Late-Onset Bioprosthetic Mitral Valve Thrombosis Treated With Apixaban

HomeCirculation: Cardiovascular ImagingVol. 14, No. 2Late-Onset Bioprosthetic Mitral Valve Thrombosis Treated With Apixaban Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessCase ReportPDF/EPUBLate-Onset Bioprosthetic Mitral Valve Thrombosis Treated With Apixaban Tushar Mishra, MD John Dawdy, MD Aditya Sood, MD Anupama Kottam, MD Luis AfonsoMD Tushar MishraTushar Mishra Tushar Mishra, MD, Detroit Medical Center, Department of Internal Medicine, Wayne State University, 4201 St Antoine St, Suite 2E, Detroit, MI 48201. Email E-mail Address: [email protected] https://orcid.org/0000-0002-6539-0594 Department of Internal Medicine (T.M.), Wayne State University, Detroit, MI. Search for more papers by this author , John DawdyJohn Dawdy https://orcid.org/0000-0002-5827-1757 Division of Cardiology, Department of Medicine (J.D., A.S., A.K., L.A.), Wayne State University, Detroit, MI. Search for more papers by this author , Aditya SoodAditya Sood https://orcid.org/0000-0002-4849-1879 Division of Cardiology, Department of Medicine (J.D., A.S., A.K., L.A.), Wayne State University, Detroit, MI. Search for more papers by this author , Anupama KottamAnupama Kottam Division of Cardiology, Department of Medicine (J.D., A.S., A.K., L.A.), Wayne State University, Detroit, MI. Search for more papers by this author and Luis AfonsoLuis Afonso Division of Cardiology, Department of Medicine (J.D., A.S., A.K., L.A.), Wayne State University, Detroit, MI. Search for more papers by this author Originally published1 Feb 2021https://doi.org/10.1161/CIRCIMAGING.120.011148Circulation: Cardiovascular Imaging. 2021;14:e011148A 58-year-old woman with a past medical history of rheumatic heart disease status post–mitral valve replacement (with a 25 mm Hancock II porcine bioprosthetic valve) 4 years ago, presented to the cardiology clinic with a chief complaint of progressive shortness of breath. The dyspnea has gradually progressed to New York Heart Association Class III over the past month and was accompanied by orthopnea. Her last cardiac workup was 2 years ago and a transthoracic echocardiogram at the time showed normal left ventricular systolic function with no evidence of prosthetic mitral valve stenosis or regurgitation.During this presentation, she did not experience any chest pain, palpitations, paroxysmal nocturnal dyspnea, lightheadedness, or episodes of syncope. She denied fever, chills, weakness in her extremities, numbness/tingling among other symptoms. Physical examination revealed signs of elevated jugular venous pulsation, fine crackles on bilateral lung base and leg edema.A transthoracic echocardiogram was performed and showed thickened mitral leaflets, restricted posterior cusp mobility along with a narrowed, turbulent color Doppler vena contracta in diastole, exhibiting flow convergence (Figure 1A and 1C, Movie I in the Data Supplement). Mitral valve Doppler parameters were consistent with prosthetic valve stenosis (Table). Differential diagnoses at this point included prosthetic valve thrombosis, pannus formation versus degenerative fibrosis and a low likelihood of endocarditis.Table. Doppler Parameters of Prosthetic Mitral Valve Function, Before and After 2 mo of Anticoagulation (DOAC) TherapyPre-treatmentPost-treatmentMitral valve area (pressure half- time)2.0 cm23.5 cm2VTIPrMv/VTILVO3.21.6Peak velocity2.46 m/s1.79 m/sMean gradient9.4 mmHg4.2 mmHgPretreatment values were suggestive of prosthetic valve stenosis, and posttreatment values are consistent with normalization of prosthetic valve function. DOAC indicates direct oral anticoagulant; VTILVO, PW Doppler velocity time integral left ventricular outflow tract; and VTI PrMv, CW Doppler velocity time integral.Download figureDownload PowerPointFigure 1. Parasternal long-axis views with and without color Doppler. Immediately before treatment (A) and after 2 mo of apixaban treatment (B). Corresponding pre- and post-treatment transmitral Doppler tracings (C and D). Note resolution of leaflet thickening, restoration of laminar flow, widened vena contracta, and normalized gradients post-treatment.The patient was offered a transesophageal echocardiogram (TEE) and retrospectively gated cardiac computed tomography (CCT) as the next step to characterize the lesion. Given the low invasive nature of the modality, the patient opted for CCT. The images showed noncircumferential, hypoattenuating leaflet thickening of prosthetic leaflets with reduced leaflet motion (Figure 2). Morphologic findings were deemed to be consistent with prosthetic valve thrombosis.Download figureDownload PowerPointFigure 2. Hypoattenuated leaflet thickening (HALT) suggestive of thrombus formation on the subvalvular surface, restricting leaflet motion (A). Extension of HALT lesions underneath the prosthesis variably along the valve struts (B). Three-dimensional reconstruction of isolated mitral valve demonstrating thrombus formation on sub valvular surface (C).The patient was started on oral apixaban therapy at a dose of 5 mg twice daily and was periodically followed in the clinic. Two months later, after complete symptomatic improvement, she underwent a repeat transthoracic echocardiogram that revealed normalization of mitral valve Doppler parameters with complete resolution of previously observed leaflet restriction and thickening (Figure 1B and 1D; Movies IIA IIB in the Data Supplement). She has been prescribed apixaban 2.5 mg bid indefinitely.Bioprosthetic valves have a relatively lower risk of developing thrombosis compared with a mechanical valves, and a low incidence of 0.03% per year has been reported, thus not warranting long-term anticoagulation treatment 1.The thrombotic risk is higher with the mitral valve compared with the aortic valve, and the majority of cases are asymptomatic. The exact incidence of this complication is not clear since screening imaging is not routinely performed. However, recent studies point out that the incidence might actually be higher than previously thought. A study by Egbe et al2 described the overall thrombosis risk to be around 0.7% to 1.5%, of which the majority (65%) were identified >12 months after implantation, while 15% were identified 5 years after implantation. The peak incidence is reported to be around 13 to 24 months. Typical manifestations of bioprosthetic valve thrombosis include signs and symptoms of heart failure because of valve dysfunction, presyncope, or syncope and possible signs of thromboembolism.The first step in the evaluation bioprosthetic valve thrombosis is performing a transthoracic echocardiogram with a focus on measuring gradients to assess for obstruction and the presence of regurgitation. Elevation in the gradients >50% compared with the baseline or >95% CI per American Society of Echocardiography guidelines, which is not otherwise explained by other factors, points toward an obstruction. 2The next step is to proceed with an advanced imaging technique like a 3D-TEE or CCT. TEE is nonionizing and can provide detailed hemodynamic information on valve function, but imaging is often hindered by acoustic masking and tissue differentiation can be challenging. CCT, on the other hand, is non-invasive but involves radiation exposure. Bioprosthetic valve thrombosis is diagnosed when there is diffuse or focal cusp thickness >2 to 3 cm (echo dense on TEE) or hypoattenuating leaflet thickening appearance on CCT(best imaged in the systolic phase for mitral prostheses) associated with reduced leaflet motion (best appreciated in the diastolic phases) 3. In terms of management, while the use of thrombolytics and Vitamin K antagonists has been described in case reports and series, there are limited data on the role of direct oral anticoagulants in the management of these patients 4. As demonstrated in this case, direct oral anticoagulants are an appealing option for empiric treatment of suspected prosthetic valve thrombosis.In conclusion, this case highlights the need to consider late-valve thrombosis in the differential before entertaining degenerative prosthetic stenosis that often culminates in transcatheter (valve-in-valve) or redo surgical valve replacement. It also illustrates the complementary role of CCT and the potential utility of direct oral anticoagulants in the management of these patients.Sources of FundingNone.Disclosures None.FootnotesThe Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.120.011148.Tushar Mishra, MD, Detroit Medical Center, Department of Internal Medicine, Wayne State University, 4201 St Antoine St, Suite 2E, Detroit, MI 48201. Email [email protected]eduReferences1. Grunkemeier GLLi HHNaftel DCStarr ARahimtoola SH.Long-term performance of heart valve prostheses.Curr Probl Cardiol2000 2573154. doi: 10.1053/cd.2000.v25.a103682CrossrefMedlineGoogle Scholar2. Egbe ACPislaru SVPellikka PAPoterucha JTSchaff HVMaleszewski JJConnolly HM.Bioprosthetic valve thrombosis versus structural failure: clinical and echocardiographic predictors.J Am Coll Cardiol2015 6622852294. doi: 10.1016/j.jacc.2015.09.022CrossrefMedlineGoogle Scholar3. Jilaihawi HAsch FMManasse ERuiz CEJelnin VKashif MKawamori HMaeno YKazuno YTakahashi Net al.Systematic CT methodology for the evaluation of subclinical leaflet thrombosis.JACC Cardiovasc Imaging2017 10461470. doi: 10.1016/j.jcmg.2017.02.005CrossrefMedlineGoogle Scholar4. Sachdev SBardia NNguyen LOmar B.Bioprosthetic valve thrombosis.Cardiol Res2018 9335342. doi: 10.14740/cr789CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails February 2021Vol 14, Issue 2Article InformationMetrics Download: 90 © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.120.011148PMID: 33517675 Originally publishedFebruary 1, 2021 Keywordsdyspneachest painbioprosthesisedemamitral valvePDF download SubjectsComputerized Tomography (CT)EchocardiographyValvular Heart DiseaseImaging