Subcutaneous Self-Injection Therapy of Heparin for a Case of Ebstein Disease with Artificial Valve and Warfarin-Induced Skin Ulcer

Abstract

We report a successful conversion of anti-coagulant therapy from warfarin to heparin for a case of mechanical heart valve and warfarin-induced skin ulcer. A 57-year-old female who was diagnosed with Ebstein disease and underwent mechanical valve replacement suffered from a recurring and resistant leg skin ulcer. Nine years after the induction of warfarin, her right leg skin ulcer occurred suddenly and worsened gradually. No dermatological treatment could cure it and three auto-skin transplantations were performed in the past four years. The definitive cause of the ulcer could not be diagnosed by any laboratory study or image inspection. Further, after every transplant surgery, the resumption of warfarin had made her ulcer recur and worsen. Therefore, we finally came to think of this disease as the warfarin-induced skin ulcer. To avoid warfarin, subcutaneous self-injection therapy of Heparin-Ca was applied as her anti-coagulation after the 4th transplant surgery. The patient was discharged from hospital on post-operative day 78 with a good condition of the transplanted skin graft and right leg. An adequate level of APTT could be maintained with injections of 10,000 units of Heparin-Ca twice a day and data on D Dimer and cardiac echography show no thromboembolism at the out-patient visits. The result of auto-skin transplantation is also a good course under this therapy. As we have very few reports concerning heparin self-injection therapy for artificial valves, it is very important that careful observation should be continued.