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: dr s venkatesan 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
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