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A woman in her mid-50s presented to the hospital with acute, worsening dyspnea, with shortness of breath at rest and with minimum exertion. She had undergone mechanical mitral valve replacement and aortic dissection repair 2 months prior to presentation. On physical examination, she was found to have elevated jugular venous pressure, bilateral rales in her lungs, and reduced intensity of the mitral valve closure sound, and her international normalized ratio was subtherapeutic (1.5). An echocardiographic image showed a mean gradient of 12 mm Hg across the mitral valve, suggesting valve stenosis. Fluoroscopy showed restricted mobility of the leaflets (Video 1). Transesophageal echocardiography showed a large thrombus on the mechanical mitral valve, along with a small new dissection flap in the aortic root (Figure and Video 2). A chronic dissection flap was evident in the aortic arch and descending aorta, which was unchanged from the previous aortic dissection repair.
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Acute mechanical mitral valve thrombosis
B. Start intravenous heparin
The decision was made to start the patient on intravenous heparin. Repeat surgery (choice A) was considered high risk in this patient because she had New York Heart Association functional class IV symptoms, pulmonary edema, and a history of surgery 2 months ago. The new dissection flap was small, with a small leak of blood into the false lumen. The patient presented with decompensated heart failure symptoms but had no chest pain. Tissue plasminogen activator (choice C) was not given because of the small stable dissection flap seen in the aortic root. Performing an emergency percutaneous clot removal procedure (choice D) is not correct because, for practical purposes, there is no device that can perform percutaneous removal of clots formed on mechanical valves.
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Corresponding Author: Nureddin K. Almaddah, MD, Division of Cardiology, Department of Medicine, University of Tennessee Health Science Center, 956 Court Ave, Ste A312, Memphis, TN 38163 (firstname.lastname@example.org).
Published Online: January 30, 2019. doi:10.1001/jamacardio.2018.4705
Correction: This article was corrected on February 20, 2019, to delete a mention of “Video 2A, B, and C.” The video was combined to 1 file and is now correctly labeled “Video 2.”
Conflict of Interest Disclosures: None reported.
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