PROSTHETIC HEART VALVE THROMBOSIS - A HEADACHE FOR THE HEART TEAM - A CASE REPORT /TROMBOZA VEŠTAČKOG SRČANOG ZALISKA - GLAVOBOLJA ZA TIM ZA SRCE - PRIKAZ SLUČAJA

• Published in: Medicinski pregled Vol. 76; p. 112
• Main Authors: Majdevac, Slavica, Preveden, Andrej, Dračina, Nina, Bakić, Nikola, Preveden, Mihaela, Å uÅ¡ak, Stamenko
• Format: Journal Article
• Language: English
• Published: Drustvo Lekara Vojvodine 01.03.2023
• Subjects: Anticoagulants (Medicine); Blood clot; Cardiovascular agents; Care and treatment; Evidence-based medicine; Heart; Heart failure; Implants, Artificial; Prosthesis; Thrombosis
• ISSN: 0025-8105
• DOI: 10.2298/MPNS2304112M

Introduction. Prosthetic valve thrombosis is usually a subacute or chronic condition, although it may also present with a fresh thrombus. It occurs in two forms: obstructive and non-obstructive thrombosis. Case Report. We present a case of a female patient who underwent mitral valve replacement with mechanical prosthesis due to severe mitral stenosis. The postoperative course was uneventful and the patient was discharged on vitamin K antagonist therapy with international normalized ratio target 3.0. Five months later, the patient was admitted with severe shortness of breath and signs of acute heart failure. International normalized ratio at that moment was 2.3. Transthoracic echocardiography indicated severely raised gradient across the prosthetic valve and mechanical valve malfunction was suspected. Cinefluoroscopy showed that one of the prosthetic valve leaflets was completely immobile. Transesophageal echocardiography definitely confirmed thrombosis of the prosthetic valve with large multiple thrombi that completely fixed one leaflet in closed position, and partially limited the motion amplitude of the other leaflet. There were thrombi floating between the left ventricle and left atrium. Thrombectomy of the prosthetic valve was performed, which was sufficient for the complete restoration of the mechanical valve function. The vitamin K antagonist dosage was carefully up-titrated in order to reach and maintain the target international normalized ratio of 3.0. Conclusion. Prosthetic valve thrombosis is a serious and life-threatening condition that requires urgent management. Coordination and cooperation of the whole heart team is necessary for optimal choice of treatment, which primarily includes surgery or fibrinolysis. Key words: Heart Valve Prosthesis; Thrombosis; Mitral Valve; Heart Valve Prosthesis Implantation; Anticoagulants; Vitamin K; Signs and Symptoms; Diagnosis; Reoperation Uvod. Tromboza veštačkog zaliska obično predstavlja subakutno ili hronično stanje, mada može biti i akutno sa svežim trombom. Tromboza može da se javi se u dve forme - kao opstruktivna i neopstruktivna. Prikaz slučaja. Prikazujemo slučaj pacijentkinje kojoj je zamenjen mitralni zalistak mehaničkom protezom zbog teške stenoze. Postoperativni tok je protekao uredno i pacijent-kinja je otpuštena sa terapijom antagonistom vitamina K sa ciljnim internacionalnim normalizovanim odnosom od 3,0. Pet meseci kasnije, pacijentkinja je primljena zbog gušenja i znakova akutne srčane slabosti. Vrednost protrombinskog vremena iznosila je 2,3. Transtorakalna ehokardiografija ukazala je na značajno povišene gradijente nad veštačkim zaliskom i postavljena je sumnja na malfunkciju mehaničke valvule. Sinevalvulografija je pokazala da je jedan listić veštačkog zaliska potpuno nepokretan. Transezofa-gealna ehokardiografija je definitivno potvrdila trombozu veštačkog zaliska sa multiplim velikim trombima koji su u potpunosti fik-sirali jedan listić u zatvorenoj poziciji, a takode delimično ograničili amplitudu pokreta drugog listića. Trombne mase su flotirale izmedu leve komore i leve pretkomore. Načinjena je trombektomija veštačkog zaliska, sto je bilo dovoljno za potpuni oporavak funk-cije mehaničkog zaliska. Doza antagoniste vitamina K je pažljivo povećana kako bi se dostigla i održala ciljna vrednost protrombinskog vremena od 3,0. Zaključak. Tromboza veštačkog zaliska je ozbiljno i životnougrožavajuće stanje koje zahteva hitno zbrinjavanje. Za optimalan izbor lečenja, koji primarno obuhvata operaciju ili fibrinolizu, neophodna je koordinacija i saradnja celog tima za srce. Ključne reči: veštački srčani zalistak; tromboza; mitralni zalistak; implantacija veštačkog zaliska; antikoagulanti; vitamin K; znaci i simptomi; dijagnoza; reoperacija