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This case describes Heyde syndrome, a triad of aortic stenosis, gastrointestinal bleeding, and acquired von Willebrand syndrome caused by high shear forces that break down von Willebrand factor multimers. The syndrome is usually treated definitively with aortic valve replacement, but management becomes complicated when the patient has a mechanical valve and must remain anticoagulated.<br /><br />An elderly woman in her 80s with a prior mechanical aortic valve replacement on warfarin presented with three days of melena and severe anemia. She was hemodynamically stable but pale. Labs showed marked blood loss anemia and a supratherapeutic INR. Hemolysis and bone marrow dysfunction were excluded. Warfarin was held, vitamin K was avoided because of the risk of mechanical valve thrombosis, and the patient was bridged with heparin after INR reduction. She received packed red blood cell transfusions. Colonoscopy later revealed angiodysplasias, which were ablated. An echocardiogram also suggested possible mechanical valve dysfunction. Warfarin was then restarted, heparin was stopped once the INR reached goal, and her hemoglobin normalized. She had no further melena at follow-up, and valve re-replacement was deferred.<br /><br />The discussion highlights the dilemma of “to clot or to bleed” in patients with mechanical valves and GI bleeding. Stopping warfarin increases thrombosis risk, while continuing it worsens bleeding. In this case, the team chose temporary warfarin interruption, heparin bridging, endoscopic ablation of angiodysplasia, and resumption of warfarin afterward. Because this was a first episode and the patient was elderly, definitive redo valve surgery was postponed.

Asset Subtitle

Michael Sabina

Meta Tag

Author List Anas Bizanti, Jennifer Jost, Michael Sabina, Rachel Tatro, Zein Barakat

Category Clinical Vignettes

Concept Heyde Syndrome

Concept Aortic Valve Replacement

Concept Aortic Stenosis

Concept Gastrointestinal Bleeding

Concept Acquired von Willebrand Syndrome

Distinguished Non-Finalist

Presenter Organization Lakeland Regional Health Medical Center

Presenting Author Michael Sabina

Track Adult

Keywords

Heyde syndrome

aortic stenosis

gastrointestinal bleeding

acquired von Willebrand syndrome

mechanical aortic valve

warfarin

melena

angiodysplasia

heparin bridging

vitamin K avoidance

Heyde Syndrome

Aortic Valve Replacement

Aortic Stenosis

Gastrointestinal Bleeding

Acquired von Willebrand Syndrome