Background: Mechanical heart valves require lifelong anticoagulation. Either inadequate therapy or superimposed factors can precipitate prosthetic valve thrombosis (PVT). Severe cases may require urgent surgery or fibrinolysis. For most patients, however, optimal therapy remains unclear. Case: A 24 year old woman presented at the emergency room with sudden right hemiparesis and dysarthria. She had a personal history of rheumatic heart disease, submitted to mitral valve replacement with bioprosthesis in 2003 and prosthetic replacement with a 29 mm bileaflet valve in 2012. She had a past obstetric history of two medically induced abortions in 2011 because of heart failure. One month before admission she discovered she was 7 weeks pregnant and was advised to replace Warfarin for Enoxaparin 60 mg/day. Physical examination confirmed the right hemiparesis. Fetal ultrasound confirmed an 11 week pregnancy. Cranial CT scan did not reveal abnormalities. Decision-making: Transthoracic echocardiogram showed a mean transprosthetic gradient of 8 mmHg and a 2 m/s maximum velocity. Transesophageal echocardiogram (TEE) revealed two large protruding thrombi (15 and 17 mm), attached to the atrial aspect of the mechanical valve, diagnosing non obstructive PVT complicated with stroke. She was offered the choice to terminate pregnancy but refused. In a context of recent inadequate anticoagulation she started a continuous perfusion of unfractionated heparin. Surgery was deemed less appropriate by our Heart Team because of prior heart surgeries and a high risk of miscarriage. Fibrinolysis was considered inappropriate as well because of recent stroke, current anticoagulation and pregnancy. She evolved favourably with deficit resolution in 36 hours and no complications related to therapy. Control TEE showed progressive decrease in size and mobility of thrombi. Low-dose aspirin was added in order to improve endogenous fibrinolysis. Conclusion: This case demonstrates how difficult it can be to select the appropriate treatment strategy for PVT. Hemodynamic stability, valve obstruction, systemic embolism, thrombus size, patient preference and co-morbidities have to be taken into consideration.
Morgado, G. J., Loureiro, M. J., Almeida, A. R., Miranda, R., Cotrim, C., & Pereira, H. (2014). A PREGNANT WOMAN WITH PROSTHETIC VALVE THROMBOSIS AND ISCHEMIC STROKE. Journal of the American College of Cardiology, 63(12), A625. https://doi.org/10.1016/s0735-1097(14)60625-2