Thrombosed Mechanical Mitral Valve in a Pregnant Patient
A 37-year-old pregnant woman who is nine weeks pregnant presented to an outside hospital with progressive dyspnea.
Her past surgical history was notable for three prior valve surgeries in 1999 and 2001, including mitral valve repair, mechanical mitral valve replacement, and tricuspid ring annuloplasty. Given the potential teratogenic effects of warfarin, her initial anticoagulation regimen included enoxaparin. Several days prior to admission, however, she ran out of enoxaparin and restarted warfarin without medical guidance. The patient ultimately presented to an outside hospital with progressive shortness of breath and transthoracic (TTE) echocardiogram demonstrating complete thrombosis of her mechanical mitral valve (Video 1)
On exam, she appeared comfortable with only mild respiratory distress. Her vital signs included: heart rate 114 beats/min.; blood pressure 100/70 mm Hg; fraction of inspired oxygen (FiO2) 97% on 2 L nasal cannula; and respirations 20/min.
Shortly after admission, the patient developed acute respiratory failure, hypoxia, and pulmonary edema necessitating intubation. PaO2 was 50 mm Hg on 100% FiO2 with chest X-ray demonstrating florid pulmonary edema.
Which of the following are acceptable therapeutic options for the patient?