Failure of guideline-based anticoagulation in a patient with mitral prosthetic valve and recurrent thromboembolism

Successful Long-term Anticoagulation with Enoxaparin in a Patient with a Mechanical Heart Valve

Thromboembolism related to a mechanical heart valve (MHV) is a major complication after surgical valve replacement. Warfarin remains as guideline-endorsed thromboprophylaxis in patients with MHVs. Alternative anticoagulation therapy for patients who do not tolerate or who fail warfarin is not adequately covered in the current guidelines. We report a case of successful long-term anticoagulation with enoxaparin in a patient with a mechanical aortic valve who had a contraindication to warfarin. The patient developed a left thigh hematoma requiring surgical evacuation 1 month after initiation of weight-based dosing of enoxaparin. His dose was then titrated based on peak anti-factor Xa levels (goal 0.6-1.0 IU/ml). He remained free of signs and symptoms of thromboembolic events, valve dysfunction, bleeding complications, or major adverse effects from long-term enoxaparin use for the next 13 years. Our case provides promising evidence of the potential role of enoxaparin in patients with MHVs in whom warfarin thromboprophylaxis is not possible. Meticulous monitoring of anti-factor Xa levels and dosage adjustments are crucial to treatment success.

Surgical treatment for papillary fibroelastoma of the aortic valve

Although cardiac papillary fibroelastomas are benign tumors, they have the potential to cause life-threatening complications such as stroke and myocardial infarction and may even lead to sudden cardiac death. We report a case of surgical treatment for a papillary fibroelastoma of the aortic valve. The patient was a 62-year-old woman who was asymptomatic for cardiac papillary fibroelastoma. Echocardiography demonstrated a mobile, rounded mass on the left coronary cusp of the aortic valve. The patient underwent surgical excision, had an uneventful recovery, and was discharged 10 days after the operation. Pathology examination confirmed papillary fibroelastoma. Surgical excision of the tumor is recommended for patients with symptoms, but the treatment of asymptomatic patients is controversial. We believe that surgical treatment should be performed if the tumor is mobile.

Nonsurgical management of a tricuspid valvular pedunculated papillary fibroelastoma

A 25-year-old woman with a history of kidney transplantation for lupus nephritis was referred for the evaluation and management of a mass incidentally found on echocardiography. An oval and pedunculated mass attached to the tricuspid valve was managed with nonsurgical treatment. No symptoms and complications attributable to the mass developed. Three years later, the size of the mass decreased. Here we report the case of a probable cardiac papillary fibroelastoma (PFE), a mobile mass, with a stalk on the septal leaflet of the tricuspid valve that was managed for three years without surgical treatment.