ABC | Volume 111, Nº4, Octuber 2018

Anatomopathological Correlation Ávila et al. Mechanical cardiac prosthesis, pregnancy and respiratory failure and shock Arq Bras Cardiol. 2018; 111(4):629-634 Figure 3 – Chest X-ray showing significant pulmonary congestion. Table 1 – Echocardiographic evolution Echocardiographic measures Date Pre-admission June 04, 2018 June 14, 2018 Aorta (mm) 24 28 28 Left atrium (mm) 45 55 57 Right ventricle (mm) 24 26 41 Septum (mm) 10 9 9 Posterior wall (mm) 9 10 9 Left Ventricle Diast./Syst. (mm) 53/33 40/28 40/25 LVEF (%) Normal Normal Normal Max. trans-mitral gradient (mm Hg) 16 39 45 Mean trans-mitral gradient (mm Hg) 6 25 30 Mitral prosthesis (mobility) Good Low Low Thrombus No No Yes RV Syst pressure (mm Hg) 46 75 73 Diast.: diastolic; Syst.: systolic; LVEF: left ventricular ejection fraction; RV: right ventricle. Clinical aspects The case reported is of a 36-year-old pregnant woman with repaired complex congenital heart disease, with a mechanical mitral valve prosthesis implanted 28 years before, paroxysmal atrial fibrillation, and a history of thromboembolism, a triad that characterizes a high thromboembolic risk. 1 Notwithstanding, the patient maintained the adequate anticoagulation goal (INR = 3) until the pregnancy diagnosis, when the anticoagulation regimen of warfarin was replaced by enoxaparin due to the risk of fetal warfarin syndrome, which occurs between the 6 th and 12 th weeks of gestation (characterized by nasal hypoplasia, dysplasia of the bony epiphyses, limb deformities, neurological and respiratory problems). 1 However, there is less evidence of the erratic bioavailability and distribution of enoxaparin during pregnancy, 2 although it constitutes a current challenge to define the best anticoagulation strategy in this population with high thromboembolic risk. As a therapeutic option for the treatment of prosthesis thrombosis, the thrombolysis with streptokinase or alteplase, guided by serial transesophageal echocardiography, was shown to be safe and effective. 3 However, considering the clinical situation of the patient, such as NYHA functional class IV, the need for intensive care, mechanical mitral prosthesis with a thrombus size > 0.8 cm², the surgical treatment was chosen. 4-6 631