主动脉瓣狭窄是最常见的心脏瓣膜病,尤其是老年人。如果不治疗,有症状的主动脉瓣狭窄与不良预后和高死亡率有关。严重症状性主动脉瓣狭窄的唯一有效治疗方法是使用机械或生物假体进行主动脉瓣置换术。机械瓣膜假体,虽然非常耐用,是血栓形成的,需要口服抗维生素K剂的终身抗凝,如acenocoumarol。相反,生物人工瓣膜,虽然不太耐用,具有最小的血栓形成风险,不需要抗凝。目前,直接作用口服抗凝药(DOACs)在有机械心脏瓣膜的患者中没有被证实的作用,因为在该患者人群中关于其安全性的临床试验数据不足.在这里,我们介绍了一个59岁女性主动脉瓣狭窄的病例,八年前接受了机械主动脉瓣置换术的手术治疗。手术后,acenocoumarol开始。然而,在我们机构出庭前18个月,该患者开始服用利伐沙班(DOAC)而不是acenocoumarol,因为在黎巴嫩持续的经济危机期间无法使用acenocoumarol,没有咨询她的心脏病专家.尽管她的全科医生随访并报告有机械瓣膜,她的儿子反驳了这一点,声称她有生物瓣膜.经过彻底调查,包括胸部X光,超声心动图,和透视,经证实,患者确实具有正常功能的机械主动脉瓣。立即采取了纠正措施,从静脉注射普通肝素和acenocoumarol开始,以2.5至3之间的国际标准化比率(INR)为目标,同时对患者进行有关她的病情和坚持acenocoumarol治疗的重要性的教育。
Aortic stenosis is the most common heart valve disease, especially among the elderly. Symptomatic aortic valve stenosis is linked to a poor prognosis and a high mortality rate if left untreated. The only effective treatment for severe symptomatic aortic stenosis is aortic valve replacement using either a mechanical or a biological prosthesis. Mechanical valve prostheses, while highly durable, are thrombogenic, necessitating lifelong anticoagulation with oral anti-vitamin K agents, such as acenocoumarol. Conversely, bioprosthetic valves, though less durable, carry a minimal thrombogenic risk and do not require anticoagulation. Currently, there is no proven role for direct-acting oral anticoagulants (DOACs) in patients with mechanical heart valves due to insufficient clinical trial data regarding their safety in this patient population. Herein, we present the
case of a 59-year-old female known to have aortic stenosis, who underwent surgical treatment with mechanical aortic valve replacement eight years ago. Post-surgery, acenocoumarol was initiated. However, 18 months prior to presenting at our institution, the patient started taking rivaroxaban (a DOAC) instead of acenocoumarol due to the unavailability of acenocoumarol during the ongoing economic crisis in Lebanon, without consulting her cardiologist. Although she was followed up by her general practitioner and reported having a mechanical valve, her son contradicted this, claiming she had a biological valve. After thorough investigations, including chest X-ray, echocardiography, and fluoroscopy, it was confirmed that the patient indeed had a normally functioning mechanical aortic valve. Immediate corrective measures were taken, starting with IV unfractionated heparin and acenocoumarol, targeting an International Normalized Ratio (INR) between 2.5 and 3, while educating the patient about her condition and the importance of adhering to acenocoumarol therapy.