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Abstract
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CLEAR FILTERS
Prosthetic valve thrombosis: misfortunes never come alone
Session:
Prémio Melhor Caso Clínico
Speaker:
Mariana Passos
Congress:
CPC 2022
Topic:
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Theme:
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Subtheme:
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Session Type:
Prémios
FP Number:
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Authors:
Mariana Passos; Joana Lima Lopes; Carolina Mateus; Inês Fialho; Marco Beringuilho; João Baltazar; João Bicho Augusto; Gonçalo Simôa; José Morais; António Freitas; Luís Brízida; Carlos Morais; David Roque
Abstract
<p style="text-align:justify"><span style="font-size:10pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif">A 46-year-old woman, admitted in the orthopedic service due to a femoral exposed fracture caused by a shotgun, developed sudden chest pain and dyspnea after 13 days without anticoagulation. Medical history included mitral and aortic mechanical valve replacement, due to rheumatic disease, and an aortic valve redo surgery due to prosthetic valve thrombosis (PVT). TTE and TEE showed an anterolateral mitral leaflet block with a mean gradient of 18 mmHg and an increased transaortic flow (mean gradient 34mmHg) suggesting, in this context, prosthetic aortic and mitral valves thrombosis. The mitral valve thrombotic burden was considered low; however the aortic valve burden was not possible to estimate. </span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif"><span style="color:black">RV was severely dilated with a D-shaped LV and a SPAP of 95mmHg. </span></span></span></span></span><span style="font-size:10pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif"><span style="color:black">T</span></span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif">he patient was admitted to the ICCU, hemodynamically stable, and started on unfractionated heparin (UFH), 100mg of ASA, and furosemide. 4 days after, she developed cardiogenic shock. Due to prohibitive surgical risk and hemorraphic risk we proceeded to low dose-slow infusion fibrinolysis (25mg/6h) with alteplase (t-PA), as well as inhaled nitric oxide (iNO) at 20 ppm. 24h later, TTE revealed no regression of the prothesis gradients. There were no hemorrhagic complications. Since she was sliding on NA, we employed an accelerated fibrinolytic approach with 100mg of t-PA, during a 4h infusion, with maintenance of the iNO. There was clinical and hemodynamic improvement and mild hemorrhagic complications. A new TTE showed persistence of the mitral leaflet occlusion, but improvement of transprosthesis gradients, reduction of the RV dimensions and SPAP 65mmHg. Fluoroscopy confirmed mitral leaflet occlusion and revealed preserved aortic leaflets motion. 4 days after fibrinolysis, sedation was stopped and a right hemiparesis was noted. Brain CT angiogram showed a thrombus on the left middle cerebral artery, without indication for thrombectomy. The patient was maintained 6 days on UFH and ASA, and switched to warfarin to a target INR of 3-3.5. A FUP TTE showed a normalization </span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif">of both valves transprosthetic gradients and </span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif">normal mobility of mitral prosthetic valve leaflets. </span></span></span></span></p> <p style="text-align:justify"><span style="font-size:10pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif">We report a case of mitral and aortic PVT, with proihibitve surgical risk, treated with 2 different fibrinolysis protocols, complicated with stroke. We further show the utility of iNO on acute pulmonary hypertension, with reduction </span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif">of</span></span> <span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif">RV</span></span> <span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif">afterload </span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif">and consequent reduction of reverse Bernheim effect and increase LV filling and cardiac output</span></span><span style="font-size:11.0pt"><span style="font-family:"Calibri Light",sans-serif">. </span></span></span></span></p>
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