Organized Prosthetic Tricuspid Valve Thrombosis Treated Successfully with Medical Treatment
A 57-year-old female patient was admitted to the hospital with the complaint of dyspnea [The New York Heart Association (NYHA) Functional class II] in December, 2010. TTE showed left ventricular ejection fraction of 59%, severe mitral stenosis, severe aortic stenosis and severe tricuspid regurgitation. In January 2011, the patient underwent mitral valve replacement with a 25 mm On-X Valve (On-X Life Technologies Inc., Austin, TX, USA), tricuspid valve replacement with a 31/33 mm On-X Valve, and aortic valve commissurotomy. Also, because of persistent atrial fibrillation, she received Cox-maze procedure. Eleven days after valve replacement, TTE revealed that the normal function and gradients of the two prosthetic valves. At the time of discharge, the patient's international normalized ratio (INR) was 2.36. She was discharged from the hospital with the recommendation to use warfarin with goal INR 2.0-3.0.\nIn December 2012, the patient complained of dyspnea again. Her blood pressure was 137/68 mmHg and pulse rate was 55 beats per minute. TTE and TEE demonstrated that two prosthetic valves had normal functions and gradients. Doppler echocardiographic examination of the prosthetic tricuspid valve demonstrated the peak E velocity of 1 m/s, peak pressure gradient of 5 mmHg, and pressure half time of 144 ms (). Fluoroscopic evaluation revealed that both leaflets of the two prosthetic valves moved freely. She complained of intermittent, small amount of melena and microcytic and hypochromic anemia with hemoglobin level of 7.8 mg/dL was detected. Therefore, under impression of iron deficiency anemia caused by gastrointestinal bleeding, oral iron supplement was prescribed and esophagogastroduodenoscopy (EGD) was planned. The patient's INR was 2.51 before procedure. After four days of withholding warfarin therapy without reversal the effect of it, EGD was done. Her INR was 1.82 at that time. EGD showed erosive gastritis without active bleeding focus, no hemostatic intervention was performed and the patient resumed taking warfarin the next day.\nThe patient was hospitalized for evaluation of the causes of worsening dyspnea (NYHA Functional class III) despite correction of anemia in February 2013. On admission day, her blood pressure was 121/59 mmHg, pulse rate was 80 beats per minute and INR was 2.13. TTE revealed that the prosthetic mitral valve had normal function and gradients, whereas the prosthetic tricuspid valve showed limited motion without definite obstruction. Doppler measurements including peak E velocity and mean gradient, however, were within acceptable range. The peak E velocity was 1 m/s and mean gradient was 3 mmHg. The only parameter suggested prosthetic tricuspid valve dysfunction was prolonged pressure half time, 382 ms (). Considering the fact that warfarin was recently discontinued, fluoroscopic evaluation was done. The fluoroscopy showed that one leaflet of the prosthetic tricuspid valve had limited motion (). For evaluation of the cause of impaired prosthetic tricuspid valve motion, MDCT was performed. Computed tomography demonstrated the large thrombus on prosthetic tricuspid valve (, and ). With the diagnosis of prosthetic tricuspid valve thrombosis, the patient was administered 60 mg of low molecular weight heparin twice a day for three days. Her blood pressure and pulse rate were stable during hospitalization. After three days, she discharged from the hospital with the recommendation to adjust warfarin dose with goal INR 3.0-3.5. Two weeks after discharge from the hospital, she visited the outpatient clinic for follow-up. Dyspnea was disappeared and her exercise capacity was improved. Then, after four months, follow-up TTE was done. The images showed unrestricted motion of prosthetic tricuspid valve with normal pressure half time ().