Four months after mechanical mitral valve replacement, a 44-year-old woman returns with sudden dyspnoea. The prosthetic clicks have become muffled. Echo shows restricted disc motion with a transmitral mean gradient of 22 mmHg and a mobile echogenic mass on the atrial side of the leaflet. Fluoroscopy shows reduced excursion of one leaflet. Onset was abrupt and C-reactive protein is raised. The most appropriate initial treatment is:
- A Observation with serial echocardiography
- B Immediate redo valve replacement in all cases
- C Fibrinolytic therapy ✓
- D Dual antiplatelet therapy alone
Correct answer: C. Fibrinolytic therapy
Explanation
Early presentation (within months of surgery), abrupt symptom onset, raised inflammatory markers, and a mobile echogenic mass favour prosthetic valve thrombosis over pannus ingrowth, which is insidious and non-mobile. Fibrinolysis is the accepted first-line option for obstructive left-sided prosthetic thrombosis when surgery carries prohibitive risk and in many centres even otherwise, especially for thrombosis presenting soon after implantation.
Reference: Braunwald's Heart Disease, 12th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.