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A 75 year old female patient with a four year history of aortic valve replacement with mechanical prosthesis (Medtronic Hall 20) was admitted to the cardiology department with a one month history of progressing dyspnoea and coughing episodes. She denied having chest pain. Admission ECG showed signs of hypertrophy and overload of the left ventricle and 1 mm ST segment elevations in leads II, III, and aVF. Routine laboratory tests revealed significant increases in cardiospecific enzymes and an international normalised ratio (INR) of 1.71, confirming inadequate anticoagulation treatment with long term administration of warfarin sodium.
Further management was strongly influenced by echocardiography findings. Transoesophageal echocardiography (TOE) on the day of admission revealed a non-dilated hypertrophic left ventricle (LV) with a hypokinetic inferior wall and good global ejection fraction (60%). Mechanical disc prosthesis was present in the aortic position, with severe dysfunction. The whole right coronary sinus was filled with a hyperechogenic mass that hindered the movement of the disc and perfusion of the right coronary artery (panels A, B). Significant aortic stenosis was present with a peak gradient of 95 mm Hg along with grade 2 regurgitation. Because of the high risk of surgery due to the ongoing myocardial infarction we decided to administer a thrombolytic agent. Actilyse 100 mg was given intravenously in a two hour continual infusion, followed by a continuous infusion of unfractioned heparin during the following days.
A follow up TOE on day 5 after admission revealed a completely clear aortic bulb with no pathological masses, good function of the aortic mechanical valve, full motion range of the disc without any limitations, and a significant reduction of the peak grade down to 51–52 mm Hg, which was the patient’s pre-morbid value (panels C, D). Global left ventricular function had no significant abnormalities. Anticoagulation treatment with warfarin sodium was resumed and the patient was discharged home on day 11 in satisfactory condition with an INR of 3.30.