2019 Research Forum

Applicant: Ahana Sandhu MD R3 Principal Investigator & Faculty Sponsor: Fowrooz Joolhar MD

Anticoagulation Conundrum: Mechanical Mitral Valve Thrombosis in Pregnant Patient on Enoxaparin

Ahana Sandhu MD R3, Kieran Doyle MS IV, Kathleda Tangonan MS IV, Ramanjeet Sidhu MD R3, Fowrooz Joolhar MD

INTRODUCTION Mechanical prosthetic valves for many decades have bestowed upon patient’s around the world a second chance after their native valves have been ravaged by disease or rendered non-functional by congenital anomalies. However, these miraculous interventions have their own hidden costs in the form of increased risk of thrombosis, which to a great extent is dependent as much as on the type of the valve but also its position. PURPOSE Furthermore, the patient’s own propensity towards thrombus formation, be it a hereditary predilection or being in an increased hypercoagulable physiological state such as pregnancy, makes the presence of these prosthetic valves an issue of even greater concern. DISCUSSION We present here a case of a 33-year-old gravid female with a mechanical prosthetic valve at the mitral position who had been on anticoagulation with Warfarin when she discovered she was pregnant. She then abruptly stopped this medication. Subsequently this patient was found to have a thrombus on her mechanical mitral valve on transesophageal echo after presenting to the emergency department with left upper quadrant pain and elevated troponin. This patient was initiated on a therapeutic dose of Enoxaparin and levels of Xa were monitored every 4-6 hours to ensure therapeutic targets were met. This patient had declined to restart Warfarin earlier due to concerns of the risks it posed to her pregnancy. This patient was transferred to a higher level of care due to being a high-risk OB pregnancy with plans to continue monitoring thrombus progression with serial transthoracic echoes. CONCLUSION Multiple recommendations exist regarding the management of thrombus formation in patients with prosthetic valves be it bio prosthetic or mechanical. However, there is no clearcut dictum in the literature regarding the approach to this issue. This case serves to highlight the importance of tailoring the treatment plan in accordance with the priorities of the patient, as well as ensuring clear communication regarding the treatment including a detailed discussion of the risks, benefits and alternatives.

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