Interesting case: ischaemic heart failure in a patient ... · specific Thalassemia unit we decided...
Transcript of Interesting case: ischaemic heart failure in a patient ... · specific Thalassemia unit we decided...
INTERESTING CASE: ISCHEMIC
HEART FAILURE IN A PATIENT
WITH THALASSEMIA
INTERMEDIA AND PULMONARY
HYPERTENSION
Χρονόπουλος Παναγιώτης ,Ειδικευόμενος Καρδιολογίας ΠΓΝΠ
Chronopoulos Panagiotis, Resident Cardiologist ,University Hospital of Patras
History
▪ 38years old ,Female
▪ STEMI Anterolateral received thrombolysis in cardiogenic shock ,and recurrent episodes of VT referred to us for Rescue-PCI
▪ Thalassemia intermedia with repeated treatment with transfusions,1st transfusion and Splenectomy at the age of 5
▪ According to her medical records undisciplined to the follow-up and her iron overload treatment
▪ Smoking
▪ Established osteoporosis, hypothyroidism, liver iron overload and fibrosis
ECG
❑ Hospitalization due to
typical angina and
severe anemia Hb: 7
g/Dl
❑ Received transfusion
therapy
❑ Asymptomatic until
sudden crescendo
angina occurs
❑ First ECG associated
with the symptom
❑ Thrombolytic treatment
with tenecteplase was
administered
ECG early after thrombolytic treatment
30 min after
thrombolytic
treatment was
administered
Killip Class IV
▪ The patient developed cardiogenic shock and repeated episodes of VT terminated with DC shock and Lidocaine
▪ Vasopressors were administered to stabilize the patient
▪ Immediate transfer to our Centre for Rescue-PCI
ECG On arrival
Cardiogenic shock
and signs of overt
heart failure persist
Coronary Angiography Left System
LAD & LCX total occlusions. The culprit lesion is the Left Circumflex
RCA
LCx Primary PCI
PCI+Stent 2,75/12 Promus 2,75/12→ TIMI III Flow
LAD PCI
Wire Crossing successful but PTCA unsuccessful even with NC
Balloon→ TIMI 0 Flow
Final Result after Stent Implantation
PCI+Stent Promus 2,75/20 mm
Cath Lab & Cardiac ICU
▪ The patient during the Intervention was in cardiogenic shock with vasopressor support and in overt pulmonary oedema ( NIPPV-CPA – dilemma to further intubate and set to mechanical ventilation)
▪ The patient was transferred immediately after the intervention at Coronary-ICU where her status was gradually stabilized, weaned of the NIPPV and gradual decrease the dosage of vasopressors and good diuresis with iv loop diuretic
TTE Assessment
▪ Patient was stabilized and vasopressor treatment terminated
▪ Stable vital signs( BP:95/65mmhg and ventilation with a MV (FiO2: 35% )
▪ Evident signs of congestion with slow amelioration by intravenous loop diuretic
▪ ACEI , B-BLOCKERS intolerable because of hypotension
▪ The patient was transferred at the Echo Lab for assessment
TTE PLAX
Moderate LV Dilation, Reduced LVEF , Moderate MR, Trace Pericardial
Effusion
TTE PSAX
Anterior & Lateral Wall Severe Hypokinesia, Mild Dilation RVOT, Trileaflet
Aortic Valve with normal opening
TTE A4C
Depressed LVEF Mid-Apical IVS –Apical-Lateral Wall Severe Hypokinesia
Moderate Ischemic MR
TTE A2C & A3C
LV Hemodynamic Assessment: Diastolic Function
Grade II Diastolic Dysfunction
E=A ,E/e’=13,
Ischemic MR
EROA 0,33cm2
RV Function
RV Function (2)
Moderate-Severe TR,Tricuspid Annulus Mild Dilation, RV dilation, Severe Pulmonary Hypertension
PASP 70 mmhg, meanPAP ( PR Vel) : 40 mmhG ,PADP (PR Vel) : 15 mmhg
S’TDI normal IVRT> 35msec ( Sign of PHT ) , Dilated IVC < 50% Resp Change → High CVP
Speckle Tracking Echocardiography
Results-Discussion
▪ Depressed LVEF 35%
▪ Moderate Ischemic MR
▪ Grade II Diastolic Dysfunction, High
LV Filling Pressure
▪ Severe PHT
▪ Moderate Severe TR
▪ High CVP
Lack of Follow up
▪ The patients last cardiovascular imaging was an Cardiac
MRI 2008 normal LVEF 65% LvmassEDi= 51g/m2
▪ No signs of heart iron overload T2* relax time 40msec(
normal) ,R2*=25msec (normal)
▪ Last TTE 2004 ! No signs of PHT or structural heart
disease▪ . Wood JC, Enriquez C, Ghugre N, Tyzka JM, Carson S, Nelson MD, Coates TD. MRI R2 and R2*
mapping accurately estimates hepatic iron concentration in transfusion-dependent thalassemia and
sickle cell disease patients. Blood. 2005;106:1460 –1465
Clinical assessment
▪ The patients symptoms were refractory
▪ Due to hypotension intolerant to standard of care
medications (ACEI,B-BLOCKER)
▪ No weaning from mask ventilation and loop diuretics
▪ NYHA IV clinical status
▪ Need for extra iv diuresis in order to ameliorate
paroxysmal nocturnal dyspnea episodes and sleeping in
upright position
Our keys to diagnosis and PLAN
Ferritin Level: 2908 ng/ml
Lack of follow up , Established Iron Overload,
Undisciplined in iron overload treatment
High Output HF associated with thalassemia + Iron
Overload Cardiomyopathy with a devastating acute
decompensation due to massive infarction
Plan
▪ In close collaboration with the Hematology Department and the specific Thalassemia unit we decided to deliver the patient intravenous iron overload treatment with deferoxamine and check her status
▪ The patients clinical status was stabilized we managed to treat her with the lowest dose of bisoprolol( 1,25-2,5 mg) and ivabradine 5mg x2 , eplerenone 50mg
▪ After a period of stability a 2-day course with dobutamine (5 μγ/κg/min) improved the congestion and the patient weaned from 02 therapy and per os diuretics were given
▪ Discharge in a few days was our plan AND SCD assessment for ICD implantation in 40 days, and a CMR to assess iron overload
SCD beat us ALL
DC Defibrillation→
ROSC→Intubation→
Immediate Coronary
Angiography
Emergency Catheterization
LAD CTO , LCX stent patent, RCA patent ( No changes from baseline
angiography)
Outcome
▪ The patient was transferred at the cardiac ICU in cardiogenic shock refractory to very high doses of vasopressors
▪ Her status was complicated with resistant respiratory failure and anuria
▪ Died 2 days after the in-hospital cardiac arrest
First Case Reports
References
The American Journal of Medicine (2005) 118, 957-967
Blood. 2001 Jun 1;97(11):3411-6.
Iron Overload treatment AND Prognosis
THANK YOU VERY MUCH