Ultrasound-Facilitated, Catheter-Directed Thrombolysis to Treat Transcatheter Pulmonary Valve Frame Thrombosis

Objective

We present a patient with tetralogy of Fallot who underwent transcatheter pulmonary valve replacement complicated by elevated pulmonary valve gradients and subvalvular mural thrombus, and was treated using ultrasound-facilitated, catheter-directed thrombolysis.

Key Steps

Right internal jugular access was obtained, and the EKOS endovascular system was advanced across the pulmonary valve and used to deliver slow infusions of alteplase. We then performed balloon valvuloplasty of the transcatheter pulmonary valve after 48 hours of lysis.

Potential Pitfalls

There is risk for intracranial hemorrhage while receiving prolonged infusions of intravascular lytic therapy; the patient was monitored in the intensive care unit with frequent neurologic examinations and serum coagulation tests.

Take-Home Messages

Valve thrombosis is a known complication of transcatheter pulmonary valve replacement, the management of which typically involves either percutaneous valve-in-valve implantation or surgical valve replacement. The novel approach detailed in this report presents an alternative that avoids sternotomy or implanting a second transcatheter valve.