What is the diagnosis and treatment for a patient with blood being pushed back into organs, such as the liver and pancreas, due to a mechanical heart valve issue with an implanted device that the heart has grown over?

Diagnosis: Mechanical Heart Valve Complication with Congestive Hepatopathy

This patient has a mechanical heart valve that has become overgrown with tissue (pannus formation), causing severe valve dysfunction with backward flow of blood into the liver and pancreas—a condition known as congestive hepatopathy secondary to right heart failure from prosthetic valve malfunction.

Immediate Diagnostic Evaluation

• Transthoracic echocardiography (TTE) is the essential first-line imaging study to assess prosthetic valve function, detect valve thrombosis or pannus formation, quantify regurgitation severity, and evaluate ventricular function 1

• Transesophageal echocardiography (TEE) should be performed urgently if TTE is inadequate or if detailed assessment of the valve mechanism, thrombus, or pannus is needed, as TEE provides superior visualization of prosthetic valves 1

• Assess for signs of end-organ dysfunction including hepatic congestion (elevated liver enzymes, bilirubin, INR), renal dysfunction, and pulmonary hypertension, as these indicate severity and guide treatment urgency 1

• Check INR immediately to determine if subtherapeutic anticoagulation contributed to valve thrombosis 2

Definitive Treatment: Surgical Valve Replacement

Complete replacement of the malfunctioning mechanical valve is the definitive treatment for symptomatic prosthetic valve dysfunction causing organ congestion and is a Class I recommendation. 3

Surgical Approach

• Valve replacement surgery is indicated when prosthetic valve dysfunction causes heart failure symptoms or end-organ damage (hepatic/pancreatic congestion in this case), as the mechanical valve cannot be adequately repaired when overgrown with tissue 1, 3

• Reoperative valve surgery carries substantially higher operative mortality (4.7-17.5%) compared to primary operations, requiring careful preoperative risk assessment 3

• Right heart catheterization should be performed preoperatively to assess pulmonary artery pressures, as elevated pressures significantly increase operative mortality in valve reoperations (Class I recommendation) 3

Medical Stabilization Prior to Surgery

• Intravenous diuretics are essential to reduce hepatic and systemic congestion while preparing for definitive surgical intervention 1

• Inotropic support may be needed if there is severely reduced cardiac output with end-organ hypoperfusion 1

• Intra-aortic balloon counterpulsation (IABC) should be considered for hemodynamic stabilization in patients with severe heart failure not responding to medical therapy as a bridge to definitive surgery (Class I, Level B) 1

• IABC is contraindicated if significant aortic insufficiency is present 1

Alternative: Mechanical Circulatory Support as Bridge to Surgery

If the patient cannot be stabilized with medical therapy and IABC, ventricular assist device (VAD) support should be considered as a bridge to definitive valve replacement surgery (Class IIa, Level B) 1

VAD Candidacy Criteria

• No response to conventional treatment including diuretics, inotropes, and vasodilators 1

• Progressive end-organ dysfunction (hepatic/renal) due to reduced perfusion 1

• Potential for recovery after corrective surgery (valve replacement in this case) 1

• Absence of irreversible multi-organ failure or severe systemic disease 1

VAD Complications to Monitor

• Thromboembolism, bleeding, and infection are the most common complications with VAD support 1

• Device malfunction and hemolysis occur frequently and require specialized monitoring 1

• VAD support should only be used at tertiary heart failure centers with experienced cardiovascular teams 1

Post-Operative Anticoagulation Management

After mechanical valve replacement, lifelong warfarin anticoagulation is mandatory with target INR depending on valve type and position 2

• For bileaflet mechanical valves in the mitral position (most common scenario with pannus formation), target INR is 3.0 (range 2.5-3.5) 2

• For bileaflet mechanical valves in the aortic position, target INR is 2.5 (range 2.0-3.0) 2

• Addition of low-dose aspirin (75-100 mg daily) is recommended for certain high-risk mechanical valves 2

Critical Pitfalls to Avoid

• Do not delay surgery in patients with progressive end-organ dysfunction (hepatic/pancreatic congestion), as irreversible organ damage significantly worsens surgical outcomes 1

• Do not attempt percutaneous interventions for mechanical valve dysfunction with pannus overgrowth, as this requires surgical correction 3

• Ensure meticulous INR monitoring post-operatively, as unstable INR is a major risk factor for both thrombotic and bleeding complications 4

• Avoid using direct oral anticoagulants (DOACs) in patients with mechanical valves, as warfarin is the only proven anticoagulant 5