Successful nonsurgical therapeutic management in a case of early mechanical aortic prosthetic thrombosis and coronary embolism after a modified Bentall procedure

Prosthetic valve thrombosis, although rare, is a life-threatening complication of valve replacement surgery. The authors present an atypical case of a modified Bentall procedure with the CarboSeal Valsalva™ conduit complicated by an early mechanical prosthetic aortic valve thrombosis and coronary embolism. The patient was successfully treated with an emergency percutaneous coronary angioplasty and intracoronary thrombus aspiration of the left anterior descending artery, followed by a systemic 10 mg bolus of tissue plasminogen activator followed by ultraslow (25 h) infusion of low-dose (25 mg), while supported with venoarterial extracorporeal membrane oxygenation. Prosthetic valve thrombosis, although rare, is a life-threatening complication of a modified Bentall procedure. Although surgical treatment is usually preferred in cases of obstructive prosthetic valve thrombosis, therapeutic options include: optimizing anticoagulation with unfractionated heparin ± antiplatelet therapy; thrombolysis; surgery. Ultraslow infusion of low-dose of tissue plasminogen activator (25 mg/25 h), after an initial bolus (10 mg), could be considered as a viable treatment in critically ill patients with hemodynamic instability due to obstructive prosthetic heart valve thrombosis, supported with venoarterial extracorporeal membrane oxygenation and with a non-negligible risk of bleeding.