Transcript
ISCHEMICHEART FAILURE
TYPE 1VCASE
PRESENTATION. Dr Asadullah Khan soomro
E-mail; hssbasadsoomro@gmail.com
Case No 1 ( 100020548)Date &time of admission 17. 3. 2015, at 6.11
PmMode of Admission: Through ER.Date & time of Expiry: 8 . 4 . 2015 , at 10.50
Pm(Expired on 21th day of hospitalization)
DIAGNOSISPost CABG , haemorrhagic shock
severe diffuse 3 VD CAD Ischemic heart failure syndrome with severe LV systolic dysfunction ( type 1V) stage C ( Compensated) .Acute hypoxic
liver injury, cardio-renal syndrome. Syncope, moderate MR, Severe TR &
pulmonary hypertension. HTN & Smoker.
Executive Summary50 year non saudi male hypertensive
& smoker ,presented to KFHH ER with history of progressive
breathlessness & fatigue for the last 6 months became severe at rest on the day of admission. No H/o chest pain suggestive of angina or
myocardial infarction.Evaluated by on call ,and admitted as
acute decompensated heart failure syndrome, echocardiogram showed
severe global LV systolic dysfunction EF < 20%.
Cont, After HF stablization underwent Coronary angiogram and showed
severe diffuse 3VD CAD.Discussed in combined meeting and
was recommended for viability study, which showed dilated LV
prominent RV with increase lung uptake.
There were two totally reversible defect in LAD & LCX territory.
However RCA had irreversible ( non viable scar)
defect EF, 19%
Cont, He was re discussed and was
accepted for high risk PCI. Later reviewed by
interventionalist team and deferred for PCI.
Again third time discussed in combined meeting and was
accepted for high risk CABG ( Euro-score 6.4 &
mortality around 5-10%)
Cont,
Prepared for CABG IABP was inserted on 6th April, evaluated by pulmonologist and CT chest was done for pleural effeusion
prior to CABG.On 7 th April underwent CABG, all
arteries were deeply intramyocardial.
Had 4 grafts, LIMA to mid LAD, SVG to Diagonal & PDA of the RCA. OM was totally
occluded.
Cont,
In recovery suddenly became hypotensive VT/Vib , re-opened again, bleeding
points were secured, another SV Grafting was done to LAD.
In view of his haemodynamic instability along with IABP ,ECMO was inserted and shifted to ICU in critical condition,
on multiple ionotropes .Bleeding continued through
drains ,platelets dropped to 42 along with HB% ,transfused various &
multiple blood products ( total 101, Rbc, Platelets, fresh frozen plasma &
Cryo precipitates) , all invain.
Cont,
On 8th April again shifted to OR because of bleeding, re-thoracotomy done,
clots removed, areas of bleeding close to LAD were again sutured.
Chest packed with three large swabs, and shifted back to ICU.
On maximum haemodynamic support ( IABP ,ECMO & multiple
ionotrops) Dialysed through CRRT , subsequently developed hypoxic
hepatitis ( AST,ALT & LDH) in thousands. On the same day around 10 .20 pm developed bradycardia progressed to
asystole , resuscitation done but failed and expired at 10.50 Pm.
PAST HISTORY6 months back was admitted to PSBJ H with
H/O progressive breathlessness FC11 & syncope .
Fell down from the bed while he was sitting alone ,recovered spontaneously after some time , sustained fascial injury with bleeding ,therefore went to hospital EKG & X-rays were done ,but prior to full evaluation left against medical advise ( LAMA).
Last time admitted to KFHH with worsening of symptoms of heart failure, however considered as suspected corona virus and remained in isolation ward untill cleared from dammam reports that corona is negative.
Echocardiogram (26.3.15)
Moderately dilated LA /LV with severe global LV systolic
dysfunction EF < 20%. Normal RA/ RV size, and function.
Moderate Mitral Regurgitation. Severe TR, PASP= 50 – 55 mm. Intact septa , IVC mildly dilated.No pericardial effusion. No Clot.
Coronary Angiogram
( 26.3.2015)LM: 30% plaque mid and at bifurcation.LAD: Type 3 vessel , mid 90% diffuse
disease, distally graftable .LCX: Non dominant . CTO proximally,
filling from RCA.
RCA: Dominant, diffuse disease, 50% proximal, 75% mid and 90% distal. PLVB diffusely diseased, PDA occluded filling from LCA .
Conclusion : Severe 3 VD diffuse disease for
discussion.
CBC/Biochemistry (100020548)
8.4.2015
After CABG 7.4.2015
18.3.2015
50-100
Troponin
8.8 8.7 17.1 6.5 WBC
10.2 10 10 15.3 HEMOGLOBIN %
45,23,40 279 193 325 PLATELETS
1.8 PTT> 120
3.1 0.9 INR
21.8 5.2 4.6 GLUCOSE
8.1,6.9 9.1 7.7 BUN
170,171 113 87 CREATININE
840,947 493 99 CPK
Negative Sickling 315,313 125 17 CKMB
4.8 T3, 158,150 146 138 SODIUM
15.2 T4 4.8 , 5.2 3.9 3.9 POTASSIUM
2.4 TSH 1.5 2.1 CALCIUM
1.02 0.7 MAGNESIUM
420 564 URIC ACID
1.4 3.7 CHOLESTEROL
0.8 0.8 TRIGLYCERIDE
0.5 1.0 HDL
0.5 2.1 LDL
Troponin
Liver function test (10020548)
8.4.2015 7.4.2015Post CABG
31.3.14 18.3.2015 Name of Test
B+Ve Bloodgroup
22.7 33.0 Total Bilirubin
5.1 19.0 Direct Bilirubin
Negative
HCV 1915 697 27 30 ALT
Negativ
Hbs 2784 695 47 36 AST
Negativ
HIV 2976 3185 299 354 LDH
18.4 / 9 14 ,13 32 72.4/22 T protein/
Albumin
190 117 Alpo4
Transfusion ( total 101 units)
( Haemorrhagic shock)
Fresh FrozenPlasma
22Units
RBC
26Units
Cryo precipitate
23Units
Platelets
30Units
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