Massive Acute Thrombosis of a Mechanical Mitral Valve in a Young Patient on Acenocoumarin: A Case Report Comparing Surgical and Thrombolytic Approaches

Figures

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  FIGURE 1. Preoperative frontal chest X‐ray showing bilateral basal opacities with blunting of both pleural recesses, a normal‐appearing cardiac silhouette, sternal wire sutures, and the projection of the mechanical valve ring.

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  FIGURE 2. Contrast brain CT scan in axial slices, performed to investigate delayed thromboembolic complications, returned without abnormalities.

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  FIGURE 3. TEE in mid‐esophageal view, transducer at 0°, showing a thickened appearance of the St. Jude mechanical valve ring in an anatomical anti‐position (a) (red arrow) with multiple thrombi on the atrial (a, b) (black arrow) and ventricular (b) (orange arrow) sides of both the internal and external leaflets.

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  FIGURE 4. TEE 2D in the mid‐esophageal view, transducer at 105° (a, b), showing thrombi on the atrial side of both the internal and external leaflets of the mechanical valve on the aortic valve side as well as on the opposite side (black arrows), with a thickened appearance of the mechanical valve ring (red arrow) and multiple thrombi on the ventricular side (orange arrows).

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  FIGURE 5. TEE Doppler with the transducer at 105 degrees showing a very high mean transvalvular gradient of 27.85 mmHg on continuous Doppler, with a calculated valve area of 109.4 cm2 (a) in favor of stenosis, and severe thrombotic regurgitation with a mean gradient of 28.80 mmHg (b) in favor of severe mitral regurgitation.

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  FIGURE 6. Surgical image after right arteriotomy and expanded transseptal approach at the roof of the left atrium showing the appearance of the St. Jude mechanical valve completely thrombosed, encompassing the ring, both leaflets, and the core.

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  FIGURE 7. Perioperative image showing the St. Jude mechanical valve partially cleaned in its initial anatomical anti‐position during the extraction of remaining thrombi using forceps on the atrial side (a) (black arrow), the ventricular side (b) on the internal and external leaflets, and at the level of the coated ring (c, d) (blue arrows).

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  FIGURE 8. Surgical image showing a clean appearance of the St. Jude Medical mitral valve after being completely cleared of thrombi following saline washing, returned to its anatomical position, and opened freely around its pivot with both the anterior and posterior leaflets.

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  FIGURE 9. Postoperative continuous Doppler TEE on the mechanical mitral valve after weaning from CPB, showing a low mean gradient measured at 3 mmHg following cleaning of the valve.

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  FIGURE 10. Postoperative continuous Doppler TEE on the mechanical mitral valve 1 h after weaning from CPB, showing a mean gradient of approximately 4 mmHg, with a mitral valve area of around 22 mmHg.

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  FIGURE 11. Thoracic CT scan in the parenchymal window with axial cuts showing a posterior basal left alveolar consolidation syndrome consistent with pneumonia, given the clinical context of the patient (blue arrows).

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  FIGURE 12. Clinical course of prosthetic mitral valve thrombosis in a young patient with rheumatic heart disease.