Case report
A pregnant woman with a mechanical prosthetic valve
Uma mulher grávida com uma prótese valvular mecânica
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Inadequate therapy or overlapping factors can precipitate prosthetic valve thrombosis (PVT). Severe cases may require urgent surgery or fibrinolysis. For most patients, however, the optimal therapy remains unclear.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 24-year-old woman who presented at the emergency department with sudden right hemiparesis and dysarthria. She had a history of rheumatic heart disease and mitral valve replacement with a biological valve in 2003 and with a 29-mm mechanical bileaflet valve in 2012. Her obstetric history included two medically induced abortions in 2011 in the context of heart failure. One month prior to admission, she discovered she was seven weeks pregnant and was advised to replace warfarin with enoxaparin 60 mg/day. Physical examination confirmed right-sided hemiparesis, while fetal ultrasound confirmed an 11-week pregnancy. Cranial computed tomography (CT) revealed no abnormalities.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography (TTE) showed a mean transprosthetic gradient of 8 mmHg and maximum velocity of 2 m/s, while transesophageal echocardiography (TEE) revealed two large protruding thrombi (measuring 15 and 17 mm) attached to the atrial side of the mechanical valve (Supplementary Video 1). This led to a diagnosis of non-obstructive PVT complicated by stroke. The patient was offered the option of terminating the pregnancy but refused. In view of recent inadequate anticoagulation, she was started on a continuous infusion of unfractionated heparin (UFH). She was deemed unsuitable for surgery by our heart team due to prior heart surgeries and a high risk of miscarriage. Fibrinolysis was also considered inappropriate because of recent stroke, ongoing anticoagulation and pregnancy. Her clinical course was favorable, with the neurological deficit resolving in 36 hours and no treatment-related complications. A follow-up TEE showed progressive decrease in the size and mobility of the thrombi (Supplementary Video 2) and low-dose aspirin was initiated in order to improve endogenous fibrinolysis. As soon as she entered the second trimester of pregnancy, it was considered safe to resume treatment with warfarin.</p><p id="par0020" class="elsevierStylePara elsevierViewall">She was discharged on warfarin and aspirin, but readmitted a week later with a transient ischemic attack despite an adequate international normalized ratio. At this point, TEE revealed small thrombi attached to the prosthetic valve. Warfarin was discontinued and continuous UFH was restarted. A follow-up TEE during week 25 of gestation revealed no obstruction or thrombi. The patient remained in the obstetric ward until the day she was 29 weeks pregnant. That morning, she was found with left-sided hemiparesis, facial palsy, conjugate eye deviation and dysarthria. Cranial CT showed a recent right middle cerebral artery stroke and uterine artery Doppler indicated fetal suffering. TTE revealed no prosthetic valve obstruction.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At a multidisciplinary team meeting, we decided to discontinue aspirin, reverse anticoagulation with protamine and perform an emergency cesarean section, followed by percutaneous intervention for ischemic stroke. An invasive angiogram revealed occlusion of the right middle cerebral artery in the M1 segment; blood flow was restored using stent retriever thrombectomy. However, despite the success of the procedure, the patient developed cranial edema, necessitating decompressive craniectomy. At this point, UFH was resumed due to the high risk of PVT. TEE performed four days after this ischemic event showed a normally functioning prosthesis with no thrombi.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Throughout the remainder of her hospital stay, the patient suffered multiple hemorrhagic strokes, required a damage control laparotomy for hemostasis and suffered multiple nosocomial infections. Abdominal CT revealed an infarcted area of the upper splenic pole with no clinical implications. She was eventually discharged on warfarin, fully dependent, with persistent severe neurological deficits. She died from sepsis a few months later.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Her child, a 990-g preterm female, suffered from severe respiratory distress syndrome and recurrent sepsis, requiring invasive mechanical ventilation for a month. However, her clinical course was favorable and she was discharged after two months.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusion</span><p id="par0040" class="elsevierStylePara elsevierViewall">This case demonstrates how difficult it can be to select the appropriate treatment strategy for PVT. Hemodynamic stability, valve obstruction, systemic embolism, thrombus size, patient preference and comorbidities have to be taken into account. Conservative treatment may be appropriate for non-obstructive PVT, but some patients may still develop simultaneous severe thrombotic and bleeding complications. Pregnancy, both a hypercoagulable and a hyperdynamic state, may prove fatal for some women with cardiac disease, such as those with prosthetic mechanical valves.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1269324" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1174839" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1269323" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1174838" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0055">Recommended references</span>" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-02-28" "fechaAceptado" => "2017-06-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1174839" "palabras" => array:3 [ 0 => "Pregnancy and cardiovascular disease" 1 => "Embolism and thrombosis" 2 => "Heart valve prosthesis" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1174838" "palabras" => array:3 [ 0 => "Gravidez e doença cardiovascular" 1 => "Trombose e embolia" 2 => "Prótese valvular cardíaca" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 24-year-old woman who was 11 weeks pregnant and had a mechanical mitral valve presented at the emergency department with ischemic stroke. Although treatment with aspirin and unfractionated heparin was initially successful, subsequent management was almost impossible, as she eventually suffered a right hemispheric stroke, requiring percutaneous intervention and an emergency cesarian; prosthetic valve thrombosis with hemodynamic instability; and multiple bleeding complications. This case demonstrates how difficult it can be to select the appropriate treatment strategy for prosthetic valve thrombosis.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Uma mulher de 24 anos, grávida de 11 semanas, com uma prótese mecânica em posição mitral, foi admitida no serviço de urgência com um acidente vascular cerebral isquémico. Apesar de a terapêutica com aspirina e heparina não fracionada ter sido inicialmente bem-sucedida, a gestão subsequente da doente foi dificultada por várias intercorrências: acidente vascular cerebral hemisférico direito com necessidade de intervenção percutânea e realização de cesariana emergente; trombose obstrutiva de prótese com instabilidade hemodinâmica; múltiplas complicações hemorrágicas. Este caso permite ilustrar as dificuldades na seleção do tratamento da trombose de prótese.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0065" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:2 [ 0 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 502397 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 1 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 402962 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "lecturaRecomendada" => array:1 [ 0 => array:3 [ "vista" => "all" "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0055">Recommended references</span>" "seccion" => array:1 [ 0 => array:2 [ "vista" => "all" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines on the management of valvular heart disease (version 2012)" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC)1; European Association for Cardio-Thoracic Surgery (EACTS)." 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 7 | 4 | 11 |
| 2024 Outubro | 37 | 30 | 67 |
| 2024 Setembro | 57 | 24 | 81 |
| 2024 Agosto | 52 | 20 | 72 |
| 2024 Julho | 37 | 26 | 63 |
| 2024 Junho | 46 | 24 | 70 |
| 2024 Maio | 47 | 28 | 75 |
| 2024 Abril | 37 | 30 | 67 |
| 2024 Maro | 49 | 25 | 74 |
| 2024 Fevereiro | 35 | 20 | 55 |
| 2024 Janeiro | 27 | 28 | 55 |
| 2023 Dezembro | 31 | 22 | 53 |
| 2023 Novembro | 65 | 34 | 99 |
| 2023 Outubro | 45 | 15 | 60 |
| 2023 Setembro | 29 | 15 | 44 |
| 2023 Agosto | 39 | 24 | 63 |
| 2023 Julho | 45 | 15 | 60 |
| 2023 Junho | 39 | 10 | 49 |
| 2023 Maio | 31 | 29 | 60 |
| 2023 Abril | 20 | 4 | 24 |
| 2023 Maro | 27 | 15 | 42 |
| 2023 Fevereiro | 32 | 30 | 62 |
| 2023 Janeiro | 27 | 13 | 40 |
| 2022 Dezembro | 37 | 19 | 56 |
| 2022 Novembro | 34 | 34 | 68 |
| 2022 Outubro | 58 | 31 | 89 |
| 2022 Setembro | 49 | 39 | 88 |
| 2022 Agosto | 47 | 27 | 74 |
| 2022 Julho | 41 | 39 | 80 |
| 2022 Junho | 35 | 37 | 72 |
| 2022 Maio | 39 | 22 | 61 |
| 2022 Abril | 35 | 37 | 72 |
| 2022 Maro | 53 | 45 | 98 |
| 2022 Fevereiro | 22 | 34 | 56 |
| 2022 Janeiro | 30 | 24 | 54 |
| 2021 Dezembro | 39 | 24 | 63 |
| 2021 Novembro | 45 | 38 | 83 |
| 2021 Outubro | 28 | 44 | 72 |
| 2021 Setembro | 32 | 27 | 59 |
| 2021 Agosto | 23 | 34 | 57 |
| 2021 Julho | 16 | 16 | 32 |
| 2021 Junho | 25 | 30 | 55 |
| 2021 Maio | 37 | 35 | 72 |
| 2021 Abril | 35 | 37 | 72 |
| 2021 Maro | 36 | 27 | 63 |
| 2021 Fevereiro | 44 | 28 | 72 |
| 2021 Janeiro | 36 | 14 | 50 |
| 2020 Dezembro | 29 | 11 | 40 |
| 2020 Novembro | 21 | 22 | 43 |
| 2020 Outubro | 29 | 14 | 43 |
| 2020 Setembro | 38 | 16 | 54 |
| 2020 Agosto | 21 | 6 | 27 |
| 2020 Julho | 24 | 16 | 40 |
| 2020 Junho | 30 | 18 | 48 |
| 2020 Maio | 30 | 8 | 38 |
| 2020 Abril | 41 | 17 | 58 |
| 2020 Maro | 53 | 18 | 71 |
| 2020 Fevereiro | 82 | 40 | 122 |
| 2020 Janeiro | 41 | 16 | 57 |
| 2019 Dezembro | 32 | 12 | 44 |
| 2019 Novembro | 19 | 9 | 28 |
| 2019 Outubro | 52 | 17 | 69 |
| 2019 Setembro | 138 | 19 | 157 |
| 2019 Agosto | 58 | 15 | 73 |
| 2019 Julho | 40 | 31 | 71 |
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