A 55-year-old woman with a bileaflet mechanical mitral valve presents with sudden dyspnoea and pulmonary oedema. Fluoroscopy shows reduced motion of one leaflet. She missed anticoagulation doses for two weeks. INR is 1.3. What is the most likely diagnosis and immediate next step?
- A Structural valve deterioration; elective re-replacement in six months
- B Valve thrombosis; urgent fibrinolytic therapy or emergency surgery ✓
- C Pannus ingrowth; increase warfarin target INR to 4.0 and review in one month
- D Prosthetic valve endocarditis; start empiric vancomycin and gentamicin alone
Correct answer: B. Valve thrombosis; urgent fibrinolytic therapy or emergency surgery
Explanation
Subtherapeutic anticoagulation with acute leaflet immobilisation and heart failure indicates obstructive prosthetic valve thrombosis, a medical emergency. Treatment is urgent: fibrinolysis for right-sided or critically ill patients, or emergency surgery, guided by haemodynamic stability. Pannus is a chronic fibrotic ingrowth typically seen years after implantation with stable anticoagulation, and raising the INR target does not dissolve established thrombus. Antibiotics alone address neither the obstruction nor the cause.
Reference: Braunwald's Heart Disease, 12th ed.
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Written and medically reviewed by the StethoPrep medical team.