CONGRESS ABSTRACT

An 80-year-old man presented to our clinic complaining of dyspnea.  His medical history included aortic and mitral (Medtronic Hancock II) valve replacement with bioprosthetic heart valves (BHVs) due to infective endocarditis, performed 4 years prior. At the time of the visit, the patient was in single antiplatelet therapy with Cardioaspirin. The transthoracic echocardiogram showed a suspected mitral structural valve degeneration (SVD), with elevated mean gradient; a transesophageal echocardiogram confirmed the clinical suspicion of SVD, showing thickened and hypomobile mitral leaflets, elevated mean gradient and moderate regurgitation with multiple jets; a normally functioning aortic prosthesis was observed instead. After Heart Team discussion, a valve-in-valve treatment was proposed and the patient was referred to cath lab where a preoperative coronary angiography was performed, confirming elevated transvalvular gradients and revealing a stenosis in the mid-circumflex coronary artery, treated with angioplasty and drug-eluting stent implantation. The patient was then discharged on dual antiplatelet therapy (DAPT) (Cardioaspirin 100 mg + Clopidogrel 75 mg) awaiting surgical intervention. In the subsequent period, the patient reported a gradual improvement in dyspnea; after 3 months of DAPT a preoperative echocardiogram was performed, showing a complete resolution of mitral prosthesis dysfunction, with structurally normal leaflets and normal mean gradient. The surgical intervention was therefore deferred, attributing the resolution of prosthetic dysfunction to DAPT, and diagnosis of valve thrombosis (VT) was made retrospectively.  Take home messages: – Mechanisms underlying SVD of BHVs are multiple and still incompletely understood. BHV, unlike mechanical prostheses, are less trombogenic, but the hypotesis of VT must always be considered.  – Although treatment options for VT remain controversial, anticoagulant therapy currently represents the treatment of choice: this case report inadvertently showed a low bleeding risk alternative.