THROMBOLYSIS WITH ULTRA-HIGH STREPTOKINASE DOSAGE FOR DYSFUNCTION OF A ST-JUDE PROSTHETIC AORTIC-VALVE

History and clinical findings: A 64-year-old man was hospitalised beca use of progressively worsening dyspnoea over the preceding few months, Three years previously he had undergone aortic valve replacement (St. Jude Medical bileaflet valve) for severe aortic stenosis and some reg urgitation. He was much improved postoperatively and one year after th e operation echocardiography demonstrated a well functioning prostheti c valve and a transvalvar pressure gradient (by Doppler echocardiograp hy) of 28 mm Hg, On admission the patient reported to have stopped phe nprocoumon 9 months before admission. The patient was in cardiac failu re, grade III (NYHA classification). On auscultation there was a 4/6 c rescendo-decrescendo systolic murmur and a 2/6 early diastolic decresc endo murmur maximal over the second right ICS, Investigations: Echocar diography confirmed the suspected diagnosis of dysfunction of the pros thetic va Ive, one leaflet being immobile, with severe outflow obstruc tion (peak transvalvar pressure gradient 101 mm Hg) combined with seve re regurgitation. At fluoroscopy one leaflet moved normally, the other one being fixed between opening and closing positions. Treatment and course: As thrombosis was the most likely cause of the prosthetic valv e dysfunction. thrombolysis treatment was started. After administratio n of 9 mill, IU streptokinase both leaflets showed normal movement. Th e peak transvalvar gradient (by echocardiography) was now 40 mm Hg and there was only slight regurgitation. No complications were noted. Aft er oral anticoagulation for 5 months the prosthetic Valve was function ing normally with unchanged movement pattern of both leaflets. Conclus ion: Thrombolysis may be successful in thrombotic dysfunction of a pro sthetic valve. If there are no contraindications, this form of treatme nt should be tried before reoperation is undertaken.