Abstract
Fondaparinux is a factor Xa inhibitor used for venous thromboembolic prevention and treatment. We report a case of a patient known to have a mechanical mitral valve replacement who presented with chemotherapy-induced thrombocytopenia. Bridging with fondaparinux was successful. We describe a case of a 68-year-old woman with a past medical history of mechanical mitral valve replacement, breast cancer diagnosed 1 year ago, and chronic atrial fibrillation on warfarin who presented to the emergency room complaining of fatigue and epistaxis. Blood tests revealed hemoglobin of 9.2 g/dl, platelet count of 10,000/mm3, and an international normalized ratio (INR) of 2.3. Subsequently, warfarin was stopped, and the patient received platelets transfusion. Consequently, INR level was not in range anymore. In this case, balancing the bleeding risk and valve thrombosis was the main concern since the mechanical mitral valve is at high risk of thrombosis. Fondaparinux was recommended after a hematology and cardiology discussion and was suggested as a bridging therapy until the patient had regained normal platelet levels. Fondaparinux was initiated at 7.5 mg subcutaneously once daily. On the other hand, warfarin was administered 5 days after the patient recovered from her thrombocytopenia with a normal level of 15,0000/mm3 for an INR goal of 2.5–3.5. Thus, therapeutic INR was reached 4 days after the patient was receiving concomitant warfarin and fondaparinux. Cardiac ultrasound was performed revealing both a good functional metallic mitral valve and a normal LV function. In the current absence of written guidelines and scarcity of written literature supporting the use of fondaparinux in patients with mechanical heart valves, this drug may offer an option for bridging in patients who cannot use heparin due to severe thrombocytopenia and high thrombosis risk concomitantly. However, further randomized trials are warranted to confirm both the safety and efficacy of this agent in this population.
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Key clinical message
While currently no written guidelines for the use of fondaparinux in patients with mechanical heart valves, this drug may offer an option for bridging in patients who cannot use heparin due to severe thrombocytopenia from chemotherapy.
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Tabbah, R., Rachoin, R. The Use of Fondaparinux with Mechanical Mitral Valve Replacement in a HIT-Like Situation: a Case Report. SN Compr. Clin. Med. 4, 47 (2022). https://doi.org/10.1007/s42399-022-01129-w
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DOI: https://doi.org/10.1007/s42399-022-01129-w