The correct answer is C!

This question is part of the Mayo Clinic Cardiology Board Review course.

A 45-year-old woman had a mechanical St. Jude MVR 10 years ago for severe mitral stenosis. She has been doing well but over the last week has noted progressive SOB – now with dyspnea at rest. She had not had her INR checked in the past two months due to an extended holiday vacation but continued to take her regular dose of 4 mg warfarin per day. On exam, she is dyspneic at rest with a BP 90/60 mmHg and heart rate 95 bpm. She has rales in both lung fields and a muffled closing click of the MVR. No murmur was audible. Her chest x-ray showed pulmonary edema. TTE revealed normal LV size and function, well seated MVR but a mean gradient of 20 mmHg with a halftime of 220 ms. TEE was performed, which showed opening of only one disc of the mitral valve with a small 3 mm echodensity attached to the valve ring. There was no thrombus in the left atrium.

Q: What is the next best step in her management?

A) Send out with an increased dose of warfarin to achieve INR 3.5

B) Intravenous tPA 90 mg over 60 minutes followed by UFH

C) Referral for urgent surgical consultation (correct)

D) Continuous infusion of UFH for 48 hours then reassess

Rationale

Patients who have a thrombosed mechanical valve are at high risk for heart failure and death. The optimal treatment for patients who have valve thrombosis who are otherwise surgical candidates is an emergency operation, especially those who are in heart failure. Thrombolytic therapy can be used on left-sided valves but is a second choice due to the long onset of action as well as the high risk of embolic events.

References

Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(23):e521–e643. Class I: 1. Emergency surgery is recommended for patients with a thrombosed left-sided prosthetic heart valve with NYHA class III to IV symptoms. (Level of Evidence: B)

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