Success of delayed thrombolysis for metallic tricuspid valve thrombosis.

We discuss the case of a 55-year-old woman with a history of gastric ulcer, mechanical tricuspid and mitral valve replacement and a pacemaker for post-operative total heart block. The patient underwent elective pacemaker replacement. She developed a large infra-umbilical rectal sheath haematoma during bridging therapy with low-molecular-weight heparins (LMWH), for which she was treated with angiographic embolisation of the epigastric artery. Subsequently, an intravenous unfractionated heparin (UFH) drip was started. Shortly thereafter, the patient developed severe upper gastrointestinal bleeding, caused by a gastric ulcer with a visible vessel. Anticoagulant therapy was interrupted. On the third day after cessation of the UFH drip, the patient developed thrombosis of the prosthetic tricuspid valve, confirmed by transthoracic echocardiography and cinefluoroscopy. Due to the risk of bleeding (from gastric ulcer and rectus sheath), both thrombolytic therapy and redo surgery were deemed to pose an unacceptable risk. We decided to treat the patient with intravenous heparin and postpone thrombolytic therapy until after healing of the gastric ulcer. At 5 weeks after the bleeding event, alteplase was administered, with dissolution of the thrombus and restoration of valve disc motion. No embolic or bleeding complications occurred thereafter and six months after the event, the patient is in excellent general condition.