Int J Cardiovasc Imaging (2014) 30:835–837 DOI 10.1007/s10554-014-0427-7
IMAGES IN CARDIOLOGY
Mechanical mitral valve thrombosis in an elderly patient Nasir Hussain • Atiq Rehman • Faisal H. Cheema
Received: 13 October 2013 / Accepted: 11 April 2014 / Published online: 19 April 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract Prosthetic valve thrombosis is a rare but dreaded complication of mechanical heart valves. In this clinical picture, we present an elderly female who developed mechanical mitral valve thrombosis several years after mitral valve replacement. We have provided fluoroscopy as well as intraoperative images of mitral valve thrombosis and have briefly discussed the diagnosis, and management of this complication. Keyword Prosthetic valve thrombosis Elderly Subtherapeutic anticoagulation A 79-year-old-female with a past medical history of coronary artery disease, severe mitral valve disease status post
Electronic supplementary material The online version of this article (doi:10.1007/s10554-014-0427-7) contains supplementary material, which is available to authorized users. N. Hussain Hartford Hospital, University of Connecticut, Hartford, CT, USA N. Hussain (&) Department of Internal Medicine, Saint Joseph Hospital, Presence Health, 2900 North Lake Shore Drive, Chicago, IL 60657, USA e-mail: [email protected] N. Hussain A. Rehman College of Physicians and Surgeons of Columbia University, New York, NY, USA A. Rehman Sarasota Memorial Hospital, Sarasota, FL, USA F. H. Cheema University of Maryland Medical Centre, Baltimore, MD, USA
coronary artery bypass grafting and mitral valve replacement (bi-leaflet mechanical valve, 33 mm ATS prosthesis) 9 years ago, cardiomyopathy status post automated implantable cardioverter defibrillator and chronic atrial fibrillation presented with worsening dyspnea on exertion. Physical examination, laboratory, and imaging tests confirmed diagnosis of worsening heart failure. On review of records, patient was noted to have prolonged periods (2–3 months) of subtherapeutic INR *1.3. Echocardiogram demonstrated poor visualization of the mitral valve secondary to increased clot burden in the left atrium (echo supplementary video 1 & 2). Patient was started on therapeutic heparin, diuretics; urgent fluoroscopy demonstrated mobile posterior and fixed anterior leaflet (Fig. 1a–c, video 1a–c), findings consistent with sub-acute thrombosis of the mechanical mitral valve. Patient underwent emergent sternotomy, left atriotomy, clot removal, and mechanical mitral valve replacement with a tissue valve (Fig. 2a–e). Post-operative stay was uneventful. The incidence of obstructive prosthetic valve thrombosis (PVT) for mechanical valves varies between 0.3 and 1.3 % patient years [1]. Bio-prosthetic valve thrombosis is rare and is usually diagnosed in early-postoperative period [2]. Obstructive PVT carries a mortality risk of approximately 10 % [2]. The risk of thrombosis is affected by valve type, its location and adequacy of anticoagulation treatment [2]. Although, echocardiogram and fluoroscopy are the two main diagnostic modalities, fluoroscopy remains the diagnostic procedure of choice in suspected mechanical PVT, due to poor visualization of the mechanical prosthesis on echocardiography. Available therapeutic modalities for PVT include heparin treatment, fibrinolysis, and surgery [2]. The choice of one over the other is influenced by patient’s clinical status, degree of clot burden, presence, or absence of obstruction and prosthesis location [2].
123
836
Int J Cardiovasc Imaging (2014) 30:835–837
Fig. 1 Preoperative fluoroscopy images demonstrating bi-leaflet mechanical mitral prosthetic valve with mobile posterior and fixed anterior leaflets in a Right anterior oblique (RAO) view. b Antero-posterior (AP) view. c Left anterior oblique (LAO) view
Fig. 2 Intraoperative images: a Massive left atrial thrombus hiding left atrial appendage and mitral valve is barely visible through the pannus. b Left atrial cavity after partial clot removal. c Left atrial
123
cavity after complete clot removal. d View of the mitral annulus once the valve was removed. e New mitral tissue prosthesis in place
Int J Cardiovasc Imaging (2014) 30:835–837 Conflict of interest
None.
References
837 2. Roudaut R, Serri K, Lafitte S (2007) Thrombosis of prosthetic heart valves: diagnosis and therapeutic consideration. Heart 93:137–142
1. Horskotte D, Burckhardt D (1995) Prosthetic valve thrombosis. J Heart Valve Dis 4:141–153
123
IMAGES IN CARDIOLOGY
Mechanical mitral valve thrombosis in an elderly patient Nasir Hussain • Atiq Rehman • Faisal H. Cheema
Received: 13 October 2013 / Accepted: 11 April 2014 / Published online: 19 April 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract Prosthetic valve thrombosis is a rare but dreaded complication of mechanical heart valves. In this clinical picture, we present an elderly female who developed mechanical mitral valve thrombosis several years after mitral valve replacement. We have provided fluoroscopy as well as intraoperative images of mitral valve thrombosis and have briefly discussed the diagnosis, and management of this complication. Keyword Prosthetic valve thrombosis Elderly Subtherapeutic anticoagulation A 79-year-old-female with a past medical history of coronary artery disease, severe mitral valve disease status post
Electronic supplementary material The online version of this article (doi:10.1007/s10554-014-0427-7) contains supplementary material, which is available to authorized users. N. Hussain Hartford Hospital, University of Connecticut, Hartford, CT, USA N. Hussain (&) Department of Internal Medicine, Saint Joseph Hospital, Presence Health, 2900 North Lake Shore Drive, Chicago, IL 60657, USA e-mail: [email protected] N. Hussain A. Rehman College of Physicians and Surgeons of Columbia University, New York, NY, USA A. Rehman Sarasota Memorial Hospital, Sarasota, FL, USA F. H. Cheema University of Maryland Medical Centre, Baltimore, MD, USA
coronary artery bypass grafting and mitral valve replacement (bi-leaflet mechanical valve, 33 mm ATS prosthesis) 9 years ago, cardiomyopathy status post automated implantable cardioverter defibrillator and chronic atrial fibrillation presented with worsening dyspnea on exertion. Physical examination, laboratory, and imaging tests confirmed diagnosis of worsening heart failure. On review of records, patient was noted to have prolonged periods (2–3 months) of subtherapeutic INR *1.3. Echocardiogram demonstrated poor visualization of the mitral valve secondary to increased clot burden in the left atrium (echo supplementary video 1 & 2). Patient was started on therapeutic heparin, diuretics; urgent fluoroscopy demonstrated mobile posterior and fixed anterior leaflet (Fig. 1a–c, video 1a–c), findings consistent with sub-acute thrombosis of the mechanical mitral valve. Patient underwent emergent sternotomy, left atriotomy, clot removal, and mechanical mitral valve replacement with a tissue valve (Fig. 2a–e). Post-operative stay was uneventful. The incidence of obstructive prosthetic valve thrombosis (PVT) for mechanical valves varies between 0.3 and 1.3 % patient years [1]. Bio-prosthetic valve thrombosis is rare and is usually diagnosed in early-postoperative period [2]. Obstructive PVT carries a mortality risk of approximately 10 % [2]. The risk of thrombosis is affected by valve type, its location and adequacy of anticoagulation treatment [2]. Although, echocardiogram and fluoroscopy are the two main diagnostic modalities, fluoroscopy remains the diagnostic procedure of choice in suspected mechanical PVT, due to poor visualization of the mechanical prosthesis on echocardiography. Available therapeutic modalities for PVT include heparin treatment, fibrinolysis, and surgery [2]. The choice of one over the other is influenced by patient’s clinical status, degree of clot burden, presence, or absence of obstruction and prosthesis location [2].
123
836
Int J Cardiovasc Imaging (2014) 30:835–837
Fig. 1 Preoperative fluoroscopy images demonstrating bi-leaflet mechanical mitral prosthetic valve with mobile posterior and fixed anterior leaflets in a Right anterior oblique (RAO) view. b Antero-posterior (AP) view. c Left anterior oblique (LAO) view
Fig. 2 Intraoperative images: a Massive left atrial thrombus hiding left atrial appendage and mitral valve is barely visible through the pannus. b Left atrial cavity after partial clot removal. c Left atrial
123
cavity after complete clot removal. d View of the mitral annulus once the valve was removed. e New mitral tissue prosthesis in place
Int J Cardiovasc Imaging (2014) 30:835–837 Conflict of interest
None.
References
837 2. Roudaut R, Serri K, Lafitte S (2007) Thrombosis of prosthetic heart valves: diagnosis and therapeutic consideration. Heart 93:137–142
1. Horskotte D, Burckhardt D (1995) Prosthetic valve thrombosis. J Heart Valve Dis 4:141–153
123
