CONGRESS ABSTRACT

In September 2024, a 57-year-old woman came to the emergency department with worsening dyspnea. Her medical history includes an aortic bioprosthesis implantation in July 2019 for suspected endocarditis and closure of a secundum atrial septal defect. In February 2024, she had redo surgery with a mechanical prosthesis placed due to suspected endocarditis, which later revealed a thrombus in histological findings. In the emergency department, the patient presented with pulmonary congestion and bronchospasm, leading to the administration of furosemide, aerosol therapy, and intravenous corticosteroids. An echocardiogram revealed obstructive thrombosis of the prosthetic valve. Due to a mechanical valve and a history of 2019 thrombotic events, the patient's coagulation status was suboptimal (INR 2.5). Given the patient's clinical instability, we decided on an aggressive approach to eliminate the thrombus. After a collegial meeting, we opted to postpone further surgery due to the patient's high-risk profile, especially since the last surgery was seven months ago. Following the HATTUSHA study protocol, we initiated thrombolytic therapy, which yielded low complication and mortality rates despite diverging from ESC guidelines. Low-dose thrombolytic therapy was initiated with a 5 mg bolus of rtPA, followed by 20 mg over six hours. If obstruction persisted during echocardiographic control, an additional 25 mg dose over six hours would be given. Overnight, echocardiography showed a significant reduction in gradients (5-6 mmHg) and clinical improvement, leading to the discontinuation of rtPA and the start of a heparin infusion. The next morning's echocardiographic check revealed a blocked medial hemidiscus, prompting us to stop heparin and administer another 25 mg of rtPA. In the afternoon, the patient exhibited sudden right hemiparesis, expressive aphasia, and left head deviation, raising suspicion of a stroke. An angio-CT scan showed thrombotic occlusion at the carotid apex and hypoperfusion in the right hemisphere. A two-hour mechanical thrombectomy was performed, resulting in partial reperfusion of the middle cerebral artery. Surgery and anticoagulant therapy were considered too risky due to the high risk of bleeding.  After four days in intensive care, the patient's neurological condition significantly worsened, resulting in the decision to discontinue treatment. The patient was pronounced deceased at 8:50 AM on the fifth day.