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Topics: Valvular Heart DiseasesAuthors: David Messika-Zeitoun, Claire Cimadevilla
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20 years-old lady living in Tahiti
2006: Mitral valve repair + tricuspid annuloplasty in for severe rheumatic mitral regurgitation
2010: mechanical valve replacement for recurrence of mitral stenosis and mitral regurgitation
Early 2012: Pregnancy. Vitamin K antagonists were sustained throughout pregnancy including the first trimester until the 36th week then was replaced by heparin.
Mid-October 2012: delivery complicated by a severe haemorrhage and anticoagulation was stopped for several days
In the following days, a large prosthetic thrombosis was diagnosed during systematic transesophageal echocardiography without any hemodynamic consequences
No changes after 2 weeks of correct anticoagulation + aspirin and the patient was referred to our centre for surgery
LARGE OBSTRUCTIVE PROSTHETIC THROMBOSIS Normal mobility of both leaflets (arrows) but unilateral trans-prosthetic flow
Large thrombus masking completely the medial leaflet (surgical view from the left atrium, left appendage (not seen) on the right)
The patient was operated on the next day.Surgery confirmed the large prosthetic thrombosisA new mechanical valve (St Jude mitral n°25) was implanted (no desire of any further pregnancy)
Guidelines on the management of valvular heart disease (version 2012)The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)
Obstructive valve thrombosis should be suspected promptly in any patient with any type of prosthetic valve, who presents with recent dyspnea, embolic event or inadequate anticoagulationThe analysis of the risks and benefits of fibrinolysis should be adapted to patient characteristics and local resources.
ESC Guidelines on the management of cardiovascular diseases during pregnancy
The Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC)Endorsed by the European Society of Gynecology (ESG), the Association for European Paediatric Cardiology (AEPC), and the German Society for Gender Medicine (DGesGM)
Mechanical valves offer excellent hemodynamic performance and long-term durability, but the need for anticoagulation increases fetal and maternal mortality and morbidity. Bioprosthetic valves also offer good hemodynamic performance and are much less thrombogenic. Their use in young women, however, is associated with a high risk of structural valve deterioration, occurring in 50% of women <30 years of age at 10 years post-implantation, and is greater in the mitral position than in the aortic and tricuspid position.
Urgent or emergency valve replacement is recommended for obstructive thrombosis in critically ill patients without serious comorbidity
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