Successful Use of Catheter-Directed Low Dose Alteplase Infusion for Mitral Valve Thrombus: A Case Report
by Austin M. Padilla, PharmD, Jared M. Frost, PharmD, BCCP, James S. Mathia, PharmD, BCPS, Ryan M. Servais, PharmD, BCPS, BCCCP, BCCP
"We describe a patient case of the successful use of catheter-directed alteplase 25 mg IV administered over 25 hours to treat a thrombosis in a mechanical mitral valve. Mechanical prosthetic valve thrombosis (PVT) is a rare but serious complication of valve replacement. Optimal treatment is controversial and depends on the cause of the obstruction and the hemodynamic status of the patient. The therapeutic treatment options include systemic anticoagulation, thrombolysis, surgery, or optimization of current anticoagulation strategy. In this case, the patient presented with a nonobstructive mitral valve thrombus and was initiated on catheter-directed low dose alteplase infusion, 25 mg IV over 25 hours, and subsequent bridging with IV heparin infusion to warfarin longterm therapy. Systemic heparin was monitored by activated partial thromboplastin time (aPTT) with a goal range of 45–70 seconds for a total duration of 5 days. Repeat echocardiographic imaging was done and showed complete resolution of the clot. There were no bleeding complications from anticoagulation. On discharge, the patient’s international normalized ratio (INR) goal was 2.5-3.5 and the patient continues to be followed at our institutional anticoagulation clinics."
Keywords: Tissue Plasminogen Activator, Fibrinolytic Agents, Fibrinolysin, Heparin, Fibrinolysis, Plasminogen, Fibrin, Incidence, Brain Ischemia, Stroke, Thrombosis, Heart Valve Diseases, Fibrin Clot Lysis Time, Myocardial Infarction, Thrombolytic Therapy, Pulmonary Embolism, Catheters, Anticoagulants, Arterial Occlusive Diseases, Ischemic Stroke, Venous Thrombosis
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2021 November/December Table of Contents
"We describe a patient case of the successful use of catheter-directed alteplase 25 mg IV administered over 25 hours to treat a thrombosis in a mechanical mitral valve. Mechanical prosthetic valve thrombosis (PVT) is a rare but serious complication of valve replacement. Optimal treatment is controversial and depends on the cause of the obstruction and the hemodynamic status of the patient. The therapeutic treatment options include systemic anticoagulation, thrombolysis, surgery, or optimization of current anticoagulation strategy. In this case, the patient presented with a nonobstructive mitral valve thrombus and was initiated on catheter-directed low dose alteplase infusion, 25 mg IV over 25 hours, and subsequent bridging with IV heparin infusion to warfarin longterm therapy. Systemic heparin was monitored by activated partial thromboplastin time (aPTT) with a goal range of 45–70 seconds for a total duration of 5 days. Repeat echocardiographic imaging was done and showed complete resolution of the clot. There were no bleeding complications from anticoagulation. On discharge, the patient’s international normalized ratio (INR) goal was 2.5-3.5 and the patient continues to be followed at our institutional anticoagulation clinics."
Keywords: Tissue Plasminogen Activator, Fibrinolytic Agents, Fibrinolysin, Heparin, Fibrinolysis, Plasminogen, Fibrin, Incidence, Brain Ischemia, Stroke, Thrombosis, Heart Valve Diseases, Fibrin Clot Lysis Time, Myocardial Infarction, Thrombolytic Therapy, Pulmonary Embolism, Catheters, Anticoagulants, Arterial Occlusive Diseases, Ischemic Stroke, Venous Thrombosis
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2021 November/December Table of Contents