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Clinical case: Postpartum Syncope


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Hannah Schaubroeck Belgium.JPG

Hannah Schaubroeck, MD

Cardiac Intensive Care Unit - Ghent University Hospital, Belgium

About the patient

30 year old female patient

Reason for admission at ER of regional hospital : 

  • Malaise with recurrent syncope

History of present illness:

  • Sore throat with flulike illness since 1 week
  • Chest pain and shortness of breath since 1 day
  • Pt went to GP – prescribed amoxicillin

Cardiovascular risk factors:

  • Smoking since the age of 16 +
  • Familial CV history 
  • Hypertension 
  • Hypercholesterolemia 
  • Diabetes 
  • Sedentarism 
  • Obesity 

Past medical history:

  • G1 P1 A0, recent delivery (baby of 2 months old)
  • 2007: subtotal thyroidectomy (Graves’ disease)
  • Amygdalectomy; polypectomy

Medication at admission:

  • L-thyroxine 125 mcg OD

Known allergies:

  • None

Social history:

  • Working as cleaning lady; married

Physical examination

  • BP 90/60 mm Hg; HR 145 bpm; T 38,5°C; SpO2 97%; BMI 22
  • Elevated CVP
  • Tachycardia, muffled heart sounds
  • Bibasal crackles
  • Soft non tender abdomen, normal peristalsis
  • No peripheral edema

ECG

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Quick look transthoracic echocardiography

  • Mildly dilated LV with severely impaired contractility, no RWMA
  • Mildy impaired RV function (TAPSE 14 mm)
  • Severe mitral valve regurgitation without structural abnormalities
  • No other valvular abnormalities
  • No pericardial effusion

Further course

  • Arterial line, large peripheral cannula
  • IV Amiodarone 300 mg
  • Sedation and intubation for synchronised electrical cardioversion
  • 3 DC shocks
  • Further hemodynamic deterioration

 ECG

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Evolution to pulseless electric activity start CPR   

Management

  • Transfer to our hospital while uninterrupted Advanced Life Support
  •  ECMO team activated after telephone call from regional hospital

Patient summary

  • Syncopes and chest pain 2 months postpartum
  • Cardiomyopathy with reduced left ventricular ejection fraction
  • Witnessed in-hospital cardiac arrest (VT) -> ongoing CPR without ROSC

Differential diagnosis

  • Acute myocardial infarction: coronary thrombosis – spontaneous coronary dissection
  • Peripartum cardiomyopathy
  • Thyroid related cardiomyopathy
  • Myocarditis (viral)

At arrival in our hospital:

Insertion of peripheral VA-ECMO under TEE guidance

  • Running within 35 minutes after arrival
  • Total cardiac arrest time 90 minutes
  • Minimal no flow time

Further Investigations

Transoesophageal echocardiography before VA-ECMO implantation confirming findings on TTE

Coronary angiogram showing normal coronary arteries

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Chest X-ray after VA-ECMO implantation

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Arterial bloodgas

Patient values Normal range
pH 7,28  (7,35-7,45)
pCO2 30 mm Hg  (32-45)
pO2 566 mm Hg  (83-108)
Bicarb 13,9 mmol/L  (22-28)
BE -11,7  (-2 + 3)
Lactate 130 mg/dL  (< 11) ( =  14,5 mmol/L)
Glucose 125 mg/dl  (50-200)

Labs results

Patient values Normal range Patient Value Normal range
Hct 38,5%  (35-46) ALT 538 U/L  (14-36)
WBC 10300/mm³  (4000-10000) AST 279 U/L  (7-35)
Neutrophils 76%  (45-70) G-GT 97 U/L  (12-43)
TRC 194000/mm³        (150-500000) Bilirubin 0,6 mg/dL  (0-1,2)
PT 60%  (70-100%) LDH 1552 U/L  (120-246)
D-dimer 4186ng/mL  (0-500) CK 4241 U/L  (30-135)
Na 132 mmol/L   (135-145) Hs-trop I >50 000 ng/L     (0-15,6)
K 4,7 mmol/L  (3,5-5,1) Urea 47 mg/dL  (15-36)
Mg 0,8 mmol/L  (95-107) Creatinin 0.8 mg/dL  (0,5-1)
Bicarb 13 mmol/L  (22-30) CRP 123 mg/L  (0,1 – 5)
TSH 4.4 mU/L  (0,4-4) Glucose 252 mg/dL  (74-106)

Diagnosis

  • Normal coronary angiogram
  • Good thyroid function at admission with substitution
  • Flulike illness before admission

tentative diagnosis of viral myocarditis

giant cell myocarditis not excluded at that time: corticosteroids were started

Further course 

  • Targeted temperature management (36°C) for 72h
  • Acute kidney injury at admission – full recuperation under VA-ECMO
  • Sedation hold - awake and neurologically intact 5 days post arrest
  • Heparinisation for VA-ECMO
  • Mobilisation under ECMO
  • Pneumonia - short course of piperacillin-tazobactam
  • Limited recuperation of cardiac function after 2 weeks
  • Attempt to wean VA-ECMO under inotropes - removal
  • After 3 days: high fever – deterioration of liver function
  • Co TTE: biventricular failure

Source: ESC guidelines on acute chronic heart failure 2016

 

Further course

  • LVAD - RVAD implantation – full recuperation of liver and kidney function
  • Weaning RVAD after 1 week
  • Several episodes of RV Failure – inhaled nitric oxide, high doses of milrinone and sildenafil – initial good evolution with strict fluid balance management
  • Extubation 1 month after admission at our hospital
  • critical illness polyneuropathy ++ rehabilitation
  • GI bleed colon ascendens – coiling
  • Myocardial biopsy during LVAD implantation: Lymphocytic infiltration, no giant cells. Cell necrosis ++

confirmation of viral myocarditis

Transthoracic echocardiography after LVAD implantation

Parasternal long axis

 

Parasternal short axis

TR Gradient

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Small LV cavity with apical cannula in situ, aortic valve opening with every beat, mild aortic regurgitation, dilatation of RV with mild bulging of the IVS to the left, mild TR with normal TR gradient, pleural effusion

Further course

  • Urgent heart transplant 10 weeks after admission (recurrent RV failure)
  • Discharge home 14 days after HTX

Wrap-up

  • 30-year-old woman peripartum with chest pain, flulike illness and syncope
  • Think of pregnancy-related pathology eg spontaneous coronary artery dissection or peripartum cardiomyopathy
  • Myocardial biopsy remains gold standard to confirm diagnosis of myocarditis in patient with cardiogenic shock
  • LVAD as bridge to heart transplant if no recovery - be aware of RV failure
  • Hemodynamic unstable VT = electric cardioversion!
  • Consider eCPR for witnessed cardiac arrest – ensure high quality Advanced Life Support