PMID- 31497441
OWN - NLM
STAT- PubMed-not-MEDLINE
LR  - 20201001
IS  - 2168-8184 (Print)
IS  - 2168-8184 (Electronic)
IS  - 2168-8184 (Linking)
VI  - 11
IP  - 6
DP  - 2019 Jun 26
TI  - Prosthetic Mitral Valve Obstruction with Left Atrial Appendage Thrombus: A 
      Therapeutic Dilemma.
PG  - e5011
LID - 10.7759/cureus.5011 [doi]
LID - e5011
AB  - 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.
FAU - Ravi, Venkatesh
AU  - Ravi V
AD  - Cardiology, John H Stroger, Jr. Hospital of Cook County, Chicago, USA.
FAU - Chandran, Aswathi
AU  - Chandran A
AD  - Gastroenterology, Hepatology and Nutrition, University of Texas Health Science 
      Center at Houston, Houston, USA.
FAU - Matar, Ralph
AU  - Matar R
AD  - Cardiology, John H Stroger, Jr. Hospital of Cook County, Chicago, USA.
FAU - Pulipati, Priyanjali
AU  - Pulipati P
AD  - Medicine, Jawaharlal Nehru Medical College, KLE University, Belgaum, IND.
FAU - Yadav, Neha
AU  - Yadav N
AD  - Cardiology, John H Stroger, Jr. Hospital of Cook County, Chicago, USA.
LA  - eng
PT  - Case Reports
DEP - 20190626
PL  - United States
TA  - Cureus
JT  - Cureus
JID - 101596737
PMC - PMC6716757
OTO - NOTNLM
OT  - pannus
OT  - prosthetic mitral valve obstruction
OT  - thrombolytics
OT  - thrombus
COIS- The authors have declared that no competing interests exist.
EDAT- 2019/09/10 06:00
MHDA- 2019/09/10 06:01
PMCR- 2019/06/26
CRDT- 2019/09/10 06:00
PHST- 2019/09/10 06:00 [entrez]
PHST- 2019/09/10 06:00 [pubmed]
PHST- 2019/09/10 06:01 [medline]
PHST- 2019/06/26 00:00 [pmc-release]
AID - 10.7759/cureus.5011 [doi]
PST - epublish
SO  - Cureus. 2019 Jun 26;11(6):e5011. doi: 10.7759/cureus.5011.