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Adult patient with functioning prosthetic mitral valve without


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Adult patient with functioning prosthetic mitral valve without

  1. 1. Adult Patient with Functioning Prosthetic Mitral Valve Without Anticoagulant Drug Since 12 Years case report in QAHI Mohammad Obeidat MD KHMC
  2. 2. INTRODUCTION <ul><li>Implantation of prosthetic cardiac valves to treat hemodynamically significant valvular disease has become an increasingly common procedure . It is estimated that more than 60,000 patients per year are undergoing heart valve replacement in the United States . </li></ul><ul><li>Replacement of diseased valves reduces the morbidity and mortality associated with native valvular disease but comes at the expense of risking complications unique to the implanted prosthetic device . </li></ul><ul><li>These complications include primary valve failure, prosthetic valve endocarditis PVE, prosthetic valve thrombosis PVT ) , thromboembolism, and mechanical hemolytic anemia . In addition, anticoagulant - related hemorrhage may occur . </li></ul><ul><li>acute prosthetic valve failure is associated with a high mortality rate . </li></ul><ul><li>More than 80 models of artificial valves have been introduced since 1950 . </li></ul>
  3. 3. INTRODUCTION <ul><li>This risk is significantly greater with valves in the mitral position, probably owing to lower velocities of blood flow. </li></ul><ul><li>Meticulous anticoagulation with warfarin reduces this risk considerably to approximately 0.2 per patient-year. </li></ul><ul><li>Most cases of PVT reported in the literature are associated with consistently inadequate anticoagulation. </li></ul><ul><li>Transesophageal echocardiography (TEE) is the diagnostic technique of choice. </li></ul><ul><li>The estimated incidence of PVT is 2-4% per year based on autopsy and surgical findings. The true incidence should be higher, of which 50% are asymptomatic. </li></ul><ul><li>The prevalence of asymptomatic PVT in the early postoperative period may reach 10%. </li></ul>
  4. 4. INTRODUCTION <ul><li>Heparin may be an initial treatment for non-obstructive PVT, but thrombolysis is superior in this subset. If thrombi are >5 mm in size, heparin therapy is unsuccessful and unsafe. TEE monitoring is mandatory during heparin treatment, as thrombi may increase in size and become obstructive. Thrombolysis is recommended as first-line treatment if there are no contraindications. Surgery should be reserved for patients in whom thrombolysis is either contraindicated or has been ineffective. </li></ul>
  5. 5. Case report <ul><li>We report a case of 57 year's male patient , X- smoker </li></ul><ul><li>No other risk factor for coronary artery disease (CAD), No known allergy . </li></ul><ul><li>SP; 27101997: Cardiac catheterization ;showed; </li></ul><ul><li>Normal coronaries . </li></ul><ul><li>Sever calcific mitral valve ( mitral stenosis) </li></ul><ul><li>Grade One Mitral Regurgitation </li></ul><ul><li>Grade One Aortic Regurgitation </li></ul><ul><li>Moderate –Sever Pulmonary Hypertension </li></ul><ul><li>S/P; 6121997 : Mitral valve Replacement with Carbomedics 29mm ( mechanical valve). </li></ul><ul><li>Follow up for three months with theraputic INR,2.9.his symptoms was improved . </li></ul><ul><li>Last FU 4/3/1998 ; he lost his follow up since that time </li></ul>
  6. 6. Case report <ul><li>At 2142010 : He presented to ER in KHMC with Hx of Falling down,trauma in his right leg. </li></ul><ul><li>Found to have INR 1.2 , Referred to QAHI to RO Prosthetic Valve dysfunction,thrombosis. </li></ul><ul><li>He stopped his medication for last 12 yr. </li></ul><ul><li>OE ;looks well, B.P;13080 pulse: 104(Irregular) </li></ul><ul><li>Head & Neck :Free </li></ul><ul><li>Chest ; clear , MVR Click Functioning. </li></ul><ul><li>Abdomen ; Soft lax . </li></ul><ul><li>He was admitted to the ward and started on anticoagulation. </li></ul><ul><li>Fluoroscopy : Functioning MVR </li></ul><ul><li>ECG ; Atrial fibrillation VR :104 </li></ul><ul><li>Echocardiography For MV : Max PG = 18mmhg </li></ul><ul><li>Mean PG=7mmhg </li></ul><ul><li>Grade one Paravalvular leak . </li></ul>
  7. 9. DISCUSSION <ul><li>Thromboembolism continues to be a major cause of morbidity and mortality in patients who have undergone mechanical valve replacement surgery. </li></ul><ul><li>Systemic embolization (predominantly cerebrovascular events) occurs at a frequency of approximately 0.7 to 1.0 percent per patient-year in patients with mechanical valves who are treated with warfarin . In comparison, the risk is 2.2 percent per patient-year with aspirin and 4.0 percent with no anticoagulation; patients with mitral valve prostheses are at twice the risk of those with aortic valve prostheses . </li></ul><ul><li>Thus, long-term warfarin therapy sufficient to prolong the prothrombin time to an INR of 2.5 to 3.5 is recommended for patients with mechanical heart valves. </li></ul><ul><li>The use of mechanical valves in the elderly is still controversial, largely related to the risks associated with anticoagulation. </li></ul>
  8. 10. DISCUSSION <ul><li>However, one study of 1245 patients (38 percent of whom were over the age of 65) receiving a mechanical aortic or mitral valve found that, after an average follow-up of five years, there was no difference in the rates of bleeding or thromboembolism between younger and older patients . </li></ul>
  9. 11. <ul><li>thanks </li></ul>