The Man behind the Gun: How Transthoracic Echo Examination Might Identify Thrombotic Mechanical Prosthetic Mitral Valves and Guide Therapy in Limited Resources Areas

Abstract

_{Background: Heart prosthetic valve (PV) dysfunction is still difficult to diagnose because it is hard to predict but not rare. Complete prosthetic valve evaluation by transthoracic echocardiography (TTE) is sometimes challenging due to acoustic shadowing and artifacts. Transoesophageal echocardiography (TEE) remains the first choice test to assess prosthetic valve dysfunction (PVD) but is resource-intensive and carries risk. Transthoracic 2D Doppler echocardiography is the preferred method for evaluating prosthetic valve function, particularly in areas with limited TEE or imaging facilitation. A high-quality TTE may be used to detect PVD and reduce the need for further investigation by TEE.}

_{Objective: To present a case of mitral prosthetic valves dysfunction and highlight the role of TTE in mitral prosthetic valves (MPV) evaluation.}

_{Case Illustration: A 57-year-old woman referred to our Emergency Department presented with progressive dyspnea since a week ago. Two years earlier, she had undergone mitral valve replacement with a 27-mm St. Jude bileaflet mechanical prosthesis. One month before admission, anticoagulant therapy was discontinued due to neurological problems. An echocardiogram showed obstruction with high gradient pressure at the prosthetic valve (MVA 0.44 cm2, MVG 14-18 mmHg). Heparinization was started with a target APTT 1-1.5x the normal value. After 3 days of heparinization, in-patient TEE showed a decrease in transmitral gradient compared to the previous echo (18 mmHg ???? 7 mmHg), MVA 1.3 cm2. The patient was scheduled for an outpatient TTE in 3 months and discharged home with adequate anticoagulant treatment. Repeated follow-up TTE 3 months after discharge revealed the resolution of the previous thrombi in the mitral valve ring, and the mechanical mitral valve prosthesis was functioning normally.}

_{Conclusion: Early detection and appropriate treatment can reduce the risk of valve dysfunction. The use of TTE to establish prosthetic valves dysfunction is reliable, especially in areas with minimal facilities.}