View larger version (28K):
[in this window]
[in a new window]
|
A 63-year-old woman presented for evaluation after 2 weeks of progressive dyspnea. She had a history of dilated cardiomyopathy, and a St. Jude prosthetic valve had been inserted in the mitral position 6 years earlier for mitral insufficiency. Since then she had been taking a maintenance dose of warfarin. The physical examination was notable for bibasilar crackles and a muffled S1 heart sound. The international normalized ratio was subtherapeutic at 2.0 (target range, 2.5 to 3.5). Fluoroscopy of the prosthetic mitral valve showed that one of the leaflets was stuck in the closed position (Video 1). Transesophageal echocardiography confirmed the presence of one immobile leaflet and showed an elevated transvalvular gradient (11.6 mm Hg) (Panel A, arrow) and a large thrombus in the left atrial appendage (Panel B, arrow). After continuous infusion of streptokinase for 72 hours, examination revealed the return of a metallic S1 heart sound, and fluoroscopy showed normal movement of the bileaflet St. Jude valve (Video 2). There was no evidence of embolic complications or bleeding. The patient had marked alleviation of her dyspnea. She continues to do well with warfarin and aspirin, and there has been no further dysfunction of the prosthetic valve.
|
Previous
Videos
