Authors

• Kristina Gašparović — Medicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska — ORCID: 0000-0002-1191-4831
• Margarita Brida — Medicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska — ORCID: 0000-0001-8754-8156
• Kristina Marić Bešić — Medicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska — ORCID: 0000-0002-4004-7271
• Željko Baričević — Medicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska — ORCID: 0000-0002-5420-2324
• Maja Hrabak Paar — Medicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska — ORCID: 0000-0002-0390-8466
• Darko Anić — Medicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska — ORCID: 0000-0002-7378-944X
• Maja Strozzi — Medicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska — ORCID: 0000-0003-4596-8261

Abstract

**Introduction:** Pulmonary valve (PV) disease is a known predictor of morbidity and mortality in patients with previously surgically corrected Tetralogy of Fallot resulting in right ventricle (RV) dilatation, eccentric hypertrophy, and systolic failure. RV failure can be prevented with opportune PV replacement. PV thrombosis is rare. Long term anticoagulation therapy with warfarin is not indicated with biological valves but positive effect on thrombosis has been described. There is no evidence for positive effect of new anticoagulant drugs (NOAC) on valvular thrombosis. (1, 2) **Case report:** We present a case of a young woman who was born with Tetralogy of Fallot and who underwent a complete surgical correction at the age of four. She was admitted to University Hospital Centre Zagreb with fast atrial fibroundulation requiring immediate cardioversion. Echocardiography (ECHO) revealed a dilated RV with reduced systolic function and volume overload. Cardiac magnetic resonance proved significant pulmonary insufficiency with significant regurgitant fraction and volume (RF 41%, RVEDV 233 ml, RVEDVI 116 ml/m2, RVEF 48%). Surgical implantation of biological prosthesis was done. Postoperative ECHO indicated good function of biological PV and reduction of regurgitant volume. Anticoagulation therapy with warfarin was continued for three months after the surgery. Afterwards, rivaroxaban 20 mg daily was implemented due to paroxysmal atrial fibrillation. Twenty months after bioprosthesis implantation, she presented with signs of right heart failure. ECHO revealed dilated RV but with signs of pressure overload and systolic pressure gradient of 110 mmHg. Transoesophageal ECHO showed organized thrombus formation of 25x10 mm on bioprosthesis. Surgical excision of a thrombosed tissue was done with reimplantation of St. Jude Biocor valve A 25 mm on pulmonary position, anticoagulation with warfarin was indicated. Postoperative ECHO showed reduction of RV volume and improvement of systolic function. PV systolic gradient was 25 mmHg. **Conclusion:** PV thrombosis is a rare event. Warfarin is still recommended in the early postoperative period. Rivaroxaban did not prevent valve thrombosis in our patient who was negative for thrombophilia testing and had no mechanical predisposition for thrombosis.

Keywords

pulmonary valve thrombosis, novel anticoagulant drugs, atrial fibrillation

DOI

Literature

1. Pujol C, Niesert AC, Engelhardt A, Schoen P, Kusmenkov E, Pittrow D, et al. Usefulness of Direct Oral Anticoagulants in Adult Congenital Heart Disease. Am J Cardiol. 2016 Feb 1;117(3):450–5. https://doi.org/10.1016/j.amjcard.2015.10.062
2. Egbe A, Pislaru SV, Ali MA, Khan AR, Boler AN, Schaff HV, et al. Early Prosthetic Valve Dysfunction Due to Bioprosthetic Valve Thrombosis: The Role of Echocardiography. JACC Cardiovasc Imaging. 2018 Jul;11(7):951–8. https://doi.org/10.1016/j.jcmg.2017.06.022