Case 1—a 72-year-old man with fatigue after mitral valve replacement

History

A 72-year-old man status post pericardial mitral valve (MV) replacement for a flail mitral valve and severe mitral regurgitation, Cox maze procedure for paroxysmal atrial fibrillation, and left atrial appendage ligation 10 days ago, presented with symptoms of fatigue, pleuritic precordial chest pain, intermittent blurred vision, and possible facial droop.

A brain MRI showed small new subacute cerebral infarcts, which appeared to have occurred perioperatively for MV replacement with no acute ischemic changes, and the patient was admitted under neurology service.

Cardiology was consulted for atrial fibrillation after admission and for anticoagulation guidance.

Pre-MV replacement surgery coronary angiogram had shown minimal nonobstructive coronary artery disease with 10% to 20% stenosis.

Physical examination

Blood pressure was 100/60 mm Hg. There was no focal neurologic sign. Heart sounds were muffled. There was no pericardial rub or new murmur.

Laboratory values

Hemoglobin was 10.3 g/dL, creatinine was 0.85 mg/dL.