Abstract
Background: Antiphospholipid antibody syndrome (APLAS) is an immune-mediated thrombophilia with multisystem venous and arterial thrombosis. Valvular disease is the most common cardiac presentation of APLAS, usually involving the mitral valve, and rarely affects valve function. Arterial thrombosis leading to myocardial infarction (MI) and left ventricular dysfunction have been described but are rare. We present a challenging case of APLAS with mitral valve involvement complicated by MI and new decompensated heart failure. Case: A 48-year-old male with obesity, hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, and triple-positive primary antiphospholipid antibody syndrome presented with a 3-day history of angina and dyspnea. He was started on rivaroxaban 9 years prior to presentation for breakthrough venous thrombosis while non-adherent to warfarin. During admission, he was found to have a mitral valve mass complicated by moderate mitral valve regurgitation, decompensated systolic heart failure, ST-segment elevation myocardial infarction, and multifocal strokes. Multimodality imaging (figure 1) in the setting of negative blood cultures suggested a non-infectious mitral valve mass with embolization as the culprit for his presentation. He ultimately underwent successful mechanical mitral valve replacement and bypass grafting with pathology confirming the diagnosis. Discussion: We highlight a case of a non-bacterial thrombotic mitral valve mass leading to moderate valvular regurgitation, acute heart failure, and arterial thromboembolic events in the setting of probable rivaroxaban failure. This case highlights the use of multimodality imaging and a team-based approach to correctly diagnose and treat a high-risk patient with APLAS and surgical valvular disease, as well as the inherent challenges of perioperative thrombotic and hemorrhagic risk assessment and monitoring.
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