Successful Repeated Thrombolysis for Obstructed Mechanical Mitral Valve Prosthesis: A Case Report From a Resource-Limited Setting

TL;DR

A man with a mechanical heart valve in a resource-limited setting successfully underwent repeated clot-dissolving treatments when surgery was not an option.

Contribution

Demonstrates the effectiveness of repeated thrombolysis for obstructed mechanical mitral valve prostheses in settings with limited surgical access.

Findings

Low-dose streptokinase resolved valve obstruction in two separate episodes without major complications.

Clinical and echocardiographic improvements were consistent across both thrombolytic treatments.

The case highlights challenges in maintaining anticoagulation in resource-limited environments.

Abstract

We report the case of a 40-year-old man with rheumatic heart disease (a condition where the cardiac valve is damaged due to prior streptococcal infection). He previously underwent mechanical mitral valve replacement with a bileaflet prosthesis and later developed recurrent episodes of acute obstructive prosthetic valve thrombosis. He presented first in 2023 and again in 2025 with rapidly progressive dyspnea, orthopnea, diminished mechanical valve sounds, and signs of hemodynamic compromise. Both events followed prolonged periods of inconsistent warfarin use and inadequate international normalized ratio (INR) monitoring related to financial limitations and restricted access to outpatient care. Transthoracic echocardiography during each admission demonstrated markedly elevated transmitral gradients and restricted leaflet motion, confirming obstructive thrombosis of the mechanical mitral valve.

Because urgent surgical intervention was unavailable and transfer delays carried additional risk, each episode was managed with low-dose, slow-infusion streptokinase after multidisciplinary evaluation and informed consent. The patient showed prompt and sustained improvement during both thrombolytic courses, with resolution of respiratory distress, normalization of hemodynamics, and restoration of prosthetic leaflet mobility. Follow-up echocardiography confirmed thrombus resolution and a return to acceptable transvalvular gradients. No major bleeding, systemic embolization, or neurological complications occurred during either hospitalization. He was transitioned back to therapeutic warfarin levels and discharged in stable condition with reinforced counseling regarding anticoagulation adherence.

This case demonstrates the successful use of repeated thrombolytic therapy for recurrent obstructive mechanical mitral valve thrombosis when surgical management is inaccessible. The consistent clinical and echocardiographic responses across two separate episodes emphasize the importance of early recognition, appropriate patient selection, and close monitoring during thrombolytic treatment. The case also highlights persistent challenges in maintaining reliable anticoagulation in resource-limited environments, where consistent INR monitoring and continuity of care may be difficult to achieve.

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