Don’t Bite the Hand That Feeds You: Late Complication of Mitral Valve Replacement
Amena Nayeem, Muhammad Fahad Zakir*, Sumera Nawaz Qabulio, Ghania Niazi and Fasiha Sohail
Ziauddin University and Hospital, Pakistan
Submission: January 22, 2018; Published: May 24, 2018
*Corresponding author: Muhammad Fahad Zakir, Ziauddin University and Hospital, Karachi, Pakistan, Tel: +92-333-2324002;
How to cite this article: Amena N, Muhammad F Z, Sumera N Q, Ghania N, Fasiha S. Don’t Bite the Hand That Feeds You: Late Complication of Mitral
Valve Replacement. Open Access J Neurol Neurosurg. 2018; 7(5): 555721. DOI: 10.19080/OAJNN.2018.07.555721.
Case:A 42-year old married female, known case of mitral regurgitation and chronic atrial fibrillation with mitral valve replacement in 2007 (on warfarin) with complaints of left sided motor and facial weakness. CT brain was done which showed ischemic changes.
On exam:GCS 12/15 (E4, M6, V2). Power in left upper and lower limb was ⅖. Tone in the left side was decreased. Reflexes of the left side were exaggerated. Plantars on the left side were up going. Neurological exam of the right side was normal. Gag reflex was absent and cranial nerve VII examination of the left side showed weakness
Management: Nasogastric tube and Foleys catheter were passed. Initial treatment with Tab Aspirin 75mg, tab atorvastatin 20mg, tab clopidogrel 75mg. tab digoxin 0.25mg tab bisoprolol (fumarate) 2.5mg were added to the treatment.
Outcome: Patient was discharged on the fifth day with improved symptoms and advised daily physiotherapy and a follow up in one week’s time.
Keywords: MVR; Mitral valve replacement; Mitral regurgitation; Valve replacement; Biological prosthesis; Mechanical prosthesis; Don’t bite the hands that feed you
Mitral valve regurgitation is the most frequently occurring valvular heart defect in the US and may be brought on by the degenerative changes of aging, ischemic mitral regurgitation or rheumatic disease and is the second most common valvular defect in adults. Intervention is required when there is ventricular dysfunction, NYHA class II symptoms or a change in the normal end systolic diameter . In patients with mitral valve regurgitation valve replacement is the treatment of choice. Bio prostheses or mechanical prostheses are used depending on the patient’s age and other related conditions. These replacement surgeries carry both early and long term complications, one of them being stroke. Stroke can be defined as signs of focal neurological deficit due to an acute injury to the brain caused by a vascular event; it can either be hemorrhagic or ischemic in etiology . In this report the case of a 42 year old woman with mechanical mitral valve prosthesis has been discussed.
A 42-year old married female, known case of mitral regurgitation and chronic atrial fibrillation with mitral valve replacement in 2007 (on warfarin) presented to the ER with
complaints of left sided motor and facial weakness for one day. She suffered a fall our days earlier, after which she was rushed to a government hospital and a brain CT was done, which was unremarkable and she was sent home after primary management. One day later she developed left sided facial and motor weakness (hemiparesis) and was again taken to a government hospital and a brain CT was repeated which showed ischemic changes. Primary management given to the patient also included these drugs: digoxin, amiloride, furosemide, dimenhyrinate, diclofenac sodium, atorvastatin and verapamil (hcl). After the patient did not show any progress she was brought into our set-up and admitted into the intensive care unit.
A. Primary assessment: vitals were normal and GCS was 12/15 (E4, M6, V2).
B. Neurological exam: Power in left upper and lower limb was ⅖. Tone in the left side was decreased. Reflexes of the left side were exaggerated. Plantars on the left side were up going. Neurological exam of the right side was normal. Gag reflex was absent and cranial nerve VII examination of the left side showed weakness.
C. Respiratory exam: Chest had harsh vesicular breathing.
D. Precordium exam: s1 + s2 with metallic click in the
MRI showed Right middle cerebral artery infarct. Echo
showed enlarged left and right atrium, normal right and left
ventricle, Ejection fraction 60%, no paravalvular leak. MS (mild
to moderate), MR (trace), increase flow on LVOT seen. AR (mild),
no AS, TR (moderate) with moderate PAA and PR (trace). ECG,
showed rate controlled atrial fibrillation,
Nasogastric tube and Foleys catheter were passed and strict
I/o charting was done. Initial treatment given was Tb Aspirin
75mg, tb atorvastatin 20mg, tbclopidogrel 75mg. On the second
and third day patient remained oliguric despite the hydration
GCS was 15/15. Warfarin was stopped, Capsule omeprazole
40mg, tb digoxin 0.25mg tbbisoprolol (fumarate) 2. mg and tb
furosemide 40mg were added to the treatment. Subsequently
digoxin was decreased to 0.25mg.
On the fourth day patient was responding well but speech
remained slurred, gag reflex improved slightly. Patient was
discharged on the fifth day with improved symptoms and
advised daily physiotherapy and a follow up in one week’s time.
Mitral valve replacement surgery has early and late
complications. Our case is slightly similar to a case reported by
Thomas et al, where an elderly woman had a stroke following an
open MVR surgery involving embolisation of heart tissue, was
the first to be reported . The patient in the above mentioned
case had an early complication. Our patient suffered an embolic
event ten years post valve replacement surgery with a similar
presentation however there was no evidence of thrombus. Age,
heart failure, atrial fibrillation, hypertension, smoking and
diabetes are risk factors that can lead to a thromboembolic
stroke or even a hemorrhagic stroke . Patients who undergo
mitral valve replacement with correction of atrial fibrillation
have reduced chances of developing a stroke whereas those with
only valve replacement have been shown to be susceptible to a
thromboembolic event up to 8 years after surgery.
There are a myriad of explanations for the development of
stroke in our patient. Patients who undergo valve replacement
surgery and have mechanical valve prostheses or even chronic
atrial fibrillation should have a target PT or INR more than 2.5
to 3.5 times of the normal value after the surgery and should be
on warfarin . Considering the risk factors, the normal range
of INR and PT in the patient and the chronic atrial fibrillation
may have contributed to stroke as a late complication .
Embolic stroke can occur in a patient within 6.6±4.6 years after
an MVR surgery . Additionally, tricuspid regurgitation, if left
uncorrected can lead to right ventricular enlargement over the
years resulting in right-sided heart failure .
The role of anticoagulation to prevent thromboembolic
events is crucial; combining with that, inadequate medication
to a non-compliant patient may play a role in determining
whether this was the cause of the event. The management after
MVR surgery is the initiation of warfarin therapy as it reduces
the risk of thromboembolism. While the patient is on warfarin
target PT and INR should be closely monitored. Although, the
risk of embolic and hemorrhagic stroke is high in patients with
mechanical valve prostheses, mortality is low in middle aged
patients . We believe that is the first case to report an embolic
stroke as a late complication of mitral valve replacement surgery
with mechanical valve prosthesis in a middle aged patient.
Cases that have been reported discuss older patients with early