Successful Management of Ischaemic Large Vessel Occlusion and ‘Double’ Prosthetic Valve Thrombosis: Short Report with Systematic Review of Literature

Background Treatment of embolic events, especially ischaemic stroke with large vessel occlusions (LVOs) in the context of prosthetic valve dysfunction, is a management challenge. Stroke might be the harbinger of prosthetic valve thrombosis. Timely management of ischaemic stroke and prosthetic valve thrombosis is essential to offer optimal outcomes. Methods We report our experience in the management of a young woman, a known patient with rheumatic heart disease, status post double valve replacement (St Jude mechanical valves) on anticoagulation, who presented with acute right middle cerebral artery occlusion and ‘double prosthetic valve’ thrombosis. We present a systematic review of the utility of thrombolysis in the management of prosthetic valve thrombosis. Results The patient presented within the ‘window period’ with left hemiparesis and hemineglect. Imaging revealed a right striatocapsular infarct with occlusion of the right middle cerebral artery stem. She underwent mechanical thrombectomy, which resulted in successful reperfusion. Post-procedure, she developed acute pulmonary oedema, and echocardiography (ECHO) revealed severe biventricular dysfunction with mitral and aortic valve thrombosis. As she was critically ill, she was immediately thrombolysed with two doses of reteplase. Her pulmonary oedema subsequently improved, with repeat ECHO showing normal prosthetic valve function. She was discharged on day 3 with no neurological deficits. Conclusions Coordinated input from a multidisciplinary team guided the choice of treatment strategy and was central to the favourable outcome achieved. Our findings support thrombolysis as a reasonably safe therapeutic choice for critically ill patients with prosthetic valve dysfunction.