Mechanical aortic valve without anticoagulation for 33 years in a Yemeni man: a case report

BACKGROUND: Mechanical prosthetic heart valves have been used for many decades to replace damaged native valves. Guidelines mandate the use of anticoagulant therapy in patients with mechanical prosthetic valves of any type, irrespective of the position in the heart. The rationale for this is to prevent valve thrombosis and thromboembolic complications without increasing the risk of excess bleeding. We report a case involving a patient with a functioning aortic mechanical valve without any anticoagulation therapy for 33 years. CASE PRESENTATION: A 46-year-old Yemeni man had an aortic valve replacement, using a St Jude Medical mechanical valve, 33 years ago due to aortic regurgitation grade III–IV of his native valve as a result of rheumatic heart disease. His anticoagulant therapy of Syncumar (acenocoumarol which is a derivative of coumarin) was discontinued 4 months after surgery, and he was sustained on aspirin and digoxin. He presented to our cardiac clinic 33 years later with palpitations, which had started 2 weeks previously. On clinical examination, his condition was fair with a New York Heart Association functional classification of I. He was in sinus rhythm and had normal heart size, as shown on chest X-ray. Echocardiography revealed normal heart chamber dimensions and normal left ventricular systolic and diastolic function. His mean transaortic gradient was 12.58 mmHg and the calculated aortic valve area was 1.44 cm(2). He was started on anticoagulant therapy. CONCLUSIONS: Only a few cases of well-functioning mechanical valves without the use of anticoagulant therapy for many years have been reported. Our patient is one such case who used only aspirin for 33 years. Further research is needed to understand the interpersonal variations and other unexplored factors in anticoagulant therapy for patients with mechanical prosthetic heart valves.