Balloon inflation for a mechanical tricuspid valve thrombosis: case report.

Abstract

Background: Mechanical valve thrombosis (MVT) is rare but life-threatening complication. While the clinical guideline suggests that thrombolysis for high-risk surgical candidates should be considered, the European guideline does not differentiate between left- and right-sided MVTs while the American guideline only made specific recommendations for left-sided MVT. Furthermore, the American guideline suggests that percutaneous intervention for left-sided MVT may be considered. Both clinical guidelines did not refer to percutaneous intervention for right-sided MVT.

Case summary: A 52-year-old woman with three mechanical valve replacements for rheumatic heart disease presented with subacute onset of symptoms of right-sided heart failure. Transthoracic echocardiogram (TTE) demonstrated a high transvalvular gradient across the tricuspid mechanical valve which is new from TTE 3 years prior. Further imaging confirmed thrombosis of the anterior leaflet of the tricuspid mechanical valve. Four cycles of ultra-low-dose thrombolysis and one standard-dose thrombolysis failed to restore normal valve function. Surgery was considered prohibitively high-risk, and the patient was left with either palliation or percutaneous intervention. Percutaneous mechanical valve balloon inflation was undertaken with subsequent improvement in transvalvular gradient and leaflet motion.

Discussion: There is limited data on percutaneous intervention for right-sided MVT with only one other case reported to date. In patients with prohibitively high surgical risk, thrombolysis should be considered as per the clinical guidelines. However, in ∼1 in 10 patients, thrombolysis fails to restore normal valve function. Percutaneous intervention may be an alternative option.