Ravi Venkatesh, Chandran Aswathi, Matar Ralph, Pulipati Priyanjali, Yadav Neha
Cardiology, John H Stroger, Jr. Hospital of Cook County, Chicago, USA.
Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, Houston, USA.
Cureus. 2019 Jun 26;11(6):e5011. doi: 10.7759/cureus.5011.
Valvular obstruction is a rare but life-threatening complication of mechanical prosthetic valves that raises significant challenges in management. We describe a unique case of mechanical mitral valve obstruction with co-existing left atrial appendage (LAA) thrombus. A 48-year-old man with a past medical history of atrial fibrillation and mechanical mitral valve replacement 18 months prior, presented with symptoms of new onset heart failure for 10 days. INR on presentation was sub-therapeutic. Trans-thoracic and trans-esophageal echocardiography revealed prosthetic mitral valve obstruction with mobile, echogenic masses seen on the mechanical valve as well as LAA, suggestive of thrombus. His clinical course rapidly deteriorated and he developed cardiogenic shock. He was deemed to have prohibitive risk for emergent surgical intervention. He received trial of thrombolytic therapy, with partial improvement of hemodynamic parameters and a mild decrease in thrombus burden. He then underwent surgical intervention with a favorable outcome. Intra-operative visualization of the prosthetic valve revealed a combination of pannus and thrombus. Prosthetic valve function should be promptly assessed in patients presenting with heart failure symptoms, as clinical deterioration can be rapid. Acute presentation, history of inadequate anticoagulation and appearance of soft mass on an echocardiogram, are suggestive of thrombus as the etiology of valve obstruction. However, thrombus and pannus are known to frequently co-exist. Emergent surgery is the recommended management strategy in patients with left-sided prosthetic valve thrombosis with the New York Heart Association (NYHA) III or IV symptoms, due to a lower rate of thrombo-embolism, major bleeding, and recurrent prosthetic valve thrombosis when compared with thrombolytic therapy. Slow-infusion, low-dose thrombolytics were recently shown to have favorable outcomes and can be considered when surgery is not available or the patient is deemed to have prohibitive surgical risk.
瓣膜阻塞是机械人工瓣膜罕见但危及生命的并发症，在管理方面带来了重大挑战。我们描述了一例独特的机械二尖瓣阻塞合并左心耳（LAA）血栓的病例。一名48岁男性，既往有房颤病史，18个月前接受了机械二尖瓣置换术，因新发心力衰竭症状10天前来就诊。就诊时国际标准化比值（INR）未达到治疗水平。经胸和经食管超声心动图显示人工二尖瓣阻塞，在机械瓣膜以及左心耳上可见活动的、回声增强的团块，提示血栓形成。他的临床病程迅速恶化，发展为心源性休克。他被认为紧急手术干预的风险过高。他接受了溶栓治疗试验，血流动力学参数部分改善，血栓负荷略有减轻。然后他接受了手术干预，结果良好。术中观察人工瓣膜发现有纤维蛋白沉积和血栓形成。对于出现心力衰竭症状的患者，应及时评估人工瓣膜功能，因为临床恶化可能很快。急性发作、抗凝不足病史以及超声心动图上出现柔软团块，提示血栓是瓣膜阻塞的病因。然而，已知血栓和纤维蛋白沉积经常同时存在。对于有纽约心脏协会（NYHA）III或IV级症状的左侧人工瓣膜血栓形成患者，推荐的管理策略是紧急手术，因为与溶栓治疗相比，血栓栓塞、大出血和人工瓣膜血栓复发的发生率较低。最近研究表明缓慢输注低剂量溶栓药物有良好效果，当无法进行手术或患者被认为手术风险过高时可以考虑使用。
