Ischemic stroke in patients with mechanical mitral valve and subtherapeutic INR: therapeutic challenges and multidisciplinary care

Abstract

Background. Patients with mechanical heart valve prostheses require strict and continuous oral anticoagulation to effectively prevent thromboembolic complications. Subtherapeutic INR levels increase the risk of intracardiac thrombus formation and systemic embolism, requiring urgent, multidisciplinary management. Objective(s). Highlighting the consequences of ineffective anticoagulation in patients with mechanical valve prostheses and describing the multidisciplinary management of an ischemic stroke of cardioembolic origin. Materials and methods. A 65-year-old woman with a mechanical mitral valve and atrial fibrilation was admitted to the cardiology clinic for cardiac symptoms. ECG, coagulation tests, and echocardiography were performed. She developed acute ischemic stroke with left hemiparesis, confirmed by CT and angio-CT showing right MCA occlusion, successfully treated by thrombectomy. Results. The patient presented with dyspnea, palpitations, and chronic fatigue. ECG showed atrial fibrillation with HR 75 bpm, left bundle branch block, and subtherapeutic INR (1.7). Echocardiography revealed a 10 mm floating mass on the ventricular side of the mitral prosthesis. She later developed ischemic stroke with left hemiparesis. Brain CT and angioCT confirmed a right M1 MCA thrombus. Successful endovascular thrombectomy was performed in the neurology clinic. Repeat echocardiography showed no mass, confirming the cardioembolic origin. Neurological deficit improved, anticoagulation was adjusted, and INR was within target (2.52) at discharge. Conclusion(s). Subtherapeutic INR in patients with mechanical valve prostheses increases the risk of thromboembolic complications. A multidisciplinary approach and timely intervention within the therapeutic window are essential for neurological recovery. INR monitoring and patient education remain key priorities.