4D TEE successfully identified a large mobile thrombus with coexisting pannus, guiding streptokinase thrombolysis that restored bileaflet mobility and reduced transprosthetic gradients.
Case Report (n=1)
Does 4D TEE-guided streptokinase thrombolysis improve bileaflet mobility and reduce transprosthetic gradients in a patient with mechanical mitral valve obstruction?
4D TEE can effectively differentiate thrombus from pannus in mechanical mitral valve obstruction, allowing for successful targeted thrombolytic therapy.
BACKGROUND: To describe, step by step, how 4-dimensional transesophageal echocardiography (4D TEE) can differentiate thrombus-predominant mechanical mitral valve obstruction from pannus and thereby guide urgent thrombolytic therapy. CASE SUMMARY: A 24-year-old man with a 25-mm mechanical mitral prosthesis presented with NYHA functional class III dyspnea, pulmonary congestion, and a subtherapeutic international normalized ratio of 1.2. Transthoracic echocardiography showed markedly elevated transmitral gradients, and cine-fluoroscopy demonstrated restricted single-leaflet motion. TEE confirmed prosthetic obstruction, whereas 4D TEE provided the decisive mechanistic information by showing a large mobile thrombus with coexisting left ventricular-side pannus, indicating thrombus-predominant obstruction. Streptokinase thrombolysis restored bileaflet mobility and reduced transprosthetic gradients markedly. DISCUSSION: Elevated prosthetic gradients and restricted leaflet motion confirm obstruction but do not reliably distinguish thrombus from pannus. Mixed pathology may be missed if multimodality imaging is not performed. TAKE-HOME MESSAGE: In mechanical mitral valve obstruction, 4D TEE can define the dominant mechanism of obstruction, guide selection of thrombolysis vs surgery, and document treatment success.
Gitte et al. (Mon,) conducted a case report in Mechanical mitral valve obstruction (n=1). 4D TEE-guided thrombolysis was evaluated on Bileaflet mobility and transprosthetic gradients. 4D TEE successfully identified a large mobile thrombus with coexisting pannus, guiding streptokinase thrombolysis that restored bileaflet mobility and reduced transprosthetic gradients.