Fibrinolysis for Apical Thrombus as a Bridge to Emergent Valve-in-Valve Transcatheter Aortic Valve Replacement.

BACKGROUND

Left ventricular (LV) thrombus is traditionally a contraindication to transcatheter aortic valve replacement due to embolic risk. Consequently, management of valvular cardiogenic shock complicated by LV thrombus identifies unique challenges that require innovative strategies.

CASE SUMMARY: A 58-year-old woman with critical bioprosthetic aortic stenosis, cardiogenic shock, and large LV thrombus (2.8 × 2.6 cm) underwent successful valve-in-valve transcatheter aortic valve replacement after systemic fibrinolysis bridge therapy.

WHY BEYOND THE GUIDELINES: Current guidelines contraindicate transcatheter aortic valve replacement in patients with LV thrombus. This case demonstrates the novel use of low-dose, slow infusion tissue plasminogen activator as a bridge therapy to enable life-saving intervention.

DISCUSSION: Pulsed delivery of small doses of systemic fibrinolytic with hemodynamic and echocardiographic monitoring may be suitable as a bridge to definitive management in valvular shock patients with LV thrombus. Minimizing instrumentation during structural heart procedures complicated by LV thrombus is critical.

TAKE-HOME MESSAGES: Low-dose, slow-infusion fibrinolysis coupled with echocardiographic monitoring may serve as bridge therapy to urgent structural cardiology intervention in carefully selected patients with LV thrombus and cardiogenic shock.