Thrombolysis in Prosthetic Valve Thrombosis: A Safe and Effective Alternative?

Prosthetic valve thrombosis (PVT) is a rare but life-threatening complication of mechanical heart valves. Surgery remains the standard of care, but thrombolysis has emerged as a valuable alternative in patients with high surgical risk or refusal. We describe a 38-year-old woman, five years after double mitral-aortic mechanical valve replacement, who had discontinued anticoagulation one month prior to admission. She presented with acute angina-like chest pain and severe dyspnea (New York Heart Association (NYHA) class IV). Clinical examination revealed diminished prosthetic clicks and pulmonary rales, while echocardiography and fluoroscopy confirmed obstruction of one aortic prosthetic leaflet with high transvalvular gradients. Coronary angiography showed a distal left anterior descending (LAD) artery occlusion, most likely embolic, with otherwise normal vessels. The diagnosis of obstructive aortic prosthetic thrombosis complicated by pulmonary edema and embolic ST-segment elevation myocardial infarction (STEMI) was made. As the patient declined surgical intervention, intravenous thrombolysis with tenecteplase (100 mg protocol plus unfractionated heparin) was initiated, along with diuretics. Within one hour, prosthetic sounds normalized, and echocardiography showed marked gradient reduction, with no complications. At the three-month follow-up, echocardiography remained satisfactory. This case highlights thrombolysis as a safe and effective therapeutic option in selected patients with obstructive PVT, particularly those unsuitable for or refusing surgery, provided that diagnosis is imaging-based and management involves close monitoring and multidisciplinary decision-making.