an uncommon case of acute heart failure in young

An uncommon case of acute heart failure in young

Dr Hema RaveeshAssOCIATE ProfESSOR in Cardiology DR, SADANAND.K.S, DR. MADHUPRAKASH, Dr. Bharathi, Dr.C N Manjunath SRI JAYADEVA INSTITUTE OF CARDIOVASCULAR SCIENCES AND RESEARCH, MYSORE

www.wincarsassociation.com

Case:

• 29 year old boy from a nearby village came to the E OPD with sweating ,palpitations and breathlessness of sudden onset- 4 hours

• On lifting some weights in the field, while working he felt a sense of give way in his chest

• He also had fever since 15 days for which he had received treatment at a local clinic.

• Blood reports were within normal limits.• O/E : • -hypotension • -Continuous murmur in left parasternal area• - B/L crepititions upto interscapular area


Parasternal long axis showed a dilated chamber with a VSD


4 chamber view showing mildly dilated LA and LV


4 Chamber view showing severe AR


Short axis view showing a dilated chamber communicating with the aorta


DIAGNOSIS:

• Congenital heart disease- Bicuspid Aortic Valve- severe Aortic regurgitation, Perimembranous VSD L R shunt, Rupture of sinus of Valsalva into RVOT in cardiogenic shock in sinus rhythm

• Referrred—> To cardiothoracic surgeons


Intraoperative surprise: The surgeons were taken aback to see the cause of the emergency was Infective Endocarditis!!

Perforated aortic leaflet acute severe Aortic Regurgitation

Bicuspid Aortic Valve


Intra op FINDINGS –

• Heart was distended, hypocontractile,

• epicardium was inflamed.

• PA was distended and Tense, RA,RV and LV

dilated.

• Aortic valve was bicuspid with mediolateral

commissure,

• Anterior leaflet body was perforated,

• Sinus had a rupture into RVOT

• Sinus had eroded in to myocardium forming

a cavity.

• Sinus ,annulus, VSD margin and the cavity

were inflamed.

• VSD margin at LVOT was very friable.www.wincarsassociation.com

OPERATION-

AVR (23mm SJM mechanical valve)+ RSOV closure

• Aortic valve excised, infected tissues debrided .(annulus, Wind sock)

• There was defect in the annulus at RSOV.

• VSD margin and wind socket debrided thru RA,

• VSD was not closed from RVOT side as it was the only opening for the cavity in the myocardium otherwise will lead to abscess , in a later date.

• Now the cavity will be washed through the vsd ,leading to better healing.


• Difficult weaning process OFF CPB

• After one failed attempt of weaning from CPB, second time rest on CPB, INOTROPC

ADJUSTMENT , IABP INSERTED.

• Duration : 8-10 HRS

• Pt had Complete heart block and put on bi ventricular pacing,

• Stiff inotropic support -- UN PHYSIOLOGICAL.

• Immediate POST – op period was very stormy and critical

THE NIGHT MARE WAS NOT YET OVER:


• POD 3 - Extubated

• POD 4 - IABP removed after 74 hrs.

• ON Epicardial Pacing as patient continued to have LBBB

• Ionotropes weaned off

• POD 30 –Dual chamber Permanent pacemaker insertion ( long symptomatic pauses)

• POD 36 – Patient discharged in stable condition

• ECHO - Mild RV dysfunction, LVEF 40%. No residual shunt, No paravalvular leak.

• IV Antibiotics for 4 weeks

POST OP PERIOD:

Conclusion and Take Home Message:

• CONGENITAL HEART DISEASE complicated by Infective Endocarditis should be kept in mind in young patients with Acute Decompensated Failure with Cardiogenic Shock.

• It is important to adapt an aggressive treatment strategy with

heart team approach involving multidisciplinary team of cardiologists, cardiothoracic surgeons, cardiac anaesthetists, blood bank officers, microbiologists and intensivists.

• The success story of recovery of this case is due to exemplary and concerted team effort.


The large chamber communicating with the aorta a partially treated abscess cavity rupturing into RVOT which behaved like a ruptured sinus of Valsalva.

The extra space cavity was excised and repaired with a patch. A metallic aortic valve prosthesis was used.

Patient could not be taken off pump due to acute severe RV dysfunction severe LV dysfunction IABP insertion, high ionotropic support the patient taken off pump after An 8-10 hour procedure.

Dysfunctional Right Ventricle


Day 36: Discharged!!!!!

ALLS WELL THAT ENDS WELL!!!


..Thanks to the excellent Cardiovascular , Cardiac Anaesthesia and Cardiology team.

Special thanks to Medical Superintendant & Director-for waiving off all charges (4 lakh) and encouraging this life saving procedure.


THANK YOU


an uncommon case of acute heart failure in young

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