KARTAL KOŞUYOLU YÜKSEK İHTİSAS EĞİTİM VE ARAŞTIRMA
HASTANESİ TURKEY
Prof Mustafa Yıldız İSTANBUL ÜNİ.KARDİYOLOJİ ENSTİTÜSÜ TURKEY
MD Mehmet Özkan İSTANBUL KARTAL KOŞUYOLU YÜKSEK İHTİSAS EĞİTİM VE ARAŞTIRMA HASTANESİ
TURKEY
Makale Özeti
Anahtar Kelimeler: Protez Kapak Trombozu;Trombolitik Tedavi;Transözafajeal Ekokardiyografi
Manuscript Abstract
Keywords: Prosthetic valve thrombosis;Thrombolytic therapy;Transesophageal echocardiography
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Case Presentation:
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A 46 year-old woman who had undergone mitral valve replacement (29 mm St. Jude Medical) 5
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years earlier was admitted to our institution with exertional dyspnea and palpitation. She had no
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other complaint and no history of previous stroke. International normalized ratio (INR) was
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subtherapeutic (1.2). Transthoracic echocardiography (TTE) revealed increased mitral transvalvular
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gradients of 24/12 mmHg with a decreased mitral valve area of 1.4 cm2 (Figure 1A). Two8
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dimensional (2D) transesophageal echocardiography (TEE) demonstrated a giant mobile thrombus
located on the prosthetic mitral valve, which was prolapsing into left atrial cavity during systole
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(Figure 2A) and obstructing the mitral inflow during diastole (Figure 2B). Subsequently, real-time
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three-dimensional (RT3D) TEE was performed and clearly demonstrated a huge thrombus which
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consisted of two mobile components, moving up and down during systole (Figure 2C) and diastole
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(Figure 2D). Thrombolytic therapy (TT) with a low-dose (25 mg), slow-infusion (6 hours) of tissue
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plasminogen activator (tPA) was administered according to our protochol reported before(1,2). TTE
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revealed decreased mitral transvalvular gradients of 14/6 mmHg with an increased mitral valve area
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of 2.5 cm2 (Figure 1B). Two-dimensional TEE after TT showed successful thrombolysis (Figure
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3A) and RT3D TEE revealed a residual annular thrombus which was published recently(2) (Figure
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3B). There was no evidence of embolic complications or bleeding. The patient was discharged
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under adequate anticoagulation. This case report highlights that TT with low dose (25mg) and slow
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infusion (6 hours) of tPA may be successfully performed in a relatively short time and with a very
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low dose as a first line therapy(1,2) . RT3D TEE has an incremental value in delineation of
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prosthetic heart valve thrombosis(3).
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Figure Legends:
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Figure 1 : Transthoracic echocardiography revealed increased mitral transvalvular gradients of
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24/12 mmHg with a decreased mitral valve area of 1.4 cm2 before thrombolytic therapy (TT) (A)
and showed decreased transvalvular gradients of 14/6 mmHg with an increased mitral valve area of
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2.5 cm2 after TT (B).
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Figure 2: Two-dimensional transesophageal echocardiography (TEE) demonstrated a giant mobile
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thrombus located on the prosthetic mitral valve, prolapsing into left atrial cavity during systole (A)
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and obstructing the mitral inflow during diastole (B). Real-time three-dimensional TEE clearly
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demonstrated a huge thrombus which consisted of two mobile components moving up and down
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during systole (C) and diastole(D) (LA: Left atrium, LV: Left ventricle, MV: Mitral valve, THR:
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Thrombus, Arrows show the thrombus)
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Figure 3: Two-dimensional transesophageal echocardiography (TEE) after thrombolytic therapy
showed successful thrombolysis (A) and real-time three-dimensional TEE revealed a remnant
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annular thrombus without any mobile components(B). (LA: Left atrium, LV: Left ventricle, MV:
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Mitral valve, Arrows show the annular thrombus)
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References:
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1.Ozkan M, Cakal B, Karakoyun S et al (2013) Thrombolytic therapy for the treatment of prosthetic
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heart valve thrombosis in pregnancy with low-dose, slow infusion of tissue-type plasminogen
activator. Circulation. 2013 Jul 30;128(5):532-40. doi: 10.1161/CIRCULATIONAHA.113.001145.
Epub 2013 Jun 28.
2. Ozkan M, Gündüz S, Biteker M et al (2013) Comparison of different TEE-guided thrombolytic
regimens for prosthetic valve thrombosis: the TROIA trial. JACC Cardiovasc Imaging. 2013
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Feb;6(2):206-16. doi: 10.1016/j.jcmg.2012.10.016.
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3. Ozkan M, Gürsoy OM, Astarcıoğlu MA et al. Real-time three-dimensional transesophageal
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echocardiography in the assessment of mechanical prosthetic mitral valve ring thrombosis. Am J
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Cardiol. 2013 Oct 1;112(7):977-83. doi: 10.1016/j.amjcard.2013.05.032.
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Figure 1
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