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Acute thrombosis on mechanical mitral prosthesis.

Session Poster Session 1 - Acute Heart Failure, Cardiogenic Shock and Advanced Cardiac Support

Speaker Alfredo Chauca Tapia

Event : Acute Cardiovascular Care 2018

  • Topic : coronary artery disease, acute coronary syndromes, acute cardiac care
  • Sub-topic : Acute Cardiac Care – CCU, Intensive, and Critical Cardiovascular Care
  • Session type : Poster Session

Authors : I Noval Morillas (Cadiz,ES), F Garcia Lanzas (Cadiz,ES), A Chauca Tapia (Cadiz,ES), D Villanueva Ospino (Cadiz,ES), P Cabeza Lainez (Cadiz,ES)

I Noval Morillas1 , F Garcia Lanzas1 , A Chauca Tapia1 , D Villanueva Ospino1 , P Cabeza Lainez1 , 1University Hospital Puerta del Mar, Cardiology - Cadiz - Spain ,

European Heart Journal Supplement ( 2018 ) 7 ( Supplement ), S56

Introduction: Thrombosis of a prosthetic valve is a complication that can seriously compromise the patient’s life. The traditional therapeutic solution has been reoperation, with thrombectomy or replacement of the affected valve, with a high mortality rate (up to 38%). Thrombolysis is a clear alternative to surgical treatment (80% success rate, but the procedure has the drawback of embolic complications (20%) and major hemorrhages (5%) leading to a mortality of approximately 6%. At the present time, the most appropriate therapeutic modality for these patients is not well defined, especially for those with a severe obstructive condition.
Clinical Case: A 58-year-old woman underwent mechanical aortic prosthesis in 2005. She was scheduled to have mitral valvular replacement (due to severe mitral regurgitation) and aortic prosthesis resustitution and aortic tube due to dilatation of aortic root and ascending aorta. After the surgery she stayed in the ICU, presenting a worsening postoperative clinical evolution requiring vasoactive drugs and IMV. After 6 days of the surgical intervention, a transthoracic echocardiogram of control was performed, in which a possible dysfunction of the mitral prosthesis was observed, so that TEE was performed and the diagnosis was confirmed, identifying only the movement of one of the hemidisks (the medial hemidiscus was fixe) and a hypoechogenic image, compatible with thrombus was observed at posteroseptal level on the auricular face of the prosthetic ring due to thrombosis of the mitral prosthesis Besides elevated gradients (MG 9 mmHg). He was initially treated with intravenous heparin, without success. As the surgery was very risky and technically very complicated due to lack of usual approach; it was finally decided to perform thrombolysis by streptokinase at 500,000 IU in 20min, and 1,500,000 in continuous continuous infusion in 10h. The patient presented no complications. After a computed tomography of the control brain at 24 hours without evidence of bleeding, it was decided to initiate enoxaparin 0.7mg/kg/12h. A TEE was performed 48 hours after thrombolysis revealing thrombus dissolution. On the fourth day anticoagulation was rotated to vitamin K antagonists, achieving therapeutic range in 6 days. Given the good evolution, it was decided hospital discharge after prescribing aspirin in low doses in addition to anticoagulation with warfarin indicating an RIN target of 4.
Conclusions: Prosthetic mechanical valve thrombosis is a rare complication of valvular replacement, but with a high morbidity and mortality rate. Early diagnosis is essential in the course of this disease, since successful early therapy improves short- and long-term prognosis. The risk of embolism in mechanical prosthetic valve thrombosis depends on the size and mobility of the thrombus, with thrombus greater than 8 mm the risk of embolism is greater than 80%.

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