Guessing games with prosthetic valve gradients !

  A 40 year old  women came  with acute dyspnea who had a prosthetic mitral valve implanted 2 years ago for RHD  . An emergency  echo showed  a peak gradient of 35mmhg across the valve .She was on warfarin regularly and her last INR was 2.2.Heart rate  was 138/minute, lungs showed congestion .LA,LV were dilated. LV function appeared mildly compromised  but could not be accurately quantified as the  patient  was in distress.   The fellow on duty had no hesitation  in diagnosing prosthetic valve thrombus .He Initiated Inj streptokinse bolus followed by infusion  along with diuretics . After few hours the gradient regressed .Patient felt better .Every one was happy . The consultant congratulated the fellow for  the good job done .To recognize prosthetic valve obstruction early and  successfully lysing it too !  The fellow  felt gratified . Since I  was hanging around the CCU , watching the proceedings , I Initiated  a debate which was  curious to the team that handled the  patient ! Was it really thrombotic obstruction that caused his symptoms ? No one has visualized the thrombus TEE was not done Fluroscopic evaluation of disk motion was not performed There was no documentation of raising FDP that would Indicate clot lysis. All  we have  is an unexplained  tachycardia with raised  trans prosthetic gradient . . . Why we are tuned to think  raised gradients  to be  synonymous with thrombus ? There has  been lot of assumption here . Subseque...
Source: Dr.S.Venkatesan MD - Category: Cardiology Authors: Tags: Cardiology -Hemodynamics Cardiology -Therapeutic dilemma cardiology -Therapeutics Cardiology -unresolved questions prosthetic valve dysfunction prosthetic valves false gradients across prosthetic valve pesduo prosthetic obstruction prosthe Source Type: blogs