2019 Research Forum

Ahana Sandhu MD R3, Kieran Doyle MS IV, Kathleda Tangonan MS IV, Ramanjeet Sidhu MD R3, Fowrooz Joolhar MD ANTICOAGULATION CONUNDRUM: MECHANICAL MITRAL VALVE THROMBOSIS IN PREGNANT PATIENT ON ENOXAPARIN Department of Medicine, Kern Medical, Bakersfield, CA United States

Introduction

Discussion

Conclusions

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. 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. 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 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 due to concerns of the risks it posed to her pregnancy. This patient was monitored closely with serial echoes and delivered without complications at 37 weeks and was restarted on Warfarin thereafter to continue lifelong anticoagulation for her mechanical mitral valve.

Multiple recommendations exist regarding the management of thrombus formation in patients with prosthetic valves be it bio prosthetic or mechanical, however, there are no clear cut dictum available 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. Nishimura R.A., Otto C.M., Bonow R.O., et al. (2014) 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [Published correction appears in J Am Coll Cardiol 2014;63:2489]. J Am Coll Cardiol63:e57–e185. Roudaut R., Serri K., Lafitte S. (2007) Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations. Heart 93:137–142. Lin S.S., Tiong I.Y., Asher C.R., et al. (2000) Prediction of thrombus-related mechanical prosthetic valve dysfunction using transesophageal echocardiography. J Am Coll Cardiol 86:1097–1101. ArchGynecolObstet.2016 Jan;293(1):69-74. doi: 10.1007/s00404-015-3768-0. Epub 2015 Jun 6. Anticoagulant management of pregnant women with mechanical heart valve replacement during perioperative period. Bian C, et al. J Heart Valve Diseease. 2003 May;12(3):370-6.Pregnancy after mechanical mitral valve replacement. Vural KM, et al Int Jer Infertil Steril. 2011 Apr;5(1):47-51. Epub 2011 Mar 21. Anti-coagulation during pregnancy in women with mechanical heart valves: a prospective study. Khamoushi AJ, et al. Cardiovasc Ther. 2017 Dec;35(6). doi: 10.1111/1755- 5922.12292.Comparison of anticoagulation regimens for pregnant women with prosthetic heart valves: A meta- analysis of prospective studies. Wang, J, et al. Eur Heart Journal. 2017 May 14;38(19):1509-1516. doi: 10.1093/eurheartj/ehx032.Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis. Dsouza R, et al. Howe A M Teratology Vol 46 (4) 1992 379-390 Hou JW Chang Gung Med J Vol 27 (9) 2004

Purpose

References

Health.Harvard.edu

Discussion

THROMBI ATTACHED TO SEWING RING OF ANTERIOR AND POSTERIOR MECHANICAL MITRAL VALVE LEAFLETS

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