Among patients requiring device system revision for Twiddler's syndrome, the use of nonabsorbable antimicrobial pouches was associated with significantly fewer recurrences of lead dislodgement events.
We report a 73-year-old male with late onset monomorphic ventricular tachycardia following mitral valve repair (MVR). Typically, injury to epicardial arteries following mitral valve repair/replacement presents immediately as ventricular tachycardia/fibrillation, difficulty weaning from cardiopulmonary bypass, worsening ECG changes, increasing cardiac biomarkers, or new wall motion abnormalities. Our case illustrates a “late complication” of a distorted circumflex artery following mitral valve repair and the importance of early diagnostic angiography and percutaneous intervention.
Background:
Obstruction of prosthetic heart valves may be caused by thrombus formation and/or pannus in-growth. Thrombosis is more likely with inadequate anticoagulation and associated with more acute onset of symptoms.
Case:
A 36 year old female with a history of bicuspid aortic valve, now with a mechanical aortic valve (21mm Carbomedics Top-Hat) presented with sudden onset of exertional dyspnea and orthopnea (NYHA Class III). She had been compliant with anticoagulation, with bi-monthly INRs ≥2.5. On admission, her INR was 3.14. Physical exam revealed pedal edema and 3/6 crescendo-decrescendo murmur radiating to the carotids.
Transthoracic echocardiogram (TTE) showed a left ventricular ejection fraction of 45-50% and a prosthetic aortic valve with significantly increased transvalvular gradients (peak gradient of 68 and mean gradient of 43 mmHg). Transesophageal echocardiogram revealed restricted motion of one of the leaflets without obvious vegetations or masses. Fluoroscopy in multiple views confirmed prosthetic valve dysfunction with only one functioning leaflet.
Decision-making:
Given the sudden onset of symptoms, thrombosis was suspected as the most likely etiology. The patient opted against re-do surgery, thus a decision was made to attempt thrombolysis.
After several hours of an unfractionated heparin (UH) drip, thrombolysis with Alteplase was attempted with a 10mg IV bolus followed by a 90mg infusion. The infusion was breviated due to severe abdominal pain and concern for bleeding, but her hemodynamics and hematocrit remained stable. The efficacy of the therapy was assessed by repeat TTE and fluoroscopy. TTE showed a peak gradient of 37.5 and a mean gradient of 17mmHg (within the normal range for this valve type). Fluoroscopy showed good motion of both valve leaflets. She showed significant clinical improvement. UH infusion was continued as a bridge to a new higher INR goal of 3.5 (3.0-4.0).
Conclusion:
This case demonstrates the importance of including valve thrombosis in the differential diagnosis of valve malfunction even in the setting of uninterrupted anticoagulation with goal INR. It also stresses good history taking and building a contextualized, patient-relevant differential diagnosis.
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