Extract

A 57-year-old female with previous mechanical aortic (AVR) and mitral valve (MVR) replacements presented with decompensated heart failure in the setting of an elevated troponin. The patient’s history was notable for labile international normalized ratios (INR) on warfarin that was 1.0 on presentation. At the time of cardiac catheterization, the coronary arteries were patent. However, cinefluoroscopy demonstrated an immobile AVR leaflet concerning for valve thrombosis (Panel A, Supplementary data online, Video S1A). Following anticoagulation with IV heparin, a transthoracic echocardiogram (TTE) demonstrated severe aortic stenosis and severe aortic regurgitation across the AVR (Panel B). Cardiac computed tomography (CCT) confirmed the finding of AVR thrombosis (Panel C, Supplementary data online, Video S1C). On transoesophageal echocardiography (TEE), there was a large 17 × 14 mm echo-dense mass adherent to the AVR leaflet confirming the diagnosis (Panel D, Supplementary data online, Video S1D). As the patient’s operative risk was highly prohibitive for cardiac surgery, the patient was medically treated with a low-dose alteplase (TPA) infusion. Immediately following treatment with thrombolytic therapy, the patient developed a painful and pulseless left leg, confirmed to be an acute thromboembolic femoral artery occlusion on CT angiography. The patient underwent urgent thrombectomy via a combined open and endovascular approach (Panel E). Intraoperative cinefluoroscopy demonstrated restored AVR leaflet motion (Panel F, Supplementary data online, Video S1F). Repeat TTE imaging revealed markedly improved gradients across the AVR, with peak and mean gradients of 31 and 17 mmHg, respectively. This case highlights the complementary role of multimodality cardiovascular imaging with echocardiography, cinefluoroscopy, and CCT in the diagnosis and management of complications from mechanical valve thrombosis.

You do not currently have access to this article.