Ischemic stroke as a complication of mechanical mitral valve prosthesis thrombosis in a patient with pre-existing infectious endocarditis of rheumatic mitral stenosis
General Medicine, 2024, 26(1), 44-50.
K.D. Gospodinov1, Y. M. Todorova1, K. D. Gospodinova1, G. Vasilev2, M. E. Lukanov1, S. T. Tisheva1
1 Medical University – Pleven
2 Acibadem City Clinic Tokuda Hospital – Sofia
Abstract. An ischemic stroke may be the first symptom of mechanical mitral valve prosthesis thrombosis. Therefore, rapid diagnosis and therapy are essential. Description of a clinical case: a 43-year-old patient who entered on August 19, 2023, with complaints of general weakness, fatigue, shortness of breath, heaviness in the right side, chills, and a fever up to 38.5° C. After treatment in the Clinic of Gastroenterology on the occasion of ascites and in the Department of Thoracic Surgery on the occasion of bilateral pleural effusions translated into the Clinic of Cardiology due to suspense for infectious endocarditis, From the transthoracic echocardiography with evidence of high-grade mitral stenosis (PG – 44.7 mmHg, mean – 23.6 mmHg), effective valve area (0.4-0.6 cm2), high-grade mitral regurgitation, and vegetation assumption. Transesophageal echocardiography, which visualizes a mitral valve with a large vegetation measuring 29 x 22 mm on the anterior mitral valve leaflet as well as a small vegetation in the calcification stage measuring 3 x 4 mm on the posterior mitral valve leaflet, shows morphological changes characteristic of rheumatic mitral stenosis. Measured mitral valve gradient: peak: 73 mmHg, mean: 50 mmHg. I twice examined blood cultures without evidence of bacterial or mycotic growth. Conducted broad-spectrum antibiotic and antifungal treatment. However, the patient has a persistent fever. Targeted for surgical treatment and performed valvular prosthesis with mechanical valvular prosthesis with subsequent systemic administration of the anticoagulant group of vitamin K according to the scheme. When realizing neurological symptoms in August 2023, we conducted control transthoracic echocardiography, which included data on restenosis of mechanical valve prostheses. INR – 6,1 examined. A cerebral CT scan with evidence of an ischemic area in the left middle cerebral artery basin was conducted. The patient is urgently referred to the Cardiac Surgery Center in Sofia for reoperation. Discussion: Dysfunction of mechanical valvular prosthesis can be classified as endogenous or exogenous according to etiology. The most common cause of mechanical valve dysfunction is thrombosis, which can lead to serious thromboembolic events, such as thromboembolic stroke. The latter, although rarely observed, can be observed even with the intake of an anticoagulant achieving optimal PT/INR values. Conclusion: Ensuring the ideal anticoagulation in mechanical valve prosthesis is a prerequisite, although not an assurance, for averting thrombotic problems. Hence, it is imperative to do routine echocardiographic monitoring after the first implantation of a mechanical heart valve. Prompt identification and timely surgical intervention are crucial to attain a favorable clinical outcome for the patient. The cooperation of members of the cardiac surgical team is crucial in these instances.
Key words: ischemic stroke, mechanical mitral valve prosthesis, rheumatism, infectious endocarditis, anticoagulation
Address for correspondence: Yoana Mladenova Todorova, e-mail: ioana.todorova@mu-pleven.bg