Fibrinolysis for Apical Thrombus as a Bridge to Emergent Valve-in-Valve Transcatheter Aortic Valve Replacement

Authors

Nicholas J. Valle, Macon & Joan Brock Virginia Health Sciences at Old Dominion UniversityFollow
Omar A. Saleh, Macon & Joan Brock Virginia Health Sciences at Old Dominion UniversityFollow
Mani C. Akunuri, Macon & Joan Brock Virginia Health Sciences at Old Dominion UniversityFollow
Parth K. Parikh, Sentara Medical Group
Joshua A. Cohen, Sentara Medical Group
Deepak R. Talreja, Sentara Medical Group
Matthew R. Summers, Sentara Medical Group

ORCID

0009-0000-8820-2050 (Valle)

Document Type

Article

Publication Date

2025

DOI

10.1016/j.jaccas.2025.106066

Publication Title

JACC Case Reports

Volume

31

Issue

2

Pages

106066

Abstract

Background

Left ventricular (LV) thrombus is traditionally a contraindication to transcatheter aortic valve replacement due to embolic risk. Consequently, management of valvular cardiogenic shock complicated by LV thrombus identifies unique challenges that require innovative strategies.

Case Summary

A 58-year-old woman with critical bioprosthetic aortic stenosis, cardiogenic shock, and large LV thrombus (2.8 × 2.6 cm) underwent successful valve-in-valve transcatheter aortic valve replacement after systemic fibrinolysis bridge therapy.

Why Beyond the Guidelines

Current guidelines contraindicate transcatheter aortic valve replacement in patients with LV thrombus. This case demonstrates the novel use of low-dose, slow infusion tissue plasminogen activator as a bridge therapy to enable life-saving intervention.

Discussion

Pulsed delivery of small doses of systemic fibrinolytic with hemodynamic and echocardiographic monitoring may be suitable as a bridge to definitive management in valvular shock patients with LV thrombus. Minimizing instrumentation during structural heart procedures complicated by LV thrombus is critical.

Take-Home Messages

Low-dose, slow-infusion fibrinolysis coupled with echocardiographic monitoring may serve as bridge therapy to urgent structural cardiology intervention in carefully selected patients with LV thrombus and cardiogenic shock.

Rights

© 2026 The Authors.

This is an open access article under the Creative Commons Attribution 4.0 International (CC BY 4.0) License.

Original Publication Citation

Valle, N. J., Saleh, O. A., Akunuri, M. C., Parikh, P. K., Cohen, J. A., Talreja, D. R., & Summers, M. R. (2025). Fibrinolysis for apical thrombus as a bridge to emergent valve-in-valve transcatheter aortic valve replacement. JACC Case Reports, 31(2), Article 106066. https://doi.org/10.1016/j.jaccas.2025.106066

Repository Citation

Valle, N. J., Saleh, O. A., Akunuri, M. C., Parikh, P. K., Cohen, J. A., Talreja, D. R., & Summers, M. R. (2025). Fibrinolysis for apical thrombus as a bridge to emergent valve-in-valve transcatheter aortic valve replacement. JACC Case Reports, 31(2), Article 106066. https://doi.org/10.1016/j.jaccas.2025.106066