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I always enjoy the case presentations around here and it's been a while since I contributed, so here was a fun case
54 y/o male underwent Sternotomy for CABG/MVR/MAZE/LLAA 2 months ago after presenting with an NSTEMI. BMI 42, recent hx of Meth and Marijuana use, current everyday smoker with questionable COPD (PFTs were fine), OSA on BiPAP while at hospital (non-compliant at home), and AFib on Elliquis. Surgery went uneventfully, had a Mitral Valve Repair (simple ring), good flow in coronaries, NSR during postop course, extubated postop day 1, and discharged 4 days later. Only thing worth noting was that it took 85k units of Heparin to get his ACT therapeutic for CPB. After initiating CPB, 2 units FFP were given for severe Heparin Resistance (Of note, he was not on a Heparin gtt preop, but was on a therapeutic Lovenox bridge for his Atrial Fib). Hospital system completely out of Anti-Thrombin III and says it is on a national shortage
6 weeks later....
Presented to the ED with AFib with RVR, Acute Kidney Injury and new onset Pulmonary Edema/CHF. EP consulted and decided to do a TEE/CV. CV was successful with conversion back to Sinus. However, TEE showed Ring dehiscience with Severe MR, Severe TR, EF 35-40 (previously normal), Mild AI, and moderate RV dysfunction. No evidence of vegetation. Pt medically optimized with plans for Redo MVR, possible TVR. During workup, pt gets a CT of Chest/Neck which finds an 80% Stenosis of the airway at the level of the glottis and thyroid cartilidge without external compression. According to previous records, pt was an easy Intubation with MAC 3 and 8.0 ETT. Pt was exubated within 12 hours postop. Pt admits to "throat problems" over past couple of years that has not worsened since his first surgery. Pt notes occasional difficulty clearing mucus, occasional wheezing, and occasional bloody secretions. Denied any orthopnea. During medically optimization, ICU staff also treats him for "COPD exacerbation" with a steroid course and antibiotics. Pt placed on Milrinone and was diuresed which reversed his Acute Kidney injury to the point that Creatnine is now at baseline.
Surgeon wants to do a minimally invasive MVR (Repair, possible Replace) through a Right Thoracotomy. Let's stop here and hear others plans
Have a couple videos of the Ring Dehis but can't figure out how to add it from my iPhone.
54 y/o male underwent Sternotomy for CABG/MVR/MAZE/LLAA 2 months ago after presenting with an NSTEMI. BMI 42, recent hx of Meth and Marijuana use, current everyday smoker with questionable COPD (PFTs were fine), OSA on BiPAP while at hospital (non-compliant at home), and AFib on Elliquis. Surgery went uneventfully, had a Mitral Valve Repair (simple ring), good flow in coronaries, NSR during postop course, extubated postop day 1, and discharged 4 days later. Only thing worth noting was that it took 85k units of Heparin to get his ACT therapeutic for CPB. After initiating CPB, 2 units FFP were given for severe Heparin Resistance (Of note, he was not on a Heparin gtt preop, but was on a therapeutic Lovenox bridge for his Atrial Fib). Hospital system completely out of Anti-Thrombin III and says it is on a national shortage
6 weeks later....
Presented to the ED with AFib with RVR, Acute Kidney Injury and new onset Pulmonary Edema/CHF. EP consulted and decided to do a TEE/CV. CV was successful with conversion back to Sinus. However, TEE showed Ring dehiscience with Severe MR, Severe TR, EF 35-40 (previously normal), Mild AI, and moderate RV dysfunction. No evidence of vegetation. Pt medically optimized with plans for Redo MVR, possible TVR. During workup, pt gets a CT of Chest/Neck which finds an 80% Stenosis of the airway at the level of the glottis and thyroid cartilidge without external compression. According to previous records, pt was an easy Intubation with MAC 3 and 8.0 ETT. Pt was exubated within 12 hours postop. Pt admits to "throat problems" over past couple of years that has not worsened since his first surgery. Pt notes occasional difficulty clearing mucus, occasional wheezing, and occasional bloody secretions. Denied any orthopnea. During medically optimization, ICU staff also treats him for "COPD exacerbation" with a steroid course and antibiotics. Pt placed on Milrinone and was diuresed which reversed his Acute Kidney injury to the point that Creatnine is now at baseline.
Surgeon wants to do a minimally invasive MVR (Repair, possible Replace) through a Right Thoracotomy. Let's stop here and hear others plans
Have a couple videos of the Ring Dehis but can't figure out how to add it from my iPhone.
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