Abstract 1120: Chest Pain and Dyspnea in a Pregnant Woman with a Prosthetic Valve
A 31 year old pregnant female at nine weeks gestation presented with a complaint of recurrent chest pain and dyspnea. The patient had undergone aortic valve replacement with a bileaflet mechanical valve at 25 years of age. Most recently, she had been anti-coagulated with low-molecular weight heparin. The patient had missed two doses of enoxaparin over the prior week. Physical examination was notable for muffled, but audible mechanical valve sounds with an early peaking, systolic murmur over the right sternal border. Transthoracic echocardiogram revealed an elevated mean trans-aortic gradient of 38 mm Hg. Of note, echocardiogram at an outside hospital six days earlier had revealed normal gradients. Trans-esophageal echocardiography was performed, which revealed a poorly mobile posterior leaflet without large thrombus, and confirmed elevated gradients. Fluoroscopy of the aortic prosthesis also revealed a fixed posterior leaflet. A presumptive diagnosis of prosthetic valve obstruction (PVO) due to prosthetic valve thrombosis (PVT) was made. After discussion with the patient, intravenous tissue plasminogen activator was administered. Fluoroscopy the following day revealed both aortic valve leaflets to be fully mobile and transthoracic echocardiogram demonstrated normal trans-aortic gradients. Patient was anti-coagulated with enoxaparin until twelve weeks gestation and with coumadin for the duration of her pregnancy. At 37 weeks, a healthy, baby boy was delivered. PVO can be caused by thrombus, pannus formation or endocarditis. PVT is the most common etiology, with an annual rate of 0.5 to 8%. An increase in clotting factors during pregnancy results in a physiologic hypercoagulable state and higher rates of thromboembolic complications. Management options of PVT include surgery or intravenous thrombolytic therapy. Trans-esophageal echocardiography can be used to help guide management. This case illustrates the difficulties in the diagnosis and management of a relatively uncommon condition (prosthetic valve thrombosis) in a common patient (pregnant female). In conjunction with the clinical history and physical examination, various imaging modalities were utilized to arrive at a likely diagnosis and formulate a management plan.