Case Study
Nonobstructive mechanical prosthetic valve thrombosis with acute stroke
Asian Cardiovascular & Thoracic Annals 21(2) 196–198 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312449635 aan.sagepub.com
Prashanth Panduranga1, Taha Al-Delamie2 and Mohammed Al-Mukhaini1
Abstract Nonobstructive prosthetic valve thrombosis occurs more frequently during the early postoperative period due to increased thrombogenicity precipitated by inadequate anticoagulation. There is currently no consensus in the management of prosthetic valve thrombosis. We describe a patient with acute stroke secondary to nonobstructive prosthetic valve thrombosis that was due to inadequate anticoagulation. He was managed with intravenous anticoagulation with no resolution of the thrombus. Subsequently, he underwent successful surgical thrombectomy without valve replacement.
Keywords Anticoagulants, heart valve prosthesis implantation, stroke, thromboembolism, thrombosis
Introduction Left-sided prosthetic valve thrombosis (PVT) occurs at a rate of 0.5% to 8% per patient-year.1,2 We describe a patient with acute stroke secondary to nonobstructive prosthetic valve thrombosis (NOPVT) that was due to inadequate anticoagulation.
Case report A 15-year-old boy, who had undergone a bileaflet St. Jude mechanical mitral valve prosthesis implantation 1 month earlier, presented with a 3-h history of suddenonset right-sided dense hemiplegia. On examination, he was afebrile and in sinus rhythm with well-heard clicks of the mechanical valve. Transesophageal echocardiography (TEE) showed multiple mobile thrombi, measuring 1.5 cm in length, attached to left atrial side of the mechanical valve, prolapsing into the valve, but not causing any obstruction (Figure 1, Video 1). All blood investigations, including blood cultures, were normal except for an international normalized ratio of 1.8. Initial brain computed tomography was normal. Neurologist opinion was sought and they were reluctant to advise thrombolysis because the patient’s age was 0.8 cm2) was found to be an independent
Downloaded from aan.sagepub.com at UNIV OF ILLINOIS LAW LIBRARY on March 17, 2015
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Asian Cardiovascular & Thoracic Annals 21(2)
predictor of clinical success, in addition to a history of stroke;2 it was noted that in patients presenting with stroke, small NOPVT had a lower complication rate including emboli, with thrombolysis, compared to large NOPVT. The American College of Cardiology/ American Heart Association (ACC/AHA) and American College of Chest Physicians recommend fibrinolytic therapy as first-line treatment for patients in good functional class with low thrombus burden (5 mm or >0.8 cm2) obstructive or nonobstructive, irrespective of functional class, thrombolysis should be considered first if there are no contraindications.1,7–9 This is given class I guidance by the Working Group of the Society for Heart Valve Disease in 2005.7 Surgery should be considered as the initial modality of treatment in patients with an associated large left atrial thrombus, active bleeding, a history of intracranial bleeding, evidence of ischemic stroke within the time frame of 4 h to 6 weeks, or during the early postoperative period after valve replacement (
Nonobstructive mechanical prosthetic valve thrombosis with acute stroke
Asian Cardiovascular & Thoracic Annals 21(2) 196–198 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312449635 aan.sagepub.com
Prashanth Panduranga1, Taha Al-Delamie2 and Mohammed Al-Mukhaini1
Abstract Nonobstructive prosthetic valve thrombosis occurs more frequently during the early postoperative period due to increased thrombogenicity precipitated by inadequate anticoagulation. There is currently no consensus in the management of prosthetic valve thrombosis. We describe a patient with acute stroke secondary to nonobstructive prosthetic valve thrombosis that was due to inadequate anticoagulation. He was managed with intravenous anticoagulation with no resolution of the thrombus. Subsequently, he underwent successful surgical thrombectomy without valve replacement.
Keywords Anticoagulants, heart valve prosthesis implantation, stroke, thromboembolism, thrombosis
Introduction Left-sided prosthetic valve thrombosis (PVT) occurs at a rate of 0.5% to 8% per patient-year.1,2 We describe a patient with acute stroke secondary to nonobstructive prosthetic valve thrombosis (NOPVT) that was due to inadequate anticoagulation.
Case report A 15-year-old boy, who had undergone a bileaflet St. Jude mechanical mitral valve prosthesis implantation 1 month earlier, presented with a 3-h history of suddenonset right-sided dense hemiplegia. On examination, he was afebrile and in sinus rhythm with well-heard clicks of the mechanical valve. Transesophageal echocardiography (TEE) showed multiple mobile thrombi, measuring 1.5 cm in length, attached to left atrial side of the mechanical valve, prolapsing into the valve, but not causing any obstruction (Figure 1, Video 1). All blood investigations, including blood cultures, were normal except for an international normalized ratio of 1.8. Initial brain computed tomography was normal. Neurologist opinion was sought and they were reluctant to advise thrombolysis because the patient’s age was 0.8 cm2) was found to be an independent
Downloaded from aan.sagepub.com at UNIV OF ILLINOIS LAW LIBRARY on March 17, 2015
198
Asian Cardiovascular & Thoracic Annals 21(2)
predictor of clinical success, in addition to a history of stroke;2 it was noted that in patients presenting with stroke, small NOPVT had a lower complication rate including emboli, with thrombolysis, compared to large NOPVT. The American College of Cardiology/ American Heart Association (ACC/AHA) and American College of Chest Physicians recommend fibrinolytic therapy as first-line treatment for patients in good functional class with low thrombus burden (5 mm or >0.8 cm2) obstructive or nonobstructive, irrespective of functional class, thrombolysis should be considered first if there are no contraindications.1,7–9 This is given class I guidance by the Working Group of the Society for Heart Valve Disease in 2005.7 Surgery should be considered as the initial modality of treatment in patients with an associated large left atrial thrombus, active bleeding, a history of intracranial bleeding, evidence of ischemic stroke within the time frame of 4 h to 6 weeks, or during the early postoperative period after valve replacement (
