Prosthetic valve thrombosis is a feared complication with an annual incidence ranging between 0.3 to 1.3%. Diagnostic approach is essential for a better prognosis and ultimately determines the chosen therapeutic strategy. Emergent valvular surgery is usually recommended in hemodinamically unstable patients, large thrombus or recurrent embolic episodes. These high-risk conditions are often not the case. Therefore, in many patients the surgical risk is much greater than that of bleeding associated with thrombolytic administration. Ultra-slow infusions have been reported with similar efficacy and lower rates of bleeding complications. We present a case of mitral prosthetic valve thrombosis considered not feasible to surgical management and subsequently treated with an ultra-slow tissue plasminogen activator infusion.

Prosthetic valve thrombosis is a feared complication with an annual incidence ranging between 0.3 to 1.3%. Diagnostic approach is essential for a better prognosis and ultimately determines the chosen therapeutic strategy. Emergent valvular surgery is usually recommended in hemodinamically unstable patients, large thrombus or recurrent embolic episodes. These high-risk conditions are often not the case. Therefore, in many patients the surgical risk is much greater than that of bleeding associated with thrombolytic administration. Ultra-slow infusions have been reported with similar efficacy and lower rates of bleeding complications. We present a case of mitral prosthetic valve thrombosis considered not feasible to surgical management and subsequently treated with an ultra-slow tissue plasminogen activator infusion.

Coronary embolism (CE) is a rare cause of non-atherosclerotic acute coronary syndrome (ACS). The clinical presentation is similar to ACS, and the diagnosis is supported by Shibata criteria. Atrial fibrillation is the main reported etiology in CE cases. Management includes percutaneous intervention with thromboaspiration and anticoagulation. The following case is a description of a patient with acute chest pain and recently diagnosed atrial fibrillation with a rapid ventricular response, is described. A thrombotic lesion in the distal right coronary artery of embolic origin, was documented. Successful mechanical thromboaspiration was performed; intravascular ultrasound showed no thrombus, dissection, or atherosclerotic plaque. CE is an underdiagnosed cause of ACS; diagnosis relies on Shibata criteria, and patients experience worse outcomes in follow-up.