This case illustrates that bioprosthetic thrombosis and degeneration can occur in the same valve but with different topographical distributions, suggesting they may not have a causal relationship.
Prompts vigilant echo surveillance for bioprosthetic valve thrombosis in symptomatic patients; leaves open optimal anticoagulation strategies in young adults.
A 35-year-old woman with a history of multiple valvular interventions presented with severe dyspnoea with minimal exertion. In 2010, she underwent tricuspid and mitral valve replacement with bioprostheses (personal choice) after an episode of endocarditis. In 2012, she presented with thrombosis of the mitral bioprosthesis. Typical soft echodense material was present on the ventricular side (top left: diastolic frame; see Supplementary data online, Movie S1) of the antero-lateral and antero-medial cusps, which were rendered immobile (bottom left: 3D diastolic frame). Bioprosthetic thrombosis was confirmed by resolution of echocardiographic findings after 1 month of warfarin anticoagulation; recurrent endocarditis was ruled out by inflammatory markers and serial blood cultures, and no antibiotic therapy was given. During current episode (2017), mitral gradient increased to 7 mmHg despite chronic warfarin anticoagulation. At transoesophageal echocardiography (TOE), the antero-lateral and posterior mitral bioprosthetic cusps appeared immobile, but relatively thin and echo-bright (top right; 2D diastolic frame; bottom right 3D diastolic frame; see Supplementary data online, Movie S1), consistent with bioprosthetic degeneration. These findings demonstrate that bioprosthetic degeneration can occur despite use of chronic anticoagulation. Furthermore, the presence of degenerative changes of the previously unaffected posterior cusp, and preserved appearance and mobility of the antero-medial cusp (involved in the earlier episode) suggest that bioprosthetic thrombosis and bioprosthetic degeneration were unrelated in this patient. This case illustrates how these events can occur in the same valve, but with a different topographical distribution, suggesting that thrombus formation and degeneration might share a common unknown predisposing factor, but not necessarily have a causal relationship. Supplementary data are available at European Heart Journal—Cardiovascular Imaging online.
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Petrescu et al. (2017) studied this question.
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