![]() Unfortunately, details about the type and age of the patient’s titanium valve are not included in this case. The new direct-acting anticoagulants either do not prevent valve thrombosis or have not been adequately studied for this indication therefore, use of these drugs (apixaban, rivaroxaban, edoxaban and dabigatran) is not recommended for patients with mechanical aortic valve(s). Long-term anticoagulation treatment using warfarin is necessary for all patients who have a mechanical aortic valve to reduce the risk of valvular thrombosis and systemic thromboembolism. 1 Absent fever and other symptoms of endocarditis, we assume that infective endocarditis was ruled out in this case. Although this complication occurs more commonly on a mechanical mitral valve than on a mechanical aortic valve, the latter has a cumulative incidence of infective endocarditis of about 7% during a 15-year follow-up period. It is important to recognize at the start that the differential diagnosis of peripheral arterial emboli in a patient with a mechanical valve should include infective endocarditis. The patient safety issues center on confirming the aortic valve-associated thrombosis, providing appropriate anticoagulant treatment, and properly managing both the valve-associated thrombosis and the arterial emboli in the right leg, which presumably originated from the cardiac valvular thrombus. This case involves a patient who developed thrombosis on a mechanical aortic valve during ongoing chronic warfarin therapy, which manifested as two symptomatic arterial emboli to her right lower extremity. The Commentaryīy Nasim Hedayati, MD, and Richard White, MD The surgeon later reported that it was the best he could do under the circumstances and apologized for miscommunication. ![]() The patient was taken to the Operating Room (OR) to extirpate the arterial thrombus, but the surgeon also needed to split the calf muscle with a fasciotomy to reduce pressure in the calf and restore arterial blood flow. The surgeon expressed regret that they were not informed earlier of the patient’s discoloration and discomfort, as they would have intervened earlier. The surgical consultant arrived and told the patient that amputation of the limb might be needed. Her leg was cold and pulseless her toes appeared to be turning black. Two days later, she complained of excruciating pain and more discoloration covering the entire right leg. She was told to “be patient” and not to worry about the discoloration, because she was being treated appropriately. By hospital day 3, the right leg became discolored and cold, leaving the patient in extreme discomfort. The hospital’s usual protocol for adjusting the drip rate was followed. The attending physician was notified and ordered discontinuation of warfarin and initiation of a heparin drip for at least 5 days. Echocardiography revealed a thrombus near the prosthetic heart valve. Her past medical history was notable for having had an aortic valve replaced with a titanium valve and chronic management at a therapeutic level of anticoagulation with warfarin, based on the International Normalized Ratio (INR).ĬT imaging revealed two arterial thromboses in the right lower extremity. She was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. A 61-year-old woman presented to her primary care physician with uncontrolled high blood pressure and a complaint of leg pain.
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