Surgical Management of Thromboembolic Complications Associated with Mitral Valve Stenosis

Abstract

Major systemic thromboembolism accounts for 40% of deaths in individuals with mitral valve stenosis (MS). Furthermore, atrial fibrillation (AF) occurs in approximately 45% of patients with MS, adding to the burden of disease. Contraindications to the use of oral anticoagulation such as recent intracranial haemorrhage, places patients at high risk of thromboembolic events. We present the case of a 70-year-old female who presented with symptoms of acute bilateral lower limb and spinal cord ischaemia, within 24 hours of discharge from a stroke rehabilitation unit. Her initial admission was following an atraumatic intracranial haemorrhage after the administration of warfarin as thrombo-prophylaxis for AF. Following surgery for haematoma evacuation, her anticoagulation had been completely ceased. A computed tomography angiogram of her chest demonstrated a saddle embolism of her descending aorta at the bifurcation of the common iliac arteries, and a filling defect in the left atrial appendage. She underwent emergent bilateral aorto-iliac thrombectomy and postoperative anticoagulation with intravenous heparin. Transoesophageal echocardiography showed a 4.5 × 2.2 cm mobile left atrial thrombus and moderate rheumatic MS and she underwent left atrial thrombectomy and mitral valvotomy with full heparinisation and cardiopulmonary bypass. Her postoperative recovery was unremarkable and she was re-commenced on warfarin. This case demonstrates the potentially devastating thromboembolic complications of AF and MS, and the difficulties in decision-making in regards to anticoagulation for patients with previous bleeding complications. Warfarin remains the only oral anticoagulant suitable for these patients given its potential reversibility and titratable dosing regime.