Mechanical mitral valve thrombosis in rheumatic valve disease.

To cite: Noroozian N, Bashir A, Bradlow W, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2013-201918 DESCRIPTION A lady in her late 30s was admitted with a 2-week history of shortness of breath and productive cough. She had been treated for presumed lower respiratory tract infection but had not clinically improved. Her medical history includes rheumatic fever in childhood and she had undergone bioprosthetic mitral replacement (Carpentier-Edwards) 15 years ago. She had redo-surgery with mitral (25 mm carbomedics) and aortic (21 mm carbomedics) replacement and tricuspid repair 6 years ago. She was on long-term treatment with phenindione (allergy to warfarin) but due to supply problems had been switched to sinthrone recently. Her anticoagulation record confirmed subtherapeutic International Normalised Ratios for the past 2–3 months. The patient underwent a transthoracic echocardiogram which revealed an increased gradient across the mitral valve suggestive of valve obstruction (figure 1A). Transoesophageal echocardiogram (TOE) showed that one of the mitral valve leaflets was immobile and stuck between an open and closed position (figure 1B,C; videos 1 and 2) with a thrombus seen on the annulus. The left atrium was severely dilated with thrombus in the left atrial appendage (figure 2A,B). Urgent cardiothoracic surgery was considered to be high risk due to her unstable state and a background of two previous thoracotomies and she received thrombolysis with streptokinase followed by a heparin infusion. She experienced transient inferior ST-segment elevation on her ECG with chest pain which was managed conservatively. Her clinical condition gradually improved and there were no neurological sequelae. Repeat TOE showed resolution of thrombus (figure 3A and video 3) and the normalisation of gradient across the mitral valve (figure 3B).