Her medical history indicated a prosthetic aortic and mitral MHV replacement (tilting-disc valves) 24 years ago to restore her cardiac function impaired by rheumatic heart disease. Case PresentationĪ 71-year-old Chinese woman was transferred to our Neurocritical Care Unit due to a progressive deterioration of consciousness for three consecutive days. The presented case scenario poses a therapeutic dilemma on the appropriate use of anticoagulants to maintain mechanical valve free of thrombosis meanwhile stabilizing HT hematoma volume to control bleeding event. Hemorrhagic transformation (HT) following ischemic stroke and reperfusion therapy, as one type of these bleeding events, occurs in a significant proportion of patients ( Sussman and Connolly, 2013). Patients with mechanical heart valves (MHV) require lifelong and sufficient anticoagulation however, it becomes more complex when hemorrhagic events occur. This case also suggested that the reported timing (day 6 to day 14 after hemorrhage) of anticoagulant resumption in primary intracerebral hemorrhage with mechanical valves might be late for some patients with HT. Notably, the fluctuations argatroban brings to the coagulation test results might not be interpreted as increased bleeding risk. This study is the first report of administering argatroban and titrating to its appropriate dose in the patient with valve thrombosis, antithrombin deficiency, and HT after mechanical thrombectomy for acute ischemic stroke. The intravenous argatroban was transited to oral warfarin before the patient was discharged. The anticoagulation was then strengthened by dose adjustment to keep mitral valve intact, to stabilize the aortic valve thrombosis, and to decrease the aortic flow rate. Aortic valve thrombosis was detected the next day. On day 3 of anticoagulation resumption, argatroban was discontinued for one dose when the prothrombin time and activated partial thromboplastin time significantly prolonged after argatroban infusion. The short-acting and titratable anticoagulant argatroban was immediately initiated at low dose, and thrombosis was temporarily terminated. On day 6 after the onset of hemorrhage transformation, the laboratory results of coagulation and fibrinolysis strongly suggested thrombosis as well as antithrombin deficiency. Since she had a history of prosthetic metallic valve replacement, how the anticoagulating therapy could balance the hemorrhagic and thrombotic risks was carefully evaluated. A 71-year-old woman was transferred directly to the Neurocritical Care Unit because of a HT that occurred following the mechanical thrombectomy for ischemic stroke. Such a situation was presented in this case report. 4Department of Pharmacy, First Affiliated Hospital of Nanjing Medical University, Nanjing, ChinaĪnticoagulation is essential for patients undergoing mechanical heart valve replacement however, the timing to reinitiate the anticoagulant could be a dilemma that imposes increased risk for bleeding events in patients suffering from the life-threatening hemorrhagic transformation (HT) after ischemic stroke.3Department of Cardio-Thoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.2Department of Neurosurgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.1Department of Pharmacy, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.Yi-Chen Li 1,2, Rong Wang 2*, Hang Xu 1,3, Lan-Ping Ding 1,2,4 and Wei-Hong Ge 1
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