International Journal of Cardiology and Cardiovascular Research

IJCCR
Vol. 4(2), pp. 085-088, December, 2018. © www.premierpublishers.org, ISSN: 3102-9869

Case Report

An Interesting Case of Stuck Mitral Valve by Clot, Post

Thrombolysis Developed Acute Right Limb Ischemia Treated
with Local Catheter Directed Re-Thrombolysis Successfully
*Rajeev Srivastava1, Hakim Irfan Showkat2, Vinod Kumar3, Gupta LC4, Saurabh Bharadwaj Sr.5,
Avneesh Prasad Sr.6, Uday Yadava Sr7
1,2,3,4,5,6,7National Heart Institute 49-50 Community Center, East of Kailash New Delhi 110065, India

Prosthetic mechanical valve thrombosis is seen in patients with inadequate anticoagulation,

irregular medications, and lack of proper follow up. Thrombolysis is a good alternative to surgery
in selected cases. Acute limb ischemia may one of the embolic complications that may occur post
thrombolysis. Early PAG and catheter directed re- thrombolysis despite having high risk can
further save patients from such serious complications and its sequalae.

Keywords: MVR (mitral valve replacement), PVT (prosthetic valve thrombosis), CDT catheter directed Thrombolysis.
MS [mitral stenosis], PAG (peripheral angiography)

INTRODUCTION
Prosthetic valve thrombosis is a serious complication post
valve replacement, mostly with mechanical valves.
Mortality and morbidity associated with valve thrombosis
need early evaluation and management. ECHO and
cinefluoroscopic are mainstay of diagnosis of PVT.
Thrombolysis has been introduced as an alternative to
surgery. Major complications of fibrinolytic therapy are
systemic embolization leading to acute brain infarct, limb
ischemia, major gastrointestinal bleed and intracranial
hemorrhage. Cautious approach to such complications
can help patient to come out of these unwanted sequalae.
CASE REPORT
A Twenty-five-year-old lady underwent MVR and tricuspid
repair for RHD, severe MS severe TR, four months back
presented in emergency with acute severe
breathlessness. She was in atrial fibrillation with fast
ventricular rate and blood pressure recorded was
100/70mmhg. Echocardiography done revealed
obstructed mitral valve by clot with mean gradient of
30.9mmHg [figure 1]. INR recorded was 2.14. Her blood
group was B negative not available in our hospital, so
surgeons advised to give thrombolytic therapy first to
relieve her symptoms. Injection streptokinase 2.5 lakh
unit’s bolus followed by infusion 1lakh U/hr. for 24hrs was
given. Mean valve gradient reduced to 6mmhg with well
opening and closing prosthetic mitral valve [figure 2/3].
Subsequently after couple of hours she started
complaining of right leg Pain. On examination RT sided
pulse were absent below femoral. We have done doppler
which revealed clot in superficial femoral and profunda
femoris due to systemic embolization post thrombolysis.
We have taken her to Cath lab were PAG was done which
revealed totally blocked superficial femoral and profunda
femoris with some collateralized flow seen below [figure
4]. She was given local thrombolysis with STK 1lakh
international units which was repeated again after five
minutes. Injection Streptokinase infusion was given for
further 18hrs locally. Before catheter removal repeat PAG
done revealed flows in distal superficial, Popliteal, Anterior
Tibial, Posterior Tibial artery [figure 5]. Injection heparin
infusion was followed for another 24 hrs. Later Doppler
study done also revealed good flow in right lower limb
arteries. She was further mobilized and was discharged on
aspirin and acitrom with advice to regular follow up.
*Corresponding Author: Rajeev Srivastava, National
Heart Institute 49-50 Community Center, East of Kailash
New Delhi 110065, India.
E-mail: rajeev.srivastava40@yahoo.com

An Interesting Case of Stuck Mitral Valve by Clot, Post Thrombolysis Developed Acute Right Limb Ischemia Treated with Local Catheter Directed Re-
Thrombolysis Successfully
Srivastava et al. 086

DISCCUSION of symptoms advise to go for thrombolysis. To open stuck

Prosthetic valve thrombosis is one of the serious
complication post MVR. Patients having Atrial fibrillation,
pregnancy, inadequate anticoagulation valve thrombosis
are precursor for acute valve thrombosis [Cevik C et al
2010] . Obstructive left sided PVT is considered an
indication of surgery with thrombolysis reserved for
particular situations. According to AHA guidelines
fibrinolysis to reserve for NYHA 3-4, with high surgical risk
or contraindication to surgery. Lengyl M et al [2001]
showed thrombolysis to be superior to surgery in NYHA 4
with obstructed valve. Also, it can be given to NYHA1/2
and small thrombus after failure of heparin infusion [Bonow
R O et al 1998]. The reasoning against thrombolysis in
patient NYHA class 1/2 is based on the relatively low
surgical mortality in this group as opposed to embolic risks
of 12-17% caused by thrombolysis [Roudaut R et al 1992:
S witchit et al 1980:M Rusznak et al 1983]. Our patient’s
blood group was rare B Negative so surgeons in the view
valve we gave streptokinase infusion for 24 hrs. and
revealed good results[figure 2/3] .Further acute limb
ischemia is the vascular emergency and limb viability
carries high risk of mortality and amputation[Kasirrjan K et
al 2000] .The Rochester study [Ouriel K et al 1994],the
surgery verses thrombolysis for ischemic lower extremity
trial[the STILE trial 1994] ,and thrombolysis or peripheral
arterial surgery trial [topas][Ouriel K ,Veith F et al 1996]
and others were showing that CDT should be first line
treatment for acute limb ischemia and can be done under
following conditions: [a] Symptoms of ischemia less than
14days, [b] no absolute contraindications to thrombolysis
[c] the predicted time to reestablish flow is short enough
to preserve limb viability . Referring these criteria, we have
done PAG followed by CDT. Streptokinase was given
again for 24hrs followed by heparin infusion. Repeat
doppler study was done revealed recanalized vessels.
Patient was discharged on tab Acitrom, Aspirin and other
supportive drugs with advice for regular follow up.

.
Figure 1: 2 D-ECHO showing Obstructed prosthetic mitral valve by clot with mean gradient of 30.9mmhg

An Interesting Case of Stuck Mitral Valve by Clot, Post Thrombolysis Developed Acute Right Limb Ischemia Treated with Local Catheter Directed Re-
Thrombolysis Successfully
 Int. J. Cardiol. Cardiovasc. Res. 087

Figure 2 Figure 3
[Figure 2/Figure 3]: 3 D- ECHO Post thrombolysis showing well opening and closing prosthetic mitral valve

Figure 4: PAG picture showing Obstructed Figure 5: Repeat PAG - Post local thrombolysis
superficial femoris and profunda femoris artery showing distal flows seen in Popliteal and Anterior
tibial/Posterior tibial arteries
An Interesting Case of Stuck Mitral Valve by Clot, Post Thrombolysis Developed Acute Right Limb Ischemia Treated with Local Catheter Directed Re-
Thrombolysis Successfully
Srivastava et al. 088
CONCLUSION
Thrombolysis for valve thrombosis may be a good
alternative to surgery in selected case at tertiary care
equipped with surgical and Cath lab and Neuro care facility
so that complications can be managed successfully to
achieve good results. All embolic and bleeding
complications should keep in mind.
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An Interesting Case of Stuck Mitral Valve by Clot, Post Thrombolysis Developed Acute Right Limb Ischemia Treated with Local Catheter Directed Re-
Thrombolysis Successfully
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Accepted 14 October 2018
Citation: Srivastava R, Showkat HI, Kumar V, Gupta LC,
Bharadwaj S, Prasad A, Yadava U (2018). An Interesting
Case of Stuck Mitral Valve by Clot, Post Thrombolysis
Developed Acute Right Limb Ischemia Treated with Local
Catheter Directed Re-Thrombolysis Successfully.
International Journal of Cardiology and Cardiovascular
Research, 4(2): 085-088.
Copyright: © 2018 Srivastava et al. This is an open-
access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted
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provided the original author and source are cited.