A 39-year-old woman with a history of hypothyroidism, right antiphospholipid syndrome, rheumatic heart disease, smoking, valvular heart disease with mitral stenosis underwent valve replacement with a mechanical prosthesis Carbomedics No. 27 sequelae.
The APS was diagnosed 17 years ago after presenting deep venous thrombosis on two occasions and an abortion.
During the last months he had presented episodes of colic abdominal pain and was diagnosed with gallstones.
It was planned for surgical intervention so warfarin anticoagulation was switched to tinzaparin.
Four days after the change, the patient came to the emergency department with cardiogenic shock and was admitted to the intensive care unit (ICU).
The INR was 1.0.
Transesophageal echocardiogram (TEE) revealed immobility of the intermediate hemidyscus of the mitral prosthesis and at this level an intermediate echogenicity mass of 14x11 mm was observed, suggesting prosthetic thrombosis.
The initial fibrinolytic treatment with rt-PA (10 mg bolus followed by 90 mgr infusion) was ineffective and was surgically intervened; the thrombosed prosthesis was replaced by a new one Carbomed 27.
In the postoperative course, she had serious problems to achieve adequate anticoagulation, requiring sodium heparin in continuous perfusion along with acenocoumarol to achieve INR between 2.5 and 3.5.
After 15 days of hospitalization, the patient was discharged on warfarin and tinzaparin.
A thrombophilia study was requested, which detected levels of anticardiolipin antibodies of 84 UPL.
Determinations of lupus anticoagulant, C and S proteins, antithrombin III, prothrombin gene mutation, homocysteine and Leyden factor V were within normal limits.
After 10 days she returned to the ICU with acute pulmonary edema (APE).
TEE showed abundant thrombus in LA, decreased opening mobility of both hemidyscoses and mitral gradient of 28 mmHg.
An INR of 1.2 was detected, and reviewing previous coagulation controls, it was observed that most days had an INR < 2.0.
It was decided to perform a new thrombolysis that was ineffective, so it was re-intervened and proceeded to a new valve prosthesis re-channeling biological prosthesis Edwars 27 mm in diameter.
She was discharged from the ICU 19 days after the intervention, anticoagulated with warfarin and enoxaparin.
She remained hospitalized for 14 more days with an INR > 3.0 at all times.
She was discharged home with warfarin and aspirin (ASA).
Echocardiographic abnormalities were not observed in subsequent outpatient follow-ups, and strict controls were followed by signs and symptoms.
