Hemolysis and infective endocarditis in a mitral prosthetic valve

Traumatic intravascular hemolysis after heart valve replacement can be a serious problem. It is commonly associated with either structural deterioration or paravalvular leaks. A 63-year-old woman with a six-year history of surgery for mitral stenosis presented with complaints of weakness and dyspnea. She received treatment at other centers three times in the past six months for dyspnea and anemia requiring transfusion of red blood cells. Transthoracic echocardiography showed a normally functioning mitral mechanic prosthesis. Laboratory findings were abnormal for hemoglobin, hematocrit, white blood cell count, C-reactive protein, serum haptoglobin, and lactate dehydrogenase. Peripheral blood smear showed marked schistocytes, indicative of mechanical erythrocyte destruction. Transesophageal echocardiography demonstrated severe paravalvular leak and a large (9x13 mm) vegetation adhering to the prosthetic valve, protruding into the left atrium. Enterococcus faecalis was isolated from blood cultures. Surgery was planned because of large vegetation, repeated hemolysis, and severe paravalvular regurgitation, but the patient refused surgical treatment.