54. Fibrinolytic therapy and polyvalvular heart disease in pediatric patient

Novel therapy for a stuck mechanical heart valve in pediatric patient with multiple prosthetic valves. Not much is known with the use of anticoagulation and fibrinolysis in multiple mechanical valves in pediatric patients. 10year, Saudi, male with poly-valvular disease with tricuspid, mitral, and aortic, and pulmonary valve regurgitation. Initially, he had repair of all his valves in June 2008. He required Mitral valve replacement #21, and repeat poly-valvar repair in July 2008. Eventually, tricuspid valve was replaced by CM #27, aortic valve was replaced by St.Jude #19mm, and pulmonary valve replaced by Jan 2012. He presented to cardiology clinic on March 2014in which found to have stuck disc of the tricuspid valve prosthesis on echo with increasing gradients of six mmHg, despite therapeutic INR with warfarin. Immediate fluoroscopy confirmed diagnosis. Physical exam positively mild tachypnea and liver of three cm below costal margin, with mechanical cardiac click sounds. Immediate admission to the intensive care for observation and planning starting the tPA with heparin infusion. TPA stated as a dose of 0.5mg/kg/h over 6h then repeated fluoroscopy done after 4h of the completion of tPA showed mobile tricuspid disc. He was observed for a few days in ward with therapeutic INR and discharged home. As growing surgical skills we are facing many pediatric cases with prosthetic valves with stuck valves. Which tPA dose should be used? Is streptokinase better? How long do you wait before considering surgery?