An extremely enlarged heart from a mitral valve stenosis patient
A 66-year-old woman was admitted to the hospital because of lower gastrointestinal bleeding and heart failure. Ten years before this admission, the patient was diagnosed with rheumatic heart disease and mitral valve stenosis. Nine years before, she underwent mechanical mitral valve replacement. Since then, she had been taking furosemide 20 mg qd, spironolactone 25mg bid, digoxin 0.125 mg qd, and warfarin 1.875–3.125 mg to maintain international normalized ratio (INR) in target range. She also took metoprolol and perindopril inconsistently. The patient had been hospitalized several times due to gastrointestinal bleeding episodes within the last 2 years with two times unstable hemodynamics history and every time became stable attributed to suspending anticoagulant therapy, blood transfusion and other supportive treatments. Upon this arrival, the patient was dyspneic, and her blood pressure was 85/46 mmHg. A blood count showed hemoglobin 6.8 g/dL. Computed tomography performed with intravenous contrast revealed significantly distended left atrium (LA) and left ventricle (LV) (Figure 1A). Transthoracic echocardiography demonstrated a functional mechanical mitral valve, markedly hypertrophic LA, LV and right atrium (RA), mild aortic regurgitation, mild tricuspid regurgitation, moderate pulmonary hypertension, and ejection fraction (EF) of 31% (Figure 1B).
Patients with mechanical mitral valve require the permanent use of anticoagulants, such as warfarin, to prevent thromboembolic events. Given the extremely enlarged heart and history of several short-term warfarin discontinuations, bleeding events, and blood transfusion, it is to our surprise that thromboembolism had never been evident on this patient.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jeccm-20-53). ZZ serves as an unpaid editorial board member of Journal of Emergency and Critical Care Medicine from March 2017 to February 2021. The other authors have no conflicts of interest to declare.
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Cite this article as: Chen L, Wang Q, Guo Y, Zhang Z, Chen K. An extremely enlarged heart from a mitral valve stenosis patient. J Emerg Crit Care Med 2020;4:36.