Management
The heart team evaluated and reviewed the images obtained via MDCT, objectively elected to pursue thrombolytic therapy, tissue plasminogen activator (tPA) infusion was started. The patient received 10 mg IV bolus followed by 90 mg over approximately 2 hours. A repeat aortic valve fluoroscopy demonstrated restricted valve motion [video 3]. A second round of tPA was administered at the same dosage. A limited echocardiogram showed improved gradient across the aortic valve with peak gradient of 16 mmHg and mean gradient of 10 mmHg and no regurgitation. The heart team decision was made to repeat tPA infusion at a lower dose. The patient received 1 mg/h of tissue plasminogen activator infusion for 25 hours. A repeat TTE revealed more improvement of transaortic velocity/gradient with peak gradient 15 mmHg and mean gradient of 8 mmHg but with a small thrombus still present. Patient symptoms had resolved. A valve fluoroscopy obtained a couple of days later still showed no significant movement of one of the mechanical aortic valve leaflets [Video 4]. The patient received a fourth dose of low dose tPA infusion as the previous described above. Follow up MDCT obtained three days after the fourth tPA infusion, revealed resolution of the thrombus with normal leaflets excursion [Video 5]. There were no hemorrhagic complications. IV heparin used between tPA treatment was resumed after the fourth dose as a bridge to warfarin until achievement of therapeutic INR.