Native Aortic Valve Thrombosis Research Articles

Heparin-induced DRESS syndrome in a paediatric patient and successful anaesthetic management in cardiovascular bypass surgery: case report

BackgroundDrug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome is a severe adverse drug reaction marked by delayed hypersensitivity reactions causing skin and systemic complications. DRESS diagnosis is challenging due to the variety of clinical presentations and symptom overlap with other conditions. The perioperative period in these patients requires precise pharmacological strategies to prevent complications associated with this syndrome. The treatment of DRESS induced by unfractionated heparin during cardiopulmonary bypass (CPB) surgery presents some challenges that must be considered when selecting an anticoagulant to avoid side effects. In this case, bivalirudin, a direct thrombin inhibitor, is indicated as an alternative to heparin in patients undergoing CPB. However, in contrast to heparin/protamine, there is no direct reversal agent for bivalirudin.Case presentationWe report the case of an 11-year-old male diagnosed with native aortic valve endocarditis and thrombosis in his left lower extremity. During valvular replacement surgery, systemic unfractionated heparin was administered. Postoperatively, the patient developed fever, eosinophilia and pruritic rash. Warm shock and elevated alanine transaminase (ALT) and aspartate transaminase (AST) levels followed, leading to the diagnosis of DRESS syndrome. Treatment with methylprednisolone resulted in complete resolution of symptoms. Seven years later, the patient was readmitted due to insufficient anticoagulation and a thrombus in the prosthetic aortic valve, presenting a recurrent DRESS episode due to the administration of unfractionated heparin, which was later replaced with low-molecular-weight heparin during hospitalization. Treatment with corticosteroids and antihistamines was initiated, resulting in the resolution of this episode. Ultimately, the patient required the Ross procedure. During this intervention the anticoagulation strategy was modified, unfractionated heparin was replaced with bivalirudin during the procedure and fondaparinux was administered during the postoperative period. This resulted in stable transaminases levels and no eosinophilia.ConclusionThe severity of DRESS Syndrome underscores the importance of early recognition, heightened monitoring, and a comprehensive approach tailored to each patient’s needs. This particular case highlights the significance of this approach and may have a substantial clinical impact since it provides alternatives to heparin, such as bivalirudin and fondaparinux, in the anticoagulation strategy of CPB for patients who have a hypersensibility reaction to this medication; thus, enhancing clinical outcomes by minimizing risks linked to adverse drug reactions.

Abstract 12668: Coronary CTA Finding of Libman Sacks Endocarditis Presenting as Chest Pain

Case Presentation: A 65-year-old female with a history of hypertension, hyperlipidemia, microscopic colitis, fibromyalgia, left hand dupuytren's contractures, Grave’s disease and seronegative rheumatoid arthritis presented to the outpatient office for evaluation of right sided stabbing and heavy chest pain. ECG showed sinus bradycardia without any ST segment changes. She had an Echo and exercise stress Echo prior to her office visit. Her echo showed normal left ventricular size and systolic function with no regional wall motion abnormality and thickened aortic valve with mild aortic stenosis (peak transvalvular gradient 9.9 mmHg and mean 5.9 mmHg). Her stress echo was negative for ischemia although submaximal (exercised for 6.05 minutes, achieving only 75% MPHR, and double product of 18720). It was then decided to pursue a coronary CTA given the suboptimal nature of her stress testing and intermediate pretest probability of coronary artery disease. This revealed mild-to-moderate non-obstructive CAD and thickening of her left coronary cusp. The thickening was concerning for Libman-Sacks endocarditis vs native aortic valve thrombosis (see figure). Her Antinuclear antibody (ANA) titers was 1280. She was started on therapeutic anticoagulation with a plan for repeat imaging in six months. Discussion: Coronary cusp thickening represents a variety of differentials and has comparable structural and clinical qualities. Atypical chest pain in our patient led to the incidental finding of left coronary cusp thickening. In the presence of elevated ANA and her autoimmune disorder, Libman-Sacks endocarditis vs native aortic valve thrombosis was suspected hence the initiation of anticoagulation. Both have a propensity for fatal outcomes including, but not limited to myocardial infarction, embolic events, cardiogenic shock, or death. Follow-up imaging with a resolution of thrombus would confirm the diagnosis of native aortic valve thrombus.

Native aortic valve thrombosis in a patient with chronic thromboembolic pulmonary hypertension

Spontaneous native aortic valve thrombosis is an unusual cause of coronary insufficiency and more common in patients with underlying coagulopathies, such as antifospholipid syndrome, valve disease or bacterial endocarditis. However in this case we want to demonstrate a case that doesn’t fit above mentioned criteria. Even more, a rare condition of spontaneous native aortic valve thrombosis is combined with Chronic Thromboembolic Pulmonary Hyperthension (CTEPH).

The Characteristics and Outcomes of Native Aortic Valve Thrombosis: A Systematic Review

BackgroundThere is a lack of knowledge in the current medical literature about native aortic valve thrombosis. ObjectivesThe aim of this systematic review was to summarize the characteristics, presentations, underlying etiologies, and outcomes of native aortic valve thrombosis and to present a meta-analysis of the best available data. MethodsThe authors performed a literature search, identified published cases of patients with native aortic valve thrombosis, and pooled the data in this meta-analysis. The statistical analysis included calculations of the prevalence of the various presentations, underlying etiologies, aortic cusp involvement, as well as choices of diagnostic testing. They calculated the sensitivities of the various diagnostic testing as well as in-hospital mortality event rates and the univariate ORs of the risk factors for poor outcomes. ResultsThe search strategy and screening process yielded 74 cases of native aortic valve thrombosis, which are included in this meta-analysis. The data revealed that the most common presentation was myocardial infarction in 36%, and the most common underlying etiology was hypercoagulable state in 30%. In-hospital clinical deterioration after presentation including recurrent embolism occurred in ∼38%, and in-hospital mortality rate was ∼20%. ConclusionsNative aortic valve thrombosis is clinically relevant, especially in patients presenting with embolic events. Awareness about native aortic valve or root thrombosis as well as its underlying etiologies, diagnostic work-up, and management is essential, because this condition can be associated with poor outcomes.

Native aortic valve thrombosis confined to noncoronary cusp of aortic valve

Antiphospholipid syndrome (APLS) carries numerous cardiovascular complications due to recurrent arterial and venous thromboembolism. However, thrombosis of native aortic valve in primary APLS is a ...

501 A common finding with an atypical (rare) presentation

Abstract Introduction Hypereosinophilic syndrome (HES) is characterized by persistent eosinophilia and eosinophil-mediated organ damage. Cardiac thrombosis and thromboembolic complications are common causes of morbidity and mortality in these patients. The echocardiogram is the first method of image in the assessment of cardiac involvement by HES. Clinical Case An 81 year-old male, with previous history of hypereosinophilia under investigation without specific treatment, presented to the emergency department after several episodes of syncope and exertional dyspnea. The patient denied fever. He was hemodynamically stable and had a holosystolic murmur (III/VI) audible in the entire precordium. The ECG was normal. The blood tests showed leukocytosis (26.69 x10^9/L) mainly related to hypereosinophilia (17.5 x10^9/L), thrombocytopenia (134.000/uL), elevation of troponin (hsTnT= 276 ng/L, normal range <14) and reactive C-protein (3.27mg/dL, normal range <0.5). The transthoracic echocardiogram (limited for the acoustic window) showed a mass in the aortic valve with obstruction of the left ventricle outflow tract (LVOT) during systole (maximum velocity= 3.85m/s, maximum gradient = 59mmHg, mean gradient = 31mmHg), moderate mitral regurgitation, left ventricle hypertrophy with normal ejection fraction and mild pericardial effusion. A transesophageal echo (TEE) was performed confirming the presence of a hyperechogenic sessile mass, with irregular contours, measuring 23x30 mm, attached to the aortic valve causing obstruction of the LVOT (Figure 1 A and B – TEE midesophageal long axis in diastole and systole, respectively; C and D - TEE midesophageal short axis in diastole and systole, respectively). The patient was submitted to emergent cardiac surgery for excision of the mass and aortic valve replacement (Figure 1E and F- intraoperative and macroscopic views of the mass, respectively). The anatomopathological diagnosis confirmed an aortic valve thrombus. Discussion/Conclusion: Native aortic valve thrombosis is a rare situation with severe complications like acute myocardial infarction, peripheral ischemia, stroke, cardiogenic shock and sudden death. In HES, cardiac involvement is present in up to 40-50% of patients, mainly with endomyocardial fibrosis and mural thrombus formation. Native and prosthetic mitral valve thrombosis has also been described, but aortic valve involvement is very unusual. Thrombi are one of the most common intracardiac masses, but here we present a rare case of native aortic valve thrombosis with high risk of sudden cardiac death, possibly related to HES. The echocardiogram, particularly the transesophageal echo was essential for the identification of the mass and surgical planning, but as usual in intracardiac masses, the final diagnosis was histological. Abstract 501 Figure.

Bivalirudin for Treatment of Aortic Valve Thrombosis After Left Ventricular Assist Device Implantation

Ventricular assist devices are increasingly being used for mechanical support in patients with advanced heart failure. However, thromboembolism remains a leading cause of mortality in this population. We describe the successful treatment of native aortic valve thrombosis with bivalirudin in a patient with factor V Leiden mutation, who had undergone left ventricular assist device implantation, preventing the need for further surgical intervention.

Native aortic valve thrombosis: an unusual cause of acute ST-elevation myocardial infarction

Coronary artery embolism is an infrequent cause of acute myocardial infarction. In addition, native aortic valve thrombosis is a very rare condition. We report a case of native valve thrombosis causing acute ST-elevation myocardial infarction in healthy middle-aged man who has no established cardiovascular risk factor. We diagnosed native aortic valve thrombosis using various imaging techniques and confirmed our diagnosis histopathologically after surgical operation.

Recombinant factor VIIa while on extracorporeal membrane oxygenator support: a word of caution

We read with interest the article by Chapman et al. [1]. They showed that patients receiving recombinant factor VIIa (rFVIIa) for intractable bleeding after cardiac surgery are not at an increased risk of thromboembolic events. Therefore, they concluded that this effective haemostatic agent can be used with an acceptable safety profile in this patient population. We would like to ask the authors whether, among the 236 patients receiving rFVIIa, they had patients supported by extracorporeal membrane oxygenator (ECMO). Bleeding is a major problem in postoperative ECMO implantation for post-cardiotomy cardiogenic shock [2]. Severe haemorrhage requiring re-exploration occurs in up to 58% of cases [3] and carries a dismal prognosis. Among patients who returned to the operating theatre, a surgical source of bleeding is not identified in more than half of the patients [1]. Hence, the off-label use of rFVIIa represents an attractive haemostatic agent for controlling bleeding attributed to a disseminated intravascular coagulation-like phenomenon [4]. We entirely agree with their opinion about the effectiveness of rFVIIa as a haemostatic agent, and we would like to report an exceptional thrombotic complication that we recently encountered: a native non-calcified aortic valve thrombosis in a patient on ECMO support who received rFVIIa for massive bleeding after coronary artery bypass grafting (CABG) surgery. A 60-year old male patient was admitted on an elective basis for CABG surgery. His past medical history included hypertension and multiple sclerosis. Coronary angiogram revealed triple vessel disease. Transthoracic echocardiography disclosed a normal aortic valve and an ejection fraction at 45%. The patient had a normal hepatic and renal function and a normal coagulation profile before surgery. Cardiopulmonary bypass (CPB) was established through median sternotomy. The obtuse marginal artery was not identified during surgery due to severe adherence between the lateral aspect of the left ventricle and the pericardium while the right coronary artery and the left anterior descending artery were bypassed. Weaning from CPB was unsuccessful, and femoro-femoral ECMO was instituted. The patient was transported to the angiography laboratory where a drug eluting stent was successfully implanted in the proximal circumflex artery. Massive bleeding from the chest tube was recorded. Therefore, a 90-μg/kg of rFVIIa was infused, and bleeding decreased. Heparin infusion was commenced 18 h after the surgery. On postoperative day (POD) 1, a transoesophageal echocardiogram (TEE) revealed severely depressed contractility of the left ventricle and thrombus formation on the three cusps of the aortic valve on the aortic side. Despite full heparinization, a complete thrombosis of the aortic valve was disclosed on POD 3, and no clots were noted in the ECMO tubing. His family refused permission for further treatment and he died after the removal of the support. In view of our experience with this drug, we recommend caution when rFVIIa is used in the postoperative period after cardiac surgery in the setting of ECMO support; careful patient management by routinely performing TEE and maintaining inotropic support for ventricular contractility and cusps mobility is mandatory to prevent thrombus formation on the aortic cusps.

Sudden cardiac death caused by native aortic valve thrombosis in an adult patient with a complex congenital cyanotic heart disease

Cyanotic congenital heart disease is associated with an increased risk of thromboembolism. We describe the case of sudden cardiac death caused by native aortic valve thrombosis in adult cyanotic patient. Such embolic complication was not previously described in cyanotic patient. It is also the first report of sudden cardiac death as an initial presentation of the native aortic valve thrombosis. Cyanotic congenital heart disease (CCHD) is associated with an increased risk of thromboembolism due to different haemathologic abnormalities associated with hypoxemia and secondary polycythemia [H. Kajimoto, M. Nakazawa, K. Murasaki, et al. Increased thrombogenesity in patients with cyanotic congenital heart disease. Circ J Jun 2007;71(6):948–953]. Cerebrovascular events, venous and arterial thrombosis have been described in patients with CCHD [N. Ammash, C.A. Warnes. Cerebrovascular events in adult patients with cyanotic congenital heart disease. J Am Coll Cardiol Sep 1996;28(3):768–772]. We present a case of the native aortic valve thrombosis in an adult patient with a complex cyanotic congenital heart lesion which led to sudden death.

ST-Segment Elevation Acute Myocardial Infarction Secondary to Native Aortic Valve Thrombus

Introduction Spontaneous native aortic valve thrombosis is a rare condition. Almost all published cases have been associated with heart valve disease, heart valve replacement, a hypercoagulative state or the presence of an autoimmune disease. The present case is unique in that a thrombus developed on a native aortic valve with no predisposing cause, which resulted in a potentially fatal embolism to a coronary artery.

Native aortic valve thrombosis: a rare cause of acute ischemia of the lower limb

Spontaneous native aortic valve thrombosis is an uncommon event occurring after heart valve disease, during cardiac catheterization, bacterial endocarditis, or as a hypercoagulative state as in antiphospholipid antibody syndrome. We report the case of a 55-year-old woman in whom thrombi developed on a native aortic valve with no predisposing cause. The thrombi were responsible for recurrent lower limb ischemia. Eighteen months after aortic valve replacement, the patient is doing well.

Intermittent Left Coronary Occlusion Caused by Native Aortic Valve Thrombosis in a Patient with Protein S Deficiency

A 77-year-old woman presented with chest pain and cardiogenic shock. Transesophageal echocardiography showed a mobile mass occluding intermittently the left coronary ostium. The mass was surgically resected, and histologic examination revealed an organized thrombus. Coagulation study demonstrated a protein S deficiency. This is the first case of aortic thrombosis associated with protein S deficiency, and it is the first time that transesophageal echocardiography provided definite evidence that a mass can cause intermittent left ostium coronary obstruction. (J Am Soc Echocardiogr 1999;12:1114-6.)