Successful use of ultraslow thrombolytic therapy in stuck mechanical aortic valve in a patient with COVID-19; a case report

INTRODUCTION AND IMPORTANCE: COVID-19 represents a new challenge for patients with prosthetic valve, through increasing the risk of thrombosis and reducing the frequency of anticoagulation follow up visits. CASE PRESENTATION: A 37-year-old male patient on aspirin and warfarin for a mechanical aortic valve (AV, St Jude size 21 mm), presented with generalized fatigue and loss one of the mechanical heart sounds for 10 days. Urgent fluoroscopy showed stuck one of the AV leaflets in a closed and opening positions. Echocardiography showed high peak and mean AV gradients. The patient was confirmed with COVID-19 with fever on the day of admission. Cardiac CT with contrast showed stuck right (posterior) disc with a 6 × 4 mm thrombus surrounded by pannus formation. The patient was started on ultraslow thrombolytic therapy (alteplase 1 mg, every hour for 25 h, followed by 6 h of unfractionated heparin). Repeated fluoroscopy showed normal opening and closure of both discs. Repeated echocardiography showed a significant reduction in the peak and mean AV gradients back to baselines. The patient was discharged after 7 days with INR 3.0 for two consecutive days. The patient was asymptomatic with stable INR in three- and six-month follow-up visits. Transthoracic ultrasound demonstrated normally functioning mechanical AV. CLINICAL DISCUSSION: Accurate and timely diagnosis of stuck mechanical AV requires high suspicion and timely diagnostic aids. CONCLUSION: Full recovery can be achieved after one cycle of ultraslow thrombolytic therapy. Further supportive data are still needed before recommending thrombolytic therapy as a successful alternative to surgery in COVID-19 patients.