APCU25MPA4 When valves fail, patient bleed: heyde syndrome secondary to mechanical valves dysfunction

Introduction Heyde syndrome is classically described as the association of aortic stenosis, angiodysplasia-related gastrointestinal bleeding, and acquired von Willebrand factor (vWF) deficiency. While well recognized in native valve disease, its occurrence in patients with mechanical prosthetic valves is seldom reported. Prosthetic valve dysfunction may reproduce the haemodynamic shear stress that drives vWF degradation, creating a substrate for recurrent bleeding.Case Presentation A 79-year-old woman with a history of mechanical aortic valve replacement in 2016 presented with recurrent hospitalizations for severe anaemia. Her initial bleeding manifestations included haemoptysis and epistaxis, later evolving into overt gastrointestinal bleeding. Over-anticoagulation with warfarin was initially suspected, but correction of anticoagulation parameters did not resolve her symptoms.Results Extensive diagnostic workup, including CT thorax, CT mesenteric angiography, upper endoscopy, and colonoscopy, failed to identify a bleeding source. Persistent transfusion requirements prompted capsule endoscopy and push enteroscopy, which demonstrated active jejunal angiodysplasia, consistent with Heyde syndrome. Transthoracic echocardiography subsequently revealed severe prosthetic aortic stenosis, indicating mechanical valve dysfunction.Discussion This case reinforces the importance of considering prosthetic valve dysfunction as an underlying driver of recurrent bleeding in patients with mechanical valves. While anticoagulation is frequently implicated, structural valve failure can reproduce the pathophysiological cascade of Heyde syndrome: shear-induced degradation of high-molecular-weight vWF multimers, impaired haemostasis, and mucosal angiodysplasia. Current evidence suggests that endoscopic therapy and medical management may provide temporary haemostatic control, but durable resolution often requires definitive correction of the valve pathology. In such cases, referral for cardiothoracic surgical assessment is warranted to evaluate the feasibility of redo valve replacement.Conclusion Heyde syndrome associated with mechanical prosthetic valve dysfunction is rare but clinically significant. This case highlights the need for cardiologists to maintain a high index of suspicion for valve failure in patients presenting with unexplained recurrent bleeding, and to pursue a multidisciplinary strategy that integrates cardiology, gastroenterology, and surgery for optimal patient outcomes.