Emergency surgical treatment for partial obstruction of a mitral mechanical prosthetic valve due to thrombosis in a 71-year-old woman resulted in cardiogenic shock and death.
Case Report (n=1)
This case highlights the critical role of multimodality imaging, particularly echocardiography, in the timely diagnosis of mechanical prosthetic valve thrombosis, a devastating complication associated with sub-optimal anticoagulation.
We present a case of a 71-year-old woman who came to the emergency department with incoercible vomiting and sudden onset of dyspnoea and fatigue. Vital signs are as follows: blood pressure 90/60 mmHg, heart rate 117 bpm, and O2 saturation 92% on room air. She had previous history of mitral and aortic valve replacement and a sub-optimal INR of 1.4; therefore, a transthoracic echocardiogram was immediately performed (Figure 1A and B), showing increased pulmonary arterial systolic pressure (64 mmHg) and dilation of the right cavities, as well as a high mitral gradient (24.5 mmHg) and an effective mitral orifice area of 1.63 cm2. Transesophageal echocardiography (TEE) detected a partial obstruction of the mitral prosthetic valve due to thrombosis. Magnetic resonance discarded the presence of a cerebral cardioembolic event. The patient underwent emergency surgical treatment, with the unfortunate outcome of cardiogenic shock and death. (A) Transthoracic Doppler tracing of the mitral prosthetic valve. Peak velocity of 2.47 m/s, high gradient (24.5 mmHg), and an effective orifice area of 1.63 cm2. (B) Bidimensional transthoracic echocardiography in four-chamber view. Increased pulmonary artery pressure is demonstrated, with a peak regurgitant tricuspid velocity gradient 44 mmHg and right atrial pressure 20 mmHg. (C) Transesophageal two-dimensional colour Doppler echocardiography. Isovelocity in one of the discs of the prosthetic mitral leaflet (white arrow). (D) Transesophageal three-dimensional echocardiography. Surgical view of the mitral mechanical bi-leaflet prosthetic valve showing a thrombus (red arrow) in one of the discs. (E) Cardiac fluoroscopy. Restricted mitral movement of one of the discs of the mechanical valve is pointed by yellow arrow. (F) Surgical specimen. The white arrow is pointing the site where the thrombosis occurred, and the red arrow showed the thrombus. (G) Cardiac fluoroscopy. Adequate function of the aortic mechanical prosthetic valve is observed (white arrows). (H) Transesophageal three-dimensional echocardiography. Surgical view of the tricuspid valve showing thickening of the leaflets and severe regurgitation (white arrow). Ao, aorta; LA, left atrium; LAA, left atrial appendage; RA, right atrium; RV, right ventricle; TV, tricuspid valve. The objective of this Images in Cardiology is to showcase the imaging findings of this devastating complication. Bidimensional and colour Doppler TEE showed isovelocity (white arrow) in one of the discs of the prosthetic mitral valve suggestive of partial obstruction (Figure 1C; Supplementary material online, Video S1). Surgical view of the mitral mechanical bi-leaflet prosthetic valve in three-dimensional TEE showing a thrombus (red arrow) in one of the discs (Figure 1D; Supplementary material online, Video S2). Cardiac fluoroscopy evidenced a restricted mitral motion of one of the discs of the mechanical prosthetic valve (Figure 1E; Supplementary material online, Video S3). Surgical specimen (Figure 1F) of the prosthetic mitral valve where the site of thrombosis (white arrow) and the thrombus (red arrow) are visualized. Cardiac fluoroscopy demonstrated normal function of the aortic mechanical prosthetic valve (white arrows) (Figure 1G; Supplementary material online, Video S4). Three-dimensional surgical view of the tricuspid valve, showing thickening of the leaflets and severe regurgitation (Figure 1H; Supplementary material online, Video S5). Mechanical prosthetic valve thrombosis is a challenging diagnosis; echocardiography is crucial for a timely diagnosis and treatment. Close follow-up is recommended to assure a good anticoagulation regimen to avoid these complications. Supplementary material is available at European Heart Journal—Quality of Care and Clinical Outcomes online. Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance. Conflict of interest: None declared. Funding: None declared. The data underlying this article will be available on request to the corresponding author. The supplementary material is available online. All the videos (S1–S5) are in MP4 format.
Espínola‐Zavaleta et al. (2022) conducted a case report in Partial obstruction of a mitral mechanical prosthetic valve due to thrombosis (n=1). Emergency surgical treatment was evaluated on Cardiogenic shock and death. Emergency surgical treatment for partial obstruction of a mitral mechanical prosthetic valve due to thrombosis in a 71-year-old woman resulted in cardiogenic shock and death.