Bioprosthetic Valve Thrombosis Associated With COVID-19 Infection

Abstract

HomeCirculation: Cardiovascular ImagingVol. 14, No. 5Bioprosthetic Valve Thrombosis Associated With COVID-19 Infection Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessCase ReportPDF/EPUBBioprosthetic Valve Thrombosis Associated With COVID-19 Infection Steven A. Alexander, MD, Icilma V. Fergus, MD and Stamatios Lerakis, MD, PhD Steven A. AlexanderSteven A. Alexander Steven A. Alexander, MD, Icahn School of Medicine at Mt Sinai, 1 Gustave L. Levy Pl, Box 1030, New York, NY 10029. Email E-mail Address: [email protected] https://orcid.org/0000-0002-0719-9177 The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY. Search for more papers by this author , Icilma V. FergusIcilma V. Fergus The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY. Search for more papers by this author and Stamatios LerakisStamatios Lerakis https://orcid.org/0000-0001-7487-1990 The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY. Search for more papers by this author Originally published5 Feb 2021https://doi.org/10.1161/CIRCIMAGING.120.012118Circulation: Cardiovascular Imaging. 2021;14:e012118Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 5, 2021: Ahead of Print Obstructive bioprosthetic valve thrombosis is a rare but potentially devastating complication.1 Coronavirus disease 2019 (COVID-19) predisposes patients to both venous and arterial thrombosis.2–4 The impact this may have on patients with endovascular prosthetic material is unknown. We report a case of obstructive bioprosthetic aortic valve thrombosis in a patient hospitalized with COVID-19.A 79-year-old woman presented to clinic with a 2-month history of dyspnea and cough. Four months prior, she was treated for a type A aortic dissection with hemiaortic arch and bioprosthetic aortic valve replacement. She initially recovered but was hospitalized 2 months later with COVID-19 pneumonia. Laboratory evaluation at that time showed elevated C-reactive protein (79.8 mg/dL), activated partial thromboplastin time (44.2 s), fibrinogen (489 mg/dL), and D-dimer (2.14 μg/mL). She was treated with convalescent plasma and received prophylactic low molecular weight heparin. Her hospital course was uncomplicated, and she was discharged on apixaban 5 mg twice daily.A transthoracic echocardiogram showed prosthetic aortic valve stenosis with a peak aortic velocity of 3.8 m/s, increased from 2.2 m/s postoperatively. A transesophageal echocardiogram revealed markedly thickened bioprosthetic valve leaflets (Figure 1, Movie I in the Data Supplement). A computed tomography scan showed hypoattenuated leaflet thickening involving all 3 valve leaflets consistent with leaflet thrombosis (Figure 2).Download figureDownload PowerPointFigure 1. Prosthetic aortic valve thrombosis. Biplane transesophageal echocardiogram (TEE) at the level of the aortic valve showing marked thickening of the bioprosthetic aortic valve leaflets, consistent with leaflet thrombosis.Download figureDownload PowerPointFigure 2. Hypoattenuated leaflet thickening of the prosthetic aortic valve.A, Short axis and (B) long-axis views of the aortic valve on computed tomography showing hypoattenuated leaflet thickening (HALT; white arrows). Ao indicates aorta; LA, left atrium; PA, pulmonary artery; and RA, right atrium.The patient was admitted to the hospital, started on an unfractionated heparin infusion, and bridged to warfarin with a goal internationalized normalized ratio of 2.5 to 3.5. Follow-up transthoracic echocardiogram performed 3 months later showed improvement of her aortic valve gradient back to baseline (Figure 3).Download figureDownload PowerPointFigure 3. Prosthetic aortic valve gradient before and after 3 mo of warfarin.A, The peak aortic valve velocity was 3.8 m/s before treatment and (B) decreased to 2.2 m/s after treatment.To our knowledge, this is the first report of prosthetic aortic valve thrombosis associated with COVID-19 infection. This case reminds us that patients with prosthetic heart valves and endovascular devices may be at particular risk of thrombotic complications from COVID-19. Health care providers should have a high index of suspicion for such complications and consider diagnostic imaging when appropriate. Further research is needed to determine the optimal anticoagulation strategy for both the prevention and treatment of bioprosthetic valve thrombosis in the setting of COVID-19 infection.Sources of FundingNone.Supplemental MaterialData Supplement Movie IDisclosures None.FootnotesThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.120.012118.Steven A. Alexander, MD, Icahn School of Medicine at Mt Sinai, 1 Gustave L. Levy Pl, Box 1030, New York, NY 10029. Email steven.[email protected]org