A Controversy: Warfarin Failure in Covid-19 with Supratherapeutic Inr

Background COVID-19 has been previously associated with thromboembolism. We present a unique case of a patient who was compliant with warfarin and yet developed breakthrough Deep Venous Thrombosis after recently being diagnosed with COVID-19. Case A 49-year-old female with past medical history of rheumatic fever complicated with mitral stenosis and treated with mechanical mitral valve replacement in 2003, presented with right-sided leg swelling, warmth, and pain for the past 1 week. She tested positive for COVID-19 almost 2 weeks ago but was not hospitalized or treated due to minimal symptoms. She had been on warfarin for the last 19 years due to underlying mechanical valve with an INR (international normalized ratio) goal of 2.5-3.5. On examination, the right calf was swollen and tender to palpation. Homan sign was positive. INR was elevated to 9.88 (a month ago it was within the therapeutic range of 2.5-3.5). The rest of the lab work up including fibrinogen levels, PT, aPTT, CBC, and CMP was unremarkable. A lower extremity venous duplex was performed that came back remarkable for acute right popliteal DVT. Decision-making Warfarin was held considering elevated risk of bleeding. INR was repeated daily and once it was below 2.5, therapeutic dose of enoxaparin 1mg/kg twice daily was started for 3 months. Due to limited anticoagulation options, a shared decision was made to place the patient back on warfarin, since she was out of the window of COVID-19 infection. She was not a candidate for DOAC's considering her mechanical valvular heart disease history and patient did not want to consider invasive interventions as well. Conclusion Our case study is the first ever reporting warfarin failure with supratherapeutic INR due to COVID-19 infection. It also raises concerns if warfarin is safe to use in COVID-19 patients, which might need further research studies to have clear answers. In patients with mechanical heart valves and supratherapeutic INR who present with concerns of warfarin failure, treatment options are limited. Recommended management is holding warfarin to achieve therapeutic INR levels, switch to enoxaparin temporarily, and eventually placement of IVC filter.Copyright © 2023 American College of Cardiology Foundation

Perioperative Concerns for Patients with Prior SARS-CoV-2 Infection: Our Experience

Methodology and case description: Case 1: A 55-year-old hypertensive male with complaints of chest pain presented to the cardiology department. He underwent angiography to reveal triple vessel disease and was scheduled for coronary artery bypass graft surgery. During preoperative evaluation, patient gave a history of having suffered from mild COVID-19, getting cured with conservative management under home isolation 3 months back. Examination revealed bilateral basal crepitations. Chest X-ray was indicative of fibrosis basal areas of both lungs (right > left) which was confirmed by HRCT chest. Preoperatively the patient was optimised with antifibrotic agent nintedanib and methylprednisolone. He was reviewed after 1 month and had shown significant-resolution radiologically as well as clinically (improved breath holding time, saturation and lung auscultation). Intraoperative course was uneventful and the patient was ventilated with low tidal volume. Postoperatively, the patient was extubated on day 1. Patient experienced difficulty in expectoration which was improved by N-acetyl cysteine administered intravenously and via nebulisation along with active vigorous physiotherapy. Patient was discharged on the 7th postoperative day. Case 2: A 37-yearold female, a known case of severe mitral stenosis, moderate pulmonary hypertension, moderate tricuspid regurgitation was under conservative management with diuretics and beta-blockers and was being planned for mitral valve replacement. The patient had developed COVID-19 infection 1 month back and was treated under home isolation and conservative management. However, the patient presented with an increase in exercise intolerance post COVID infection. Suspecting the possibility of fluid overload/ heart failure and pulmonary hypertension, the diuretic dose was increased post admission, but to no avail. Chest X-ray and HRCT chest were done which highlighted the possibility of allergic bronchopulmonary aspergillosis;which has been described as one of the rare findings coexisting with active COVID-19 infection. This was confirmed by the serum IgE levels and presence of eosinophilia in the complete blood picture. The patient was initiated on itraconazole and methylprednisolone which resulted in improvement in breathlessness over the next 3 weeks. The patient was subsequently posted for surgical replacement of the mitral valve. Intra-operative and post-operative course was uneventful and the patient was discharged on 5th post-operative day. Conclusion: These 2 cases who had suffered from mild COVID-19 infection presented significant challenges for safe intra- and post-operative conduct of anaesthesia. These challenges were overcome by efficient prehabilitation and optimisation of the patient and optimal post-operative critical care. Intra-operative course is often just a small segment of the overall hospital course of the patient and the role of critical care in the pre-surgical, extra-hospital care along with post-operative care needs acknowledgement and recognition.

Transatrial Balloon-Expandable Valve Implantation for Symptomatic Mitral Stenosis With Severe Annular Calcification—A Hybrid Solution

Background: Treatment of symptomatic mitral valve stenosis in severe mitral annular calcification is a surgical challenge. Transcatheter options include transfemoral transcatheter mitral valve replacement (TMVR), which poses its own risks, the most significant is left ventricular outflow tract (LVOT) obstruction. Transatrial hybrid TMVR optimizes advantages of both traditional open-heart surgery and transcatheter valve replacement. Methods: Retrospective review of seven high-risk patients (deemed ineligible for traditional surgery) undergoing transatrial implantation of a SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA) in the mitral position for severe symptomatic mitral stenosis. Laceration of the Anterior Mitral leaflets to Prevent Outflow ObstructioN procedure was not considered due to heavy leaflet calcifications. Results: Seven patients treated consecutively from June 2020 to July 2021 were included in this analysis. Mean age was 77 years;six were females, one was male. Average STS score was 9.8. Three patients had New York Heart Association (NYHA) class IV heart failure. Mean left ventricular ejection fraction was 62%. Dominant mitral valve pathology included mitral stenosis in all patients. Mean mitral valve gradient was 12 mmHg. All patients had circumferential annular calcification except one, who had predominantly anterior calcification. All patients received the Edwards SAPIEN 3 valve and had anterior leaflet resection. Surgical approach was at the discretion of the attending cardiac surgeon. Mean cardiopulmonary bypass time was 85 minutes;mean cross-clamp time was 36 minutes. No anchoring felt was used. Technical success was 100%, with no device embolization. There was no clinically significant LVOT obstruction. There were two deaths: one occurred during index hospitalization due to worsening heart failure secondary to torrential tricuspid regurgitation, and the second was 2 months later due to COVID-19 infection. Conclusion: Surgical hybrid transatrial TMVR for patients at high surgical risk is technically feasible with high procedure success. A relatively shorter cardiac ischemic duration, direct visualization and resection of the anterior mitral leaflet can allow for safe TMVR without risk of LVOT obstruction.

Thrombosis of Mechanical Mitral Valve Prosthesis Treated With Fibrinolysis

Background: Mechanical prosthetic valve thrombosis is an uncommon but serious complication associated with high mortality and morbidity. Conventionally, prosthetic valve thrombosis is treated with surgical intervention, but recent literature has shown that slow-infusion of low-dose fibrinolytic therapy could be of equal efficacy. Case: A 27-year-old lady presented to the emergency department with a three-week history of worsening shortness of breath on background of mechanical mitral valve replacement for rheumatic mitral stenosis. She had recently been non-compliant with international normalised ratio (INR) checks for warfarin dosing in the setting of local lockdown for the COVID-19 pandemic. Transthoracic echocardiography revealed mechanical mitral valve thrombosis resulting in an immobile medial disc and severely restricted lateral disc, associated with severely elevated mitral inflow gradient (mean 42mmHg at 98 beats per minute) and severe pulmonary hypertension (right ventricular systolic pressure of 92mmHg). After discussion in a multidisciplinary cardiology and cardiothoracic surgical conference, the patient was treated with three daily doses of slow-infusion low-dose fibrinolytic therapy (25mg alteplase over six hours). On day three, there was complete resolution of symptoms, associated with resolution of valve thrombosis on repeat echocardiography. There were no bleeding or embolic complications, and the patient was discharged home three days later. Conclusions: This case highlights the utility of slow-infusion low-dose fibrinolytic therapy in the management of mechanical prosthetic valve thrombosis. This conservative approach may be a useful alternative in patients with high pre-operative surgical risk.

A teenager with CHD and coronavirus disease 2019.

A 16-year-old girl with history of treated congenital mitral valve disease and signs of respiratory infection was admitted to our paediatric cardiology department. She was tested positive for severe acute respiratory syndrome coronavirus 2. Despite her severe pre-existing cardiac conditions with pulmonary hypertension, atrial arrhythmias and mitral valve stenosis, the infection did not lead to any cardiac or pulmonary deterioration. In adults, cardiac co-morbidities are known risk factors for a severe course of coronavirus disease 2019 infections. This case illustrates that in children even severe cardiac disease is not necessarily associated with a severe course of coronavirus disease 2019.