Mechanical prosthetic valve thrombosis (PVT) is a serious condition that is associated with various life-threatening complications. The utilization of multimodality imaging techniques is critical in identifying this etiology. Its management is complex and often requires repeat surgical valve replacements. Our report describes the case of a 48-year-old female who presented with mechanical mitral valve thrombosis in the setting of subtherapeutic anticoagulation. Due to her complex surgical history, nonsurgical therapeutic options were initially pursued for management. Through shared decision-making and after exhaustion of other alternatives, she was maintained on optimized medical therapy and was scheduled for repeat elective surgery. After compliance with medical therapy and close monitoring, she improved significantly, and her underlying pathology completely resolved, eliminating the need for surgery. This report indicates that the management of mechanical prosthetic valve thrombosis should be individualized and emphasizes the importance of involving a multidisciplinary team of medical and surgical professionals to achieve the best clinical outcomes

Elkhatib, Layan

Hanson, Christopher

Qintar, Mohammed

Sabanci, Rand

Saeed Al-Asad, Khalid

English

Henry Ford Health System Scholarly Commons

Henry Ford Health Henry Ford Health Scholarly Commons Cardiology Articles Cardiology/Cardiovascular Research 6-1-2023 The Complex Management of Mechanical Prosthetic Valve Thrombosis Khalid Saeed Al-Asad Rand Sabanci Layan Elkhatib Mohammed Qintar Christopher Hanson Follow this and additional works at: https://scholarlycommons.henryford.com/cardiology_articles Review began 06/21/2023 Review ended 06/29/2023 Published 06/30/2023© Copyright 2023Saeed Al-Asad et al. This is an openaccess article distributed under the terms ofthe Creative Commons Attribution LicenseCC-BY 4.0., which permits unrestricted use,distribution, and reproduction in anymedium, provided the original author andsource are credited.The Complex Management of MechanicalProsthetic Valve ThrombosisKhalid Saeed Al-Asad  , Rand Sabanci  , Layan El-khatib  , Mohammed Qintar  , Christopher Hanson 1. Internal Medicine, Michigan State University, East Lansing, USA 2. Department of Cardiology, Henry Ford HealthSystem, Detroit, USA 3. Department of Cardiology, Sparrow Hospital Thoracic and Cardiovascular Institute, Lansing,USACorresponding author: Khalid Saeed Al-Asad, saeedala@msu.eduAbstractMechanical prosthetic valve thrombosis (PVT) is a serious condition that is associated with various life-threatening complications. The utilization of multimodality imaging techniques is critical in identifying thisetiology. Its management is complex and often requires repeat surgical valve replacements. Our reportdescribes the case of a 48-year-old female who presented with mechanical mitral valve thrombosis in thesetting of subtherapeutic anticoagulation. Due to her complex surgical history, nonsurgical therapeuticoptions were initially pursued for management. Through shared decision-making and after exhaustion ofother alternatives, she was maintained on optimized medical therapy and was scheduled for repeat electivesurgery. After compliance with medical therapy and close monitoring, she improved significantly, and herunderlying pathology completely resolved, eliminating the need for surgery. This report indicates that themanagement of mechanical prosthetic valve thrombosis should be individualized and emphasizes theimportance of involving a multidisciplinary team of medical and surgical professionals to achieve the bestclinical outcomes.Categories: Cardiac/Thoracic/Vascular Surgery, CardiologyKeywords: therapeutic anticoagulation, therapeutic interventions, multidisciplinary heart team, multimodalitycardiac imaging, mechanical prosthetic valve thrombosisIntroductionProsthetic valve thrombosis (PVT) is a serious complication of valve replacement that is associated withhigh morbidity and mortality, especially with mechanical prostheses. Prompt recognition of the condition iscrucial, as it necessitates the urgent initiation of therapeutic interventions to restore valve function andprevent complications. The diagnostic approach to PVT depends on clinical evaluation, echocardiography,and other imaging modalities, including computed tomography (CT) and fluoroscopy. Different therapeuticinterventions are available for PVT, including optimization of anticoagulation, fibrinolytic therapy, andsurgery [1,2]. The choice of the optimal management strategy is usually individualized and considers variousfactors, such as the clinical presentation, thrombus burden, presence of obstruction, location of the valve,the patient's surgical risk, and the experience and expertise of the managing team. This report describes thecomplex and successful management of a challenging case of mechanical mitral valve thrombosis in apatient with a complex surgical history.Case PresentationA 48-year-old female presented with complaints of dyspnea, orthopnea, and progressively worsening fatigueover the course of two weeks. Her medical history was significant for Ehlers-Danlos syndrome, severe mitralinsufficiency that was treated with mitral valve replacement with a bi-leaflet mechanical prosthesis tenyears prior to presentation, a chronic interstitial lung disease with recurrent pleural effusions andpneumothoraces that had required bilateral thoracotomies and decortications, and severe autonomicdysfunction that had required permanent pacemaker placement.Upon evaluation, the patient looked to be in acute distress with increased breathing. Her vital signs showedthat her heart rate was 131, her respiratory rate was 27, and her oxygen saturation was low at 85% in ambientair. Her temperature and blood pressure were within normal limits. The physical exam was significant forrales on auscultation of the lung fields bilaterally and for pitting edema in the lower extremities up to theknees. The rest of her physical exam was unremarkable. Initial investigatory work-up showed an elevatedlevel of beta-natriuretic peptide (1553 pg/mL) and intermediately elevated high-sensitivity troponin levels(450 pg/mL) that down-trended shortly after (131 pg/mL). The EKG showed sinus rhythm without signs ofactive ischemia. Chest radiographs showed cardiomegaly with signs of pulmonary vascular congestion,consistent with the clinical picture of acute congestive heart failure. Further testing revealed aninternational normalized ratio (INR) of 1.0 in the setting of the patient being noncompliant with hermedication regimen, including Warfarin, during the few weeks prior to her presentation.The patient was admitted to the hospital and started on intravenous (IV) Furosemide as part of the1 1 2 3 3 Open Access CaseReport  DOI: 10.7759/cureus.41214How to cite this articleSaeed Al-Asad K, Sabanci R, El-Khatib L, et al. (June 30, 2023) The Complex Management of Mechanical Prosthetic Valve Thrombosis. Cureus15(6): e41214. DOI 10.7759/cureus.41214management of a heart failure exacerbation. She was also started on IV Heparin with a plan to bridge toWarfarin therapy given the underlying mechanical mitral prosthesis. Her respiratory status graduallyimproved throughout the course of her hospital stay, and she was weaned off supplemental oxygen. As partof the complete workup, her transthoracic echocardiogram (TTE) showed normal left ventricular functionbut revealed right ventricular dysfunction and elevated pressure gradients across the mechanical mitralvalve, suggesting severe stenosis. The mitral valve leaflets were not well visualized, and a transesophagealechocardiogram (TEE) was needed to complete the evaluation. TEE revealed a frozen posterior leaflet of theprosthetic valve with an overlying thrombus on the atrial side (Figure 1).FIGURE 1: Initial transesophageal echocardiogram.(A) Mechanical prosthesis during systole, (B) mechanical valve prosthesis during diastole with turbulent bloodflow on color doppler, and (C) elevated pressure gradients across the mechanical prosthesis.The patient was counseled on her underlying condition and was informed that the standard of care in hersituation would have been mitral valve replacement via conventional surgery. She, however, expressed adesire to explore all other nonsurgical options, considering her prior numerous thoracic surgeries. She wasoffered fibrinolytic therapy as well as the off-label use of a percutaneous aspiration thrombectomy device,which she opted to proceed with. She was subsequently evaluated by structural cardiology and underwent astructural CT scan of the heart for planning. The study confirmed that the posterior leaflet of the mechanicalvalve was frozen but did not visualize the thrombus on the mechanical prosthesis (Figure 2). In light of this,the procedure was deemed inappropriate and was subsequently canceled.FIGURE 2: Structural computed tomography of the heart.(A) Appropriately closed mechanical mitral valve leaflets during systole and (B) fixed valve leaflet (red arrow)during diastole with narrowing of the mitral opening.Eventually, the patient was evaluated by the cardiothoracic surgical team with the intention of undergoing arepeat surgical mitral valve replacement. By that time, she had significantly improved from a clinicalstandpoint, and her INR was in the therapeutic range. Through shared decision-making involving themedical and surgical teams as well as the patient, she was discharged from the hospital on Warfarin and oraldiuretics and was scheduled for surgery 30 days after her initial presentation. The patient underwent afollow-up TTE 10 days prior to her scheduled surgery with the hope that her frozen leaflet had normalizedwhile her INR was within the goal range; however, the study did not show any significant changes. Thepatient presented to the operating room on her scheduled appointment, whereby a TEE was performed,showing normalization of the pressure gradients across the mitral valve and that the previously frozenleaflet was then functional (Figure 3). The patient was subsequently discharged and treated medically on anoutpatient basis without major complications.2023 Saeed Al-Asad et al. Cureus 15(6): e41214. DOI 10.7759/cureus.41214 2 of 4FIGURE 3: Intra-operative transesophageal echocardiogram.(A) 2D visualization of the mitral prosthesis during systole with color doppler; (B) 2D visualization of the mitralprosthesis during diastole with color doppler; (C) pressure gradients across the mitral prosthesis; (D) 3Dvisualization of the mitral prosthesis during systole; (E) 3D visualization of the mitral prosthesis during diastole.DiscussionPVT is a pathological entity characterized by thrombus formation on the prosthetic structure andsubsequent prosthesis dysfunction. This can be associated with or without thromboembolism. Mechanicalprostheses are more durable than bioprosthetic valves and are preferred by younger patients requiring valvereplacement to avoid the need for reoperation [3]. Mechanical valves, however, are more thrombogenic andrequire long-term anticoagulation with a vitamin-K antagonist (VKA) [4]. The annual rate of mechanicalvalve thrombosis ranges from 0.1% to 5.7%, with the mitral location being roughly five times morecommonly involved than the aortic one [2,4]. Mechanical PVT is a complex medical condition and isassociated with significant morbidity and mortality. It requires prompt diagnosis and immediate treatmentto relieve symptoms and prevent complications.Mechanical PVT is a subacute to acute process that results in valve dysfunction due to abnormal or absentleaflet motion. Like the case presented in our report, mechanical PVT is typically seen in association withsubtherapeutic INR due to inadequate VKA anticoagulation. To date, VKAs remain the cornerstone oftherapy for patients with mechanical valve prostheses [4]. Direct oral anticoagulants are not approved forthese patients. The use of these agents has been reported to be associated with failure of therapy and thedevelopment of PVT [5].The clinical presentation of mechanical PVT can vary widely and is largely dependent on the acuity ofthrombus formation and the degree of valvular obstruction. Obstructive mechanical PVT is associated withhemodynamic compromise and typically presents with the clinical symptoms of reduced cardiac output andheart failure. The presentation is often insidious, with progressively worsening symptoms of dyspnea inmost patients. Delays in the diagnosis of obstructive mechanical PVT can lead to the development offulminant cardiogenic shock. Non-obstructive mechanical PVT is typically present in asymptomatic patientson routine echocardiography or as part of the work-up for the etiology of a thromboembolic event [2]. Thepatient described in our report had a partial valvular obstruction and presented with symptoms of heartfailure. She was diagnosed and started on medical management in a timely fashion before the developmentof shock.When suspecting PVT, a thorough physical exam should be performed. One common finding in patients withobstructive PVT is the muffling or disappearance of the prosthetic sounds or the development of a newmurmur [1]. Other signs of congestive heart failure, including jugular venous distention, lower extremitypitting edema, and crackles on chest auscultation, are typically present. Initial basic work-up includescardiac biomarkers, which are typically normal or mildly elevated, and chest radiographs that may showsigns of pulmonary vascular congestion and pulmonary edema. A definitive workup incorporatesechocardiography, TTE, and TEE, with emphasis on structural abnormalities, leaflet motion, and pressuregradients across the prosthesis. CT or cinefluoroscopic imaging is also part of the investigatory evaluation.Invasive hemodynamic testing is rarely done for the evaluation of PVT [1]. Our patient’s imaging studiesrevealed elevated pressure gradients across the mitral prosthesis and fixation of one leaflet, and they wereable to visualize the thrombus density on echocardiography. Structural CT demonstrated the frozenprosthetic valve leaflet of the mechanical mitral valve.2023 Saeed Al-Asad et al. Cureus 15(6): e41214. DOI 10.7759/cureus.41214 3 of 4The current treatment guidelines recommend that patients presenting with a thrombosed mechanical valveundergo definitive therapy. The two options of low-dose continuous-infusion thrombolytic therapy orsurgery are both effective, with the decision to proceed with either one based on multiple clinical factors andlocal experience and expertise [4]. The case described in this report shows that when the decision to proceedwith repeat surgical or thrombolytic therapies is difficult to make, medical optimization of anticoagulationand heart failure management can result in positive outcomes and even resolution of valvular obstructionand normalization of prosthesis function. The decision to proceed with this approach, however, is difficult tomake and should be individualized based on multiple variables related to the patient's stability and riskfactors.ConclusionsMechanical prosthetic valve thrombosis is a complex condition that is associated with life-threateningcomplications. Choosing the best therapeutic approach for patients with this entity should be individualizedbased on variable factors. The decision-making process involved is typically complicated and is bestrewarded when a multi-disciplinary team of medical and surgical professionals is involved.Additional InformationDisclosuresHuman subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: Incompliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/servicesinfo: All authors have declared that no financial support was received from any organization for thesubmitted work. Financial relationships: All authors have declared that they have no financialrelationships at present or within the previous three years with any organizations that might have aninterest in the submitted work. Other relationships: All authors have declared that there are no otherrelationships or activities that could appear to have influenced the submitted work.References1. Roudaut R, Serri K, Lafitte S: Thrombosis of prosthetic heart valves: diagnosis and therapeuticconsiderations. Heart. 2007, 93:137-42. 10.1136/hrt.2005.0711832. Lim WY, Lloyd G, Bhattacharyya S: Mechanical and surgical bioprosthetic valve thrombosis . Heart. 2017,103:1934-41. 10.1136/heartjnl-2017-3118563. Dangas GD, Weitz JI, Giustino G, Makkar R, Mehran R: Prosthetic heart valve thrombosis . J Am Coll Cardiol.2016, 68:2670-89. 10.1016/j.jacc.2016.09.9584. Otto CM, Nishimura RA, Bonow RO, et al.: 2020 ACC/AHA guideline for the management of patients withvalvular heart disease: a report of the American College of Cardiology/American Heart Association JointCommittee on clinical practice guidelines. Circulation. 2021, 143:e72-e227. 10.1161/CIR.00000000000009235. Carvalho Silva DM, Braga A, de Jesus I, Neves J: Mechanical prosthetic heart valve thrombosis in a patientreceiving rivaroxaban. Cardiology. 2019, 143:116-20. 10.1159/0005013612023 Saeed Al-Asad et al. Cureus 15(6): e41214. DOI 10.7759/cureus.41214 4 of 4

The Complex Management of Mechanical Prosthetic Valve Thrombosis

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The Complex Management of Mechanical Prosthetic Valve Thrombosis

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