Case presentation:
A 45-year-old woman presented to our clinic with Severe TR and degenerative Bioprosthetic TV leaflets following surgical VSD closure and Mechanical TVR 22 years before, Redo TVR with mechanical valve 17 years later, and 3do Bioprosthetic TVR after ten months due to TV malfunction. The patient underwent successful TV valve in valve implantation (Edward Sapien 3, size 29, MG: 3 mmHg) under TEE guidance with optimal results (Mg: 2mmHg, PHT:125 msec) and no complications. She was discharged on a dual antiplatelet regimen consisting of ASA and clopidogrel. She presented to the emergency department three weeks following the procedure with new onset of dyspnea and palpitation. TTE and TEE were performed and revealed: Normal LV size with mild systolic dysfunction, EF:45%, Moderate RV enlargement with severe systolic dysfunction, diffuse thickening of all three leaflets (thickness=7 mm) with reduced motion, significantly increased transvalvular gradients and PHT (MG: 13 mmHg, PHT:300 msec) with no transvalvular or paravalvular leakage (Figure 1).
Intensive anticoagulation with unfractionated heparin was initiated, and the Mean gradient dropped to 8 mmHg after two days of achieving therapeutic PTT. Nonetheless, the patient remained symptomatic, and no further improvements were made in the following days. After consultation with the heart team (Cardiac surgeon, peripheral interventionist, and echocardiologist), the decision to administer fibrinolysis was taken. 25 mg alteplase mg was infused over 25 hours using the ultra-slow regimen. Following that, unfractionated heparin was administered with the bolus of 70 units/kg and 16 units/kg/hr for 6 hours. The next day, TTE and TEE revealed a considerable decrease in transvalvular gradient and PHT (MG: 4 mmHg, PHT:200 msec), as well as relief of leaflet thickening and improved mobility (Figure 2 and 3). No complications occurred, and the patient was discharged on warfarin.