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\begin{document}

\title{The Role of multidetector CT scan in the Management of Prosthetic Aortic
Valve thrombosis: A Case Report}



\author[1]{Sheriff Dodoo}%
\author[2]{Christelle Moyine}%
\author[3]{Alicia  Agyemang-Sarpong}%
\author[2]{Abdullah Ismail}%
\author[2]{Nina Le}%
\author[1]{Falgun Patel}%
\author[1]{Nima Ghasemzadeh}%
\author[1]{Ronnie Ramadan}%
\author[1]{Khaja Mohammed}%
\author[1]{Glen Henry}%
\author[1]{Ioannis Parastatidis}%
\affil[1]{Georgia Heart Institute}%
\affil[2]{Northeast Georgia Medical Center Gainesville}%
\affil[3]{Harvard Medical School}%


\vspace{-1em}



  
  \date{May 19, 2024}


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\textbf{The Role of multidetector CT scan in the Management of
Prosthetic Aortic Valve thrombosis: A Case Report.}

Sheriff N Dodoo, MD\textsuperscript{1}; Christelle Yakana Moyine,
MD\textsuperscript{2}; Alicia Agyemang-Sarpong\textsuperscript{3};
Abdullah Ismail, MD\textsuperscript{2}; Nina Le, DO\textsuperscript{2};
Falgun Patel, MD\textsuperscript{4}; Nima Ghasemzadeh,
MD\textsuperscript{4}; Ronnie Ramadan, MD\textsuperscript{4}; Khaja
Salahuddin Mohammed, MD\textsuperscript{4}; Glen Henry,
MD\textsuperscript{4}; Ioannis Parastatidis, MD PHD\textsuperscript{5}

\begin{enumerate}
\tightlist
\item
  Georgia Heart Institute, Northeast Georgia Medical Center, 743 Spring
  Street NE, Gainesville, GA 30501, U.S.A. Email:
  sheriff.dodoo@gmail.com
\item
  Department of Internal Medicine, Northeast Georgia Medical Center, 743
  Spring Street NE, Gainesville, GA 30501, U.S.A.
\item
  Postgraduate Medical Education, Harvard Medical School, Boston
  Massachusetts, USA
\item
  Georgia Heart Institute, Interventional Cardiology, Northeast Georgia
  Medical Center 200 S Enota Dr NE, Gainesville, GA 30501,
  U.S.A\textbf{.}
\item
  Georgia Heart Institute, Northeast Georgia Medical Center 100 S Enota
  Dr NE, Gainesville, GA 30501, U.S.A\textbf{.}
\end{enumerate}

\textbf{Address for Correspondence:}

Sheriff N Dodoo, MD

Georgia Heart Institute

Northeast Georgia Medical Center

743 Spring Street NE

Gainesville, GA 30501

United States of America

Phone Number: 408-391-2050

Email: sheriff.dodoo@gmail.com

\textbf{Disclosures:} None of the Authors have conflicts of interest or
financial disclosure to disclose.

\textbf{Keywords:} Aortic Valve, Prosthesis, Fibrinolysis\textbf{.}

\textbf{Abstract}

The diagnosis and management of Prosthetic Aortic Valve thrombosis
(PAVT) is challenging. The accurate diagnosis of this entity and its
prompt management is vital to improving the prognosis of PAVT patients.
Multi detector CT plays a central role in this effort. We present a case
of PAVT in which the use of MDCT was useful in guiding management.

Learning Objectives

\begin{enumerate}
\tightlist
\item
  To understand the role of MDCT in the diagnosis of PAVT
\item
  To evaluate the utility of MDCT in guiding thrombolytic therapy of
  PAVT patients
\item
  To assess the viability of low dose, slow infusion of tPA in the
  treatment of PAVT
\end{enumerate}

\textbf{History of presentation}

A 61-year-old male presented to hospital with dizziness and dyspnea at
rest and on exertion of 3 weeks duration. He admitted to running out of
his medications about a month prior to presentation to the emergency
department. At presentation, the patient was afebrile, New York Heart
Association (NYHA) functional class III, with an average pulse of 77,
respiratory rate 22 and blood pressure 100/82. An electrocardiograph
revealed atrial flutter at a rate of 79 with right bundle branch block.
Results of initial biochemical laboratory investigations including High
Sensitivity Troponin 1, hemogram, were normal. Significant results of
biochemical tests included NT proBNP \textgreater{}3000, and
subtherapeutic INR 1.2. Chest x ray showed mild pulmonary vascular
congestion.

\textbf{Medical history}

His past medical history was significant for aortic root replacement
using Modified Bentall procedure secondary to acute type 1 Aortic
Dissection, and concomitant Aortic valve replacement using 23mm
Carbomedic bileaflet mechanical valve conduit 3 years ago. He also had a
ventricular septal defect repaired at the same time. The rest of his
history included heart failure with preserved ejection fraction,
coronary artery disease status post coronary artery bypass graft,
paroxysmal atrial fibrillation on Coumadin, peripheral artery disease,
type II diabetes mellitus and hyperlipidemia.

\textbf{Differential diagnosis}

The differential diagnosis included valvular thrombus, or valve pannus,
in the setting of acute decompensated heart failure.

\textbf{Investigations}

A transthoracic echocardiogram (TTE) revealed a moderately to severely
reduced left ventricular systolic function with an estimated ejection
fraction of 30-35\%, moderate transvalvular aortic regurgitation, with
increased transprothetic pressure gradients. Prosthetic transvalvular
velocities (Vmax 3.55m/s) were increased with peak gradient of 51 mmHg
and mean gradient of 32 mmHg {[}Figure 1{]}. A transesophageal
echocardiogram (TEE) revealed an abnormally functioning mechanical valve
with transvalvular peak gradient of 49 mmHg, mean gradient of 29 mmHg,
Doppler velocity index of 0.21 and acceleration time of 114msec,
consistent with prosthetic aortic valve stenosis {[}video 1, Figure
2{]}. Leaflet mobility and sub valvular structures could not be
evaluated because of acoustic shadowing on esophageal views. Valve
fluoroscopy revealed an immobile disc without any obvious obstructive
lesions {[}video 2{]}. A Multi detector computed tomography (MDCT) was
performed to help in assessing the etiology of valve dysfunction. It
revealed a low-density lesion (40HU), consistent with thrombus,
measuring 8 x 5 mm interfering with the mobility of the posterior disc
of the Prosthetic Aortic Valve {[}Figure 3{]}.

\textbf{Management}

The heart team evaluated and reviewed the images obtained via MDCT,
objectively elected to pursue thrombolytic therapy, tissue plasminogen
activator (tPA) infusion was started. The patient received 10 mg IV
bolus followed by 90 mg over approximately 2 hours. A repeat aortic
valve fluoroscopy demonstrated restricted valve motion {[}video 3{]}. A
second round of tPA was administered at the same dosage. A limited
echocardiogram showed improved gradient across the aortic valve with
peak gradient of 16 mmHg and mean gradient of 10 mmHg and no
regurgitation. The heart team decision was made to repeat tPA infusion
at a lower dose. The patient received 1 mg/h of tissue plasminogen
activator infusion for 25 hours. A repeat TTE revealed more improvement
of transaortic velocity/gradient with peak gradient 15 mmHg and mean
gradient of 8 mmHg but with a small thrombus still present. Patient
symptoms had resolved. A valve fluoroscopy obtained a couple of days
later still showed no significant movement of one of the mechanical
aortic valve leaflets {[}Video 4{]}. The patient received a fourth dose
of low dose tPA infusion as the previous described above. Follow up MDCT
obtained three days after the fourth tPA infusion, revealed resolution
of the thrombus with normal leaflets excursion {[}Video 5{]}. There were
no hemorrhagic complications. IV heparin used between tPA treatment was
resumed after the fourth dose as a bridge to warfarin until achievement
of therapeutic INR.

\textbf{Discussion}

Prosthetic valve thrombosis (PVT) is one of the major causes of primary
valve failure with an incidence of 0.5\%--8\% in mechanical valves in
the aortic position (1). The clinical presentation of prosthetic aortic
valve thrombosis (PAVT) is variable, with symptoms including dyspnea,
decreased exercise capacity, palpitation, chest pain, vertigo,
cerebrovascular accident. On physical examination, stenotic or
regurgitant murmurs may be revealed. Hemodynamic stability may depend on
the number of leaflets involved with better hemodynamic conditions
seeing if a single leaflet is involved as opposed to two leaflets (2).
In patients with prosthetic valve presenting with symptoms and signs
suggestive of valve dysfunction, echocardiography examination should be
urgently performed especially if there is suspicion for PVT.

Transthoracic echocardiography (TTE) and transesophageal
echocardiography (TEE) are the standard techniques for the evaluation of
prosthetic valve function (3). Cinefluoroscopic is however, considered
the gold standard as TTE and TEE do not always allow for quantitative
evaluation of leaflet motion. Cinefluoroscopic has the advantages of
being low cost, fast and easily repeatable so it can be used for
evaluation of valve motion during thrombolytic treatment (4). It is
however not useful in assessing the etiology of prosthetic valve failure
(4). Multi detector computed tomography (MDCT) diagnostic yield is in
the identification of the etiology of prosthetic valve failure (5).
Determining the cause of valvular dysfunction is important to guide
therapy as surgery is the only option for pannus, PVT may require
non-surgical approaches.

The optimal management of PAVT is controversial in part due to the lack
of clinical trials. Treatment options include surgery, thrombolytic
therapy, and anticoagulation therapy, the latest being inferior to the
first two (6). In a systematic review and meta-analysis of observational
studies, urgent surgery was found not superior to thrombolytic therapy
at restoring valve function, but substantially reduced the occurrence of
thrombo-embolic events, major bleeding, and recurrent PVT (7). The
authors recommended that in experienced centers, urgent surgery be
preferred over thrombolytic therapy for treating left-sided PVT, pending
the results of randomized controlled trials (8).

In a multicenter observational prospective study of thrombolytic therapy
involving 158 patients with PVT, the authors recommended a low-dose and
slow/ultraslow infusion of t-PA as a viable treatment in patients with
obstructive PVT. The patients in the study received slow (6 hours)
and/or ultraslow (25 hours) infusion of low-dose tissue plasminogen
activator (t-PA) (25 mg) mostly in repeated sessions (7). This study
found that a low-dose and slow/ultraslow infusion of t-PA were
associated with low complications and mortality and high success rates
(7). Furthermore, the TROIA trial also showed that slow infusion of 25
mg t-PA without a bolus appears to be the safest thrombolytic regimen
with lower complication and mortality rates for PVT compared with higher
doses or rapid infusions (8). Recently, \selectlanguage{ngerman}Özkan and his colleague also
demonstrated that Ultraslow (25hours) infusion of low-dose (25mg) t-PA
without bolus appears to be associated with quite low nonfatal
complications and mortality for PVT patients without loss of
effectiveness, when compared with higher doses or faster infusions of
t-PA (9). This Ultraslow thrombolytic infusion approach could be used
with repetition without increasing adverse events including major
bleeding and intracranial bleeding. (9,10)

In the era of cardiac multimodality imaging, evaluation and management
of prosthetic valve thrombosis should not be done only based on clinical
findings, or indirect imaging modalities. Rather, MDCT should be
incorporated into the decision-making process, as it's diagnostic
yielding in identifying the etiology of PVT is invaluable.

\textbf{Follow-up}

At his one-week follow-up, he was still asymptomatic. He reported
medication compliance although his INR had dropped from 2.6 to 1.6. The
dose of Warfarin was adjusted with lovenox bridging on outpatient basis.

\textbf{Conclusion}

We present a case of PAVT treated with repeated infusions of tPA using a
combination of high dose with rapid infusion and low dose with slow
infusion. The treatment was successful and well tolerated. Prompt
detection and treatment of PVT is importance to avoid catastrophic
outcomes. Multimodality techniques, including MDCT helped to reveal
etiology of the Prosthetic aortic valve dysfunction, including
thrombosis.

\textbf{Funding support and authors disclosures}

The authors have no potential or actual conflicts of interest to
disclose.

Informed consent and authorization were obtained prior to preparation of
this manuscript. This would be made available to editor on request.

\textbf{References}

\begin{enumerate}
\tightlist
\item
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\item
  Pibarot P, Dumesnil JG. Prosthetic heart valves: selection of the
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\item
  Muratori M, Montorsi P, Teruzzi G, et al. Feasibility and diagnostic
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\item
  Montorsi P, De Bernardi F, Muratori M, et al. Role of
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\item
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\item
  Biteker M, Altun I, Basaran O,et al. Treatment of Prosthetic Valve
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\item
  Karthikeyan G, Senguttuvan NB, Joseph J, et al. Urgent surgery
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\item
  Özkan M, Gündüz S, Biteker M, et al. Comparison of different
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\item
  Özkan M, Gündüz S, Gürsoy OM, et al. Ultraslow thrombolytic therapy: A
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  10.1016/j.ahj.2015.04.025. Epub 2015 May 2.
\item
  Gündüz S, Özkan M, Yesin M, et al. Prolonged Infusions of Low-Dose
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\end{enumerate}

Legends for videos

Video 1: Transesophageal echocardiogram (TEE) revealing an abnormally
functioning mechanical valve.

Video 2: Valve fluoroscopy showing an immobile disc without obvious
obstructive lesions

Video 3: Repeat aortic valve fluoroscopy demonstrating restricted valve
motion.

Video 4: Valve fluoroscopy showing no significant improvement in motion
of the immobile mechanical aortic valve leaflet.

Video 5: MDCT revealing resolution of the thrombus with normal leaflets
excursion.

Figure 1 Transprosthetic Pressure Gradient on Transthoracic
Echocardiography\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Transthoracic echocardiography showing increased transprosthetic
pressure gradient (PG) (maximum PG 51mmHg; mean PG 32mmHg). VTI --
Velocity time integral

Figure 2 Transesophageal Echocardiography showing increased
transprosthetic velocity of 3.51m/s with mean gradient 29mmHg\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 3 MDCT showing Bileaflet mechanical aortic valve, with thrombus
interfering with function of the posterior leaflet ( shown with arrow)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Ethics approval and consent to participate.}

Not applicable.

\textbf{Consent for publication}

Written informed consent was obtained from the patient for publication
of this case

report, and any accompanying images. A copy of the written consent is
available for review by the Editor-in-Chief of this journal.

\textbf{Competing interests}

The authors declare that they have no competing interest to disclose.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1-Transprosthetic-Pressure-Gradient-on-Transthoracic-Echocardiography/Figure-1-Transprosthetic-Pressure-Gradient-on-Transthoracic-Echocardiography}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2-Transesophageal-Echocardiography-showing-increased-transprosthetic-velocity/Figure-2-Transesophageal-Echocardiography-showing-increased-transprosthetic-velocity}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3-MDCT-showing-Bileaflet-mechanical-aortic-valve/Figure-3-MDCT-showing-Bileaflet-mechanical-aortic-valve}

\end{center}
\end{figure}

\selectlanguage{english}
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