Fatal cerebral hemorrhage complicating thromboembolic stroke in a patient with prosthetic mitral valve thrombosis treated with thrombolytic therapy

We report the case of a 66-year-old male with a history of mitral valve replacement with a Sorin tilting-disk prosthesis and a subsequent operation for severe constrictive pericarditis. After 5 years of stable anticoagulant treatment, he suffered an intracerebral hemorrhage that required temporary withdrawal of warfarin. Thrombosis of the prosthesis, presenting as acute heart failure, was then determined. Due to high-operative and hemorrhagic risk, the patient was treated with low-dose thrombolytic therapy administered as two boluses of recombinant tissue plasminogen activator (r-tPA). The patient's hemodynamics improved strikingly. However, a few hours after the second dose, a devastating cerebral hemorrhagic infarction resulted in death. Autopsy showed the primarily ischemic nature of both strokes. The schemes of thrombolytic therapy in prosthetic heart valve thrombosis and the importance of a correct interpretation of pathogenesis of stroke in anticoagulated patients are discussed.