Double Mechanical Valve Replacement Complicated by Early Cerebral Haemorrhage: 117 Days Without Coumarols


Department of Cardiac Surgery, Unit for Clinical Research in Atherothrombosis, Monzino Cardiac Centre, University of Milan, Milan, Italy



Introduction: Cerebral haemorrhage could complicate post operative course after cardiac surgery, especially after multiple mechanical  valves replacement needing for anticoagulation. The interruption of vitamin K antagonists in this cases, to avoid the enhancement of the cerebral haemorrhage, can be performed with reasonable safety.
Case Presentation: We report the case of a patient who underwent mitro-aortic valve replacement with mechanical valves. Postoperative  course was uneventful until the 6th day when he developed paresthesias on the left side and left arm paresis; CT scan showed a sub-cortical 
cerebral haemorrhage. in the right temporo-parietal area. At that time, he was receiving Enoxaparin (4000 IU/day) and Acenocoumarol (1 mg/day) which were started on the 2nd postoperative day without a loading dose. The patient was then transferred to another hospital 
where neurosurgery intensive care unit was available; he was conservatively treated without surgery. During his stay at this hospital he  did not receive vitamin K antagonists until February, 7th for a total of 117 days receiving only 4000 IU Enoxaparin daily. He was then reevaluated at our hospital on April 2nd 2008 with transthoracic echocardiography and fluoroscopy: both valves were well functioning with  no major problems.
Discussion: Withholding anticoagulant therapy after mechanical heart valve replacement due to the severe haemorrhage is a complex  problem that can occur after heart valve surgery. Although it has been shown that interruption of vitamin K antagonists can be performed 
in patients with mechanical valves with reasonable safety for a short-term period. As the patient transferred to another hospital after the  occurrence of cerebral haemorrhage, he was treated only with low doses of enoxaparin for 117 days. In less than two months after the 
coumarols resumption, the subsequent reassessment of the valves performed using echocardiography and fluoroscopy confirmed the normal performance of both mitral and aortic valves. In this case, a very long suspension of standard anticoagulant therapy did not affect 
the performance of mechanical bi-leaflet mitral-aortic prostheses.