Thrombosis of mitral annulus as an early complication following mechanical replacement of mitral and aortal valves: case report

Česká verzia

Authors: I. Andršová; T. Novotný; A. Floriánová; J. Maňoušek
Authors place of work: Interní kardiologická klinika LF MU a FN Brno-Bohunice
Published in the journal: Kardiol Rev Int Med 2011, 13(2): 117-119
Category: Case report - competitive

Summary

Introduction:
The case report describes the occurrence of a postoperative thrombotic complication of the valve apparatus in an efficiently anti-coagulated patient without any known haematological disorder.

Abstract:
On 18 September 2008, a 61-year old patient had surgical replacement of the aortal and mitral valves with mechanical prostheses due to degenerative disease. Three weeks after the surgery the patient developed neurological symptoms of transient ischemic attack (TIA) on the right-hand side, for which the patient was admitted to the Department of Neurology. The following day TIA recurred. The patient was afebrile, with an initial CRP value of 30 mg/l; based on the INR value measured by the outpatients’ department, the patient was efficiently warfarinized with an initial INR value of 3.33. Echocardiography of the oesophagus was indicated, which revealed the presence of a 4 × 7 mm formation in the area of the mitral annulus. The patient was transferred to our department. Anti-coagulation therapy was accentuated and antibiotics started to be administered. While carefully monitoring INR (which did not drop below 3.2), control echocardiography was performed after 10 days, which revealed thrombosis progression. Considering the repeatedly negative hemocultures, the stable CRP value and the absence of other symptoms of infection, the condition was evaluated as a coagulation disorder with an unlikely occurrence of infective endocarditis. The basic haematological examination was normal. Following consultations with a cardiac surgeon and haematologist, it was decided to apply systemic thrombolysis after an adequate haematological preparation. The intervention did not cause any complications and both the thrombi were fully dissolved. The patient was discharged after 10 days with an efficient anti-coagulation therapy supported by anti-aggregation. A month after performing systemic thrombolysis, a control echocardiography was carried out by the outpatients’ department, which did not reveal any pathological intracardiac formations.

Conclusion:
Thrombotic complications regarding artificial valves in efficiently warfarinized patients are rare and their cause remains unclear in many cases.

Keywords:
artificial valves – thromboembolic disease – thrombolysis – anticoagulation – antiaggregation

Zdroje

1. Tang GH, Rao V, Sin S et al. Thrombosis of mechanical mitral vlave prosthesis. J Card Surg 2005; 20: 481–648.

2. Badano LP, Oikonomon KA, Fioretti PM. Acute thrombosis of mechanical mitral valve prosthesis: Echo – doppler diagnosis and succesfull treatment with systemic thrombolisis. Eur J Echocardiogr 2003; 4: 73–75.

3. Cokkinos P, Koutrouli E, Chronidon F et al. Acute Thrombosis of a prosthetic mitral valve. Eur J Echocardiogr 2005; 6: 405–406.

4. Bottio T, Gerosa G, Basso C et al. Unexpected mechanical bileaflet valve thrombosis in mitral position: What is better to do, re-replacement or thrombolysis. Langenbeck’s Arch Surg 2002: 387: 166–169.

5. Martinel J, Jiménez A, Rábago G et al. Mechanical cardiac valve thrombosis: is thrombectomy justifield? Circulation 1991; 84 (Suppl III): 70–75.

6. Chesebro JH, Fuster V. Valvular heart disease and prosthetic heart valves. In: Verstraete M (ed.). Thrombosis in Cardiovascular Disorders. Philadelphia: WB Saunders 1992: 191–214.

7. Lus P, Giacomin A, Cavarzarani A et al. Detection of acute thrombosis of mitral tilting disk prosthesis: Clinical diagnosis and surgical or non surgical treatment. Int J Card Imaging 1994; 10: 305–308.

8. Aoyagi S, Fukunaga S, Suzuki S et al. Obstruction of mechanical valve prosthesis: clinical diagnosis and surgical or nonsurgical treatment. Surg Today 1996; 26: 400–406.

9. Silber H, Khan SS, Matloff JM et al. The St. Jude valve: thrombolysis as the first line terapy for cardiac valve thrombosis. Circulation 1993; 87: 30–37.

10. Vitale N, Renzulli A, Agozzino L et al. Obstruction of mechanical mitral prostheses: analysis of patologic findings. Ann Thorac Surg 1997; 63: 1101–1106.

11. Rizzoli G, Guglielmi C, Toscano G et al. Reoperation for acute prosthetic thrombosis and pannus: an assesment of rates, relationship and risk. Eur J Cardiothorac Surg 1999; 16: 74–80.

12. Bollag L, Attenhofer JC, Vogt PR. Symptomatic mechanical heart valve thrombosis: high morbility and mortality despite succesfull treatment options. Swiss Med Wkly 2001; 131: 109–116.

13. Aschermann M et al. Kardiologie. 1. vyd. Praha: Galén 2004: 518–519.

14. Pengo V, Prisco D, Iliceto S. Gestione attuale della terapia anticoagulante orale. Ital Heart J Suppl 2002; 3: 502–517.

15. Stein PD, Alpert JS, Bussey H et al. Antithrombotic Therapy in Patients With Mechanical and Biological Prosthetic Heart Valves. CHEST 2001; 119: 220S–227S.