Ultraslow Thrombolysis of Mechanical Tricuspid Prosthetic Thrombosis

BACKGROUND: Prosthetic heart valve implantation over the past 7 decades has revolutionized treatment of valvular heart disease. Mechanical heart valves, although more durable than a bioprosthesis, require lifelong anticoagulation, with risk of valve thrombosis-a serious, life-threatening complication with high morbidity and mortality. CASE SUMMARY: We present a case of prosthetic mechanical tricuspid valve thrombosis that was successfully treated with thrombolysis using tissue plasminogen activator. DISCUSSION: The incidence of prosthetic mechanical valve thrombosis ranges from 0.1% to 5.7% per year, with higher rates observed in the post-surgical period and for prosthetic tricuspid valves (20%) compared with aortic or mitral valves (0.5%-0.8%). American College of Cardiology /American Heart Association (AHA) 2020 guidelines recommend higher international normalized ratio (INR) for prosthetic tricuspid valve replacement (TVR) and mitral valve replacement 3.0 (INR: 2.5-3.5), as opposed to prosthetic aortic valve replacement 2.5 (INR: 2-3). Current guidelines recommend parenteral anticoagulation, thrombolysis, and redo valve replacement as treatment options for mechanical heart valve thrombosis. Thrombolytic treatment provides a suitable and effective alternative to surgery, with challenges in effective dose administration for right-sided prosthetic valves. TAKE-HOME MESSAGE: An ultraslow thrombolysis regimen can provide a suitable and effective alternative to surgery in treatment of right-sided mechanical valve thrombosis.