Hypercoagulable State and Thrombosis of Bioprosthetic Transcatheter Aortic Valve Replacement (TAVR) Refractory to Common Anticoagulation Methods in the Setting of Protein S Deficiency.

Protein S deficiency is a form of thrombophilia in which the anticoagulant protein S is underproduced or not produced at all by the body. Lifelong anticoagulation is the mainstay of treatment. Transcatheter aortic valve replacement (TAVR) is a current treatment modality for patients with severe aortic stenosis. We are reporting the case of a patient with this disease who underwent a TAVR procedure and experienced valve leaflet thrombosis and large arterial thrombosis in the following months while fully anticoagulated with typical anticoagulation methods including warfarin, apixaban, and enoxaparin. Literature-based guidance is lacking with regard to anticoagulation in the setting of TAVR patients, especially in those with protein S deficiency. Based on our observations, warfarin was the better long-term prophylactic management method for our patient's protein S deficiency. Enoxaparin was most useful during periods of elevated thrombosis risk, including intra-/post-operative care and prolonged hospitalization periods. In the setting of her TAVR, we observed that warfarin use with a target international normalized ratio (INR) of 2.5-3.5 was the most effective outpatient treatment for the reversal of thrombosed bioprosthetic valve and improvement of cardiac ejection fraction. It is also possible that initial post-operative warfarin use would have been the most effective means of preventing valve thrombosis entirely in our protein S-deficient patient.

A Rare Case of Native Mitral Valve Bacillus Cereus Endocarditis Culminating Into a Cerebrovascular Infarction.

We report a case of a 56-year-old man who presented initially with a sudden onset of right-sided facial droop and weakness, aphasia, and confusion with no associated fever, chills, syncope, fatigue, weight loss, night sweats, nausea, vomiting, diarrhea, odontalgia, palpitations, cough, or dyspnea. Code stroke was called and the patient received tissue plasminogen activator (tPA) with subsequent resolution of his symptoms. Cranial magnetic resonance imaging showed left frontal punctate cortical restricted diffusion consistent with subacute to acute infarction. Transesophageal echocardiogram showed a severely thickened anterior mitral valve leaflet with a shaggy echodensity consistent with a vegetation. Blood cultures grew Bacillus cereus sensitive to clindamycin, trimethoprim sulfamethoxazole, and vancomycin. He was initially treated with ampicillin, clindamycin, and vancomycin and was eventually maintained solely on vancomycin. He had complete return of his neurological function and was discharged on intravenous antibiotic to complete a 6-week course.