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Allergic reaction and lack of efficacy: case report A 57-year-old woman developed allergic reaction during treatment with streptokinase for right‑sided obstructive prosthetic valve thrombosis (PVT), and exhibited lack of efficacy with heparin for right‑sided obstructive PVT . The woman, who had a history of open mitral valve commissurotomy, rheumatic heart disease, tricuspid valve repair and persistent atrial fibrillation rhythm, presented to the hospital with NYHA class III dyspnoea. Her admission INR level was 2. Following admission, she was found to have large-sized (15 × 11mm) fresh semi-mobile clot in mechanical bi-leaflet mitral valve (MV) prosthesis by transthoracic echocardiography (TTE). Later, she underwent Trido open heart surgery including MV prosthesis thrombectomy with a replacement of tricuspid valve and aortic valve. After successful surgery, she was discharged on warfarin therapy. After 2 months of the surgery, a TTE showed well-functioning MV and AV prosthesis, but an increased transvalvular gradient was detected on mechanical bi-leaflet tricuspid valve (TV) prosthesis. For the right-sided obstructive PVT, she received fibrinolytic therapy with streptokinase. After 12 hours of the treatment, the transvalvular gradient reduced and the valve function normalised. She was then discharged on warfarin by targeting the INR level of 4–4.5. Six months later, she presented to the clinic with a complaint of NYHA class II dyspnoea. Her admission INR level was 4.8. Subsequent TTE revealed an increased transvalvular gradient over TV prosthesis. Fluoroscopy showed mechanical bi-leaflet TV prosthesis with immobile both disc in semi-open position during systole. Therefore, she was again treated with streptokinase [dosage and route not stated]. However, she developed an allergic reaction secondary to streptokinase [duration of treatment to reaction onset and outcome not stated]. The woman’s streptokinase was switched to heparin [unfractionated heparin] with close monitoring of activated partial thromboplastin time (aPTT). After 2 days of the heparin therapy, no clinical improvement and no change in the haemodynamic study was observed, indicative of lack of efficacy. Due to the high-risk of surgery, she started receiving reteplase therapy with an improvement. She was then discharged on warfarin therapy with a stable condition. Haghaninejad H, et al. Repeat reteplase therapy in a patient with recurrent prosthetic tricuspid valve thrombosis after trido multiple valve replacement. Annals of Cardiac 803499549 Anaesthesia 23: 351-353, No. 3, Sep 2020. Available from: URL: http://doi.org/10.4103/aca.ACA_228_18

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