[Severe thrombosis of bioprosthesis mitral valve after dabigatran].
[Severe thrombosis of bioprosthesis mitral valve after dabigatran].
复制标题
达比加群治疗后生物瓣膜二尖瓣严重血栓形成[J].
DOI：
10.5543/tkda.2013.44959
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发表时间：
2013
期刊：
影响因子：
--
通讯作者：
T. Kurtoğlu
中科院分区：
文献类型：
--
作者：
Çağdaş Akgüllü;U. Eryılmaz;T. Kurtoğlu
一名41岁女性因不明原因的发热、呼吸困难和头晕入院。经胸超声心动图显示重度二尖瓣返流，经食管超声心动图（TEE）进一步检查显示二尖瓣前叶上有7 mm赘生物。血培养阴性，经过45天的经验性12 g/天氨苄西林-舒巴坦治疗后，赘生物消失。但是，由于持续重度二尖瓣返流和瓣膜畸形，进行了人工金属二尖瓣置换术。手术后，因亚热再次进行经食管超声心动图检查，但瓣膜正常，血培养呈阴性。由于感染性心内膜炎可能复发的风险，术前静脉注射抗生素治疗持续21天，然后口服一周。然后，她被安排在我们的门诊进行随访。由于她的INR在此期间高度不稳定，她出现新发亚热性发热，她再次住院，TEE显示赘生物。血培养仍为阴性，开始万古霉素-利福平-庆大霉素联合治疗。在该治疗下，首次中风和几天后复发性跨脑缺血发作发生，并且观察到赘生物已经扩大。使用生物二尖瓣进行紧急瓣膜手术，并在微生物科的建议下，在既往抗生素治疗基础上增加氨苄西林-舒巴坦治疗。计划口服抗凝剂治疗3个月;然而，在术后期间，她的INR水平高度不稳定，甚至不能连续两天维持在治疗范围内。根据肾脏清除率，达比加群的剂量调整为110 mg/bid，与阿司匹林150 mg/天联合给药。然而，瓣膜血栓形成和大规模中风发展下，这种疗法。在持续肝素输注后血栓消失，她在末次手术后55天出院，伴有神经系统后遗症，服用150 mg/天阿司匹林。在4个月的随访期内，未发生其他临床事件。
A 41-year-old female was admitted to our hospital with an unidentified source of fever, dyspnea and dizziness. Transthoracic echocardiography demonstrated severe mitral valve regurgitation, and further examination with transesophageal echocardiography (TEE) revealed a 7 mm vegetation on the anterior mitral leaflet. Blood cultures were negative, and after 45 days of empiric 12 g/day ampicillin-sulbactam therapy, the vegetation was shown to have disappeared. However, due to ongoing severe mitral regurgitation and valve deformity, a prosthetic metallic mitral valve replacement was performed. After the operation, TEE was performed again due to subfebrile fever; however, the valve was normal and blood cultures were negative. Because of the probable relapse risk of infective endocarditis, the preoperative intravenous antibiotherapy was continued for 21 days and then orally for one week. Then, she was placed on follow-up by our outpatient clinic. As her INR was highly unstable during this period and she developed new-onset subfebrile fever, she was hospitalized again, and the TEE demonstrated vegetation. Blood cultures were still negative, and a combination of vancomycin-rifampicin-gentamicin was started. While under that therapy, first stroke and after a few days recurrent trans-ischemic attack developed, and the vegetation was seen to have enlarged. Urgent valve operation was performed with a bioprosthetic mitral valve, and ampicillin-sulbactam therapy was added to her previous antibiotherapy at the suggestion of the Microbiology Department. Oral anticoagulant therapy was planned for three months; however, during the postoperative period, her INR levels were highly unstable and could not be maintained in therapeutic ranges for even two consecutive days. Adjusted dosage of dabigatran to 110 mg/bid according to renal clearance in combination with 150 mg/day aspirin was started. However, valve thrombosis and a massive stroke developed under this therapy. The thrombosis disappeared after continuous heparin infusion, and she was discharged with neurological sequelae on 150 mg/day aspirin 55 days after her last operation. During the follow-up period of four months, no other clinical events occurred.