Journal of Medicine and Medical Sciences Vol. 3(4) pp. 200-204, April 2012
Available online@ http://www.interesjournals.org/JMMS
Copyright © 2012 International Research Journals
Case Report
Cardiorespiratory arrest due to mechanical mitral valve
thrombosis: recovery and successful late
thrombolysis in the Intensive Care Unit at the National
Teaching Hospital of Cotonou
Pierre-Claver Hounkpè1, Francis Moïse Dossou2, Moutawakilou Gomina Assoumanou3, Luc
Magloire Oké4, Dominique Atchadé1, Kémoko Osséni Bagnan2
1
Anesthesia and resuscitation service, Hubert K. MAGA National Teaching Hospital (CNHU-HKM) of Cotonou, Bénin
2
Visceral surgery service of Hubert K. MAGA National Teaching Hospital (CNHU-HKM) of Cotonou, Bénin
3
Molecular biology and Biochemistry, Faculty of Medicine, University of Parakou, Bénin
4
Department of Cardiology, Temple University Hospital, Philadelphia, Pennsylvania, USA
Abstract
In November 2011, a 59 year-old female was admitted in the Intensive Care Unit (ICU) of the National
University Teaching Hospital of Cotonou for acute respiratory distress. She is an obese female with a
history of hypertension, diabetes mellitus, and bearing mechanical prosthetic mitral valve since 2006
for rheumatic heart disease. A prosthetic valve thrombosis was suspected based on elevated D-Dimers
level, and was confirmed by a 2-D echocardiography and a CT angiography of the chest five days after
the onset of symptoms. The patient underwent a successful delayed thrombolysis with Tenecteplase
on day-6 after the onset of her symptoms due to limited available pharmacologic options and
equipment. Her clinical picture improved rapidly after thrombolysis as documented by her follow up
echocardiography and CT scan.
Keywords: Mechanical mitral valve thrombosis, tenecteplase, successful delayed thrombolysis.
INTRODUCTION
Valvular heart diseases are very common and severe
diseases. The most effective treatment is valve prosthesis. Under certain circumstances, the prosthetic
valve may thrombose, requiring urgent surgical replacement. The use of recombinant tissue-type
Plasminogen Activator (rt-PA) allows thrombolytic
therapy as long as it is given early. However, in this case
report, the authors describe a successful late thrombolysis (due to lack of availability of thrombolytic agent
and equipment) with Tenecteplase in post cardiopulmonary resuscitation.
*Corresponding Author E-mail: pierclav@yahoo.fr
CASE REPORT
A 59-year old female, 68 kg was admitted in November
2011 in the intensive care unit of the National Teaching
Hospital of Cotonou for acute respiratory distress. Three
days prior to admission, she complained of chest and
abdominal pain. Her pain was not initially well described,
however, converted into shortness of breath, which
worsened over time, and she presented to a private
clinic. She was subsequently transferred to the national
hospital for a suspicion of pulmonary embolism after a
blood work showed elevated D-Dimers at 843.97 µg/l.
The Prothrombin time was 48% and the INR 1.8. Her
Koalin-ACT was 28 for a reference of 26 seconds. Past
Medical History is significant for hypertension and
diabetes mellitus type 2, and obesity. Past surgical
history showed Starr-Edwards mechanical prosthetic
mitral valve in 2006 on prophylactic oral anticoagulant.
Hounkpè et al. 201
Figure 1. Echocardiography prior to valve thrombolysis
Of note, she recently returned few days ago from a long
trip to Asia. On physical examination, she is a middle
age female appearing ill, oral mucosa is normal, she is
mildly overhydrated and is in respiratory distress with a
respiratory rate of 40/minute, blood pressure of 180/110
mmHg and pulse of 110 bpm. Her oxygen saturation
was 40 % on room air. On lung auscultation, she had
decreased breath sounds and bilateral rales. On cardiac
auscultation, no prosthetic valve sound is noted, her
rhythm is irregular and rapid. During physical
examination, she developed a cardio-respiratory arrest,
which required resuscitation and mechanical ventilation.
Heparin infusion was rapidly started. Her hemoglobin
level was 12g/dl. Measurement of blood gas tensions
and pH was not available. ECG showed atrial fibrillation
with rapid ventricular response, there was a prominent S
in lead 1 and Q in lead 3. The 2-D echocardiography
and the CT angiography of the chest were not
immediately available.
She immediately regained
consciousness despite the persistence of respiratory
distress. Her oxygen saturation continued to worsen
and she failed weaning trial on several occasions. On
day -5, she was transported for an outpatient 2-D
echocardiography and CT angiography of the chest.
The echocardiography disclosed a mobile mass
attached to the mitral prosthetic valve. There was a
significant right-sided dilatation and a moderate
pulmonary hypertension with RV systolic pressure of
51.2 mmHg (Figure 1). The CT angiography of the chest
did not show major pulmonary embolism, however, it
disclosed alveolar infiltrates and bilateral pleural effusion
(see Figure 3). Fibrinolytic agents were not readily
available. On December 1rst, we were able to acquire
Tenecteplase (6 days after the onset of her symptoms).
She received the fibrinolytic agent according to her
weight, the recommended dosage of 40 mg. Heparin
was discontinued during fibrinolysis and resumed
afterwards.
No hemorrhage was noted; she was
successfully weaned off mechanical ventilation 12 hours
later and extubated on December 2nd 2011.
A follow up echocardiography (figure 2) and CT
angiography of the chest (figure 4) showed a mechanical
ball-in-cage prosthetic mitral valve with good mobility.
Significant reductions in size of the thrombus size as
well as decreased pulmonary pressures are noted. On
CT angiography of the chest, pleural effusions persisted,
however alveolar infiltrated were significantly reduced.
The patient was discharged from the hospital to home on
December 8th following a short physical therapy.
202 J. Med. Med. Sci.
Figure 2. Echocardiography after valve thrombolysis
Figure 3. Chest CT prior to valve thrombolysis
Hounkpè et al. 203
Figure 4. Chest CT after valve thrombolysis
DISCUSSION
One may wonder the pathophysiology of prosthetic valve
thrombosis in a patient on chronic anticoagulant
treatment with Acenocoumarol. One may surmise after
ruling out the role of sub therapeutic drug level, noncompliance, which may result in high risk of valve
thrombosis. The result of the coagulation panel appears
to support that hypothesis. The mildly elevated level of
the D-Dimers, considering the patient age suggests
increased thrombotic risk. According to Parent (2007),
obtaining D-Dimers level is integral part of the diagnostic
algorithm in thromboembolic diseases. Her previous
long flight could be considered as a risk factor for
thromboembolic events although there is no clear
association between long air flight and thromboembolic
disease (Sanchez and Meyer, 2007). The major delay in
the diagnosis is due to our limited equipment and means
resulting to a dysfunctioning health care system. These
limitations explain the inability to give priority to bedside
diagnostic tests such as echocardiography as suggested
by Meyer and Sanchez (2008). With respect to the
management of thromboembolic diseases, even though
the introduction of fibrinolytic agents was a turning point,
the use of new thrombolytic agents such as rtPA was a
major step forward. Slaoui et al. (2010) successfully
treated a 34-year-old pregnant female for a thrombosed
Starr-Edwards mechanical valve. Viedt et al (1999)
successfully treated a 48-year-old female who received
a mitral mechanical prosthetic valve 3 years earlier.
However, despite the progress noted, our limited means
and the delay in performing the non invasive imaging
studies such as echocardiography and CT angiography
of the chest plus an additional 24 hours delay before
thrombolytic treatment was administered, resulted in a
total of 6 –day delay from the onset of the symptoms.
In the absence of contraindication, thrombolysis was
the only treatment option available in our hospital where
surgical option is not an alternative. In retrospect, it was
in the best interest of this patient to avoid surgery.
According to Bastien et al (2009), advanced age results
in complicated and protracted postoperative period.
Nouette et al (2005) noted that there was no consensus
with respect to the use of anticoagulant in postoperative
management of prosthetic valve replacement. Knowing
the extent of short and long-term complications related
to Starr-Edwards prosthetic valves, such as
thromboembolic events, hemorrhages, and infections
204 J. Med. Med. Sci.
(Zouaoui et al., 2009), one should consider valve
replacement as long-term solution in our patient. Bastien
et al (2009) noted a high frequency of mechanical
prosthetic valves thrombosis compared to bioprosthetic
valves, especially those in mitral position. Nowadays,
the use of rt-PA is made easy by the simplicity of the
protocol, which consists of a single bolus injection, well
tolerated and with relative safety; especially
Tenecteplase, which was used in pregnancy (Boursier et
al., 2004; Slaoui et al., 2010). The successful outcome of
this case should result in increased availability of
thrombolytic agents in our hospital.
One should,
however realize that occasional incomplete thrombolysis
can occur, and surgical alternative should be available
(Fadel et al., 2008). The early use of unfractionated
heparin during the course of her treatment was
beneficial. While waiting for the thrombolytic agent, the
use of heparin infusion decreased the thrombus
formation (Gut-Gobert et al., 2008). The rapid clinical
improvement few hours after administration of the
Tenecteplase which allowed a quick weaning off
mechanical ventilator is in agreement with Meyer’s
observations (2007), who noted a 30 % decrease in
pulmonary artery obstruction two hours following
thrombolytic treatment in a case of pulmonary embolism.
CONCLUSION
Early use of rt-PA results in rapid thrombolysis.
However, in the absence of surgical alternative in our
setting, we successfully performed a delayed thrombolysis six days after the onset of symptoms in a patient
with thrombosed mechanical prosthetic mitral valve.
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