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Morbidity and Mortality Conference

Morbidity and Mortality Conference. Brendan Cavanaugh April 24, 2002. Initial Presentation. 58 y.o. male s/p AVR and ascending aortic aneurysm repair 10 months prior 1-2 minute episode of facial/lingual numbness Double vision Slurred speech

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Morbidity and Mortality Conference

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  1. Morbidity and Mortality Conference Brendan Cavanaugh April 24, 2002

  2. Initial Presentation • 58 y.o. male s/p AVR and ascending aortic aneurysm repair 10 months prior • 1-2 minute episode of facial/lingual numbness • Double vision • Slurred speech • No focal weakness, confusion, aura, seizure activity, headache, syncope, chest pain or dyspnea • Two similar episodes in the last 10 months

  3. Review of Systems • No recent medication changes • No recent illnesses • No recent trauma • No recent vision changes • Good performance status

  4. Past Medical History • H/O ascending aortic aneurysm leading to 4+ AI • S/P Bentall procedure with St. Jude's valve and Cabrol graft to LM (INR goal 2.5-3.5) • DDD pacemaker • Nonobstructive CAD (LM 50% by cath 10/00) • S/P Anterior MI, EF 50% • HTN • GERD • H/O esophageal stricture s/p dilation

  5. Medications: HCTZ 25 mg qd rofecoxib 12.5mg qd metoprolol 75mg qd warfarin 5mg qd omeprazole 20mg qd ALL: etodolac Social History: - Married - Retired construction worker - Remote smoking Hx - Social alcohol use Family Hx : CAD, HTN

  6. Physical Exam Gen: Pleasant, NAD VS: Afebrile BP 136/71 HR 72 Resp 20 SpO2 96% RA Card: RRR, normal S1, III/VI SEM heard best over the aortic area, loud S2, mechanical click Resp: CTA bilaterally Abd: Soft, NT, ND, +BS Extr: No C/C/E. Good peripheral pulses Neuro: Alert and oriented, Motor 5/5 throughout; sensory and cerebellar exam were normal; gait intact; reflexes 2+ bilaterally. ? Left facial droop (other CN normal)

  7. Laboratory Data 16.2 9.0 283 44.9 PT 21.1 INR 2.3 PTT 33 CTNT: <.03, CPK 149 CA, Mg, Phos all WNL 140 102 12 108 3.5 23 1.2

  8. EKG: NSR with ventricular pacing at 72. T wave inversions in anterolateral leads which were unchanged from previous CT head: Negative Carotid dopplers: 16-49% stenosis of the ICA with irregular surface contour bilaterally CT angiogram: moderate stenosis of basilar artery TTE: Normal LV size and function. EF 65%. Septal hypokinesis c/w surgery. Valve function normal Contributing data

  9. Day 2 • Awoke with substernal CP • EKG was obtained………..

  10. EKG with ST depressions in II, III, AVF • Troponin <.03 X 2 • Fresh frozen plasma • Repeat echo showing hypokinetic inferior wall and EF of 40-45%

  11. Day 3 • Pain free, b/p 105/65, pulse 60-70 • Peak CTNT 0.44, CPK 279 • Cath: 50% LM, normal distal flow • TEE: no vegetation/clot, EF 50% • Stress echo:no evidence of cardiac ischemia

  12. Day 4 and 5 • Transferred to ICCU • No further pain • CKs resolved • Discharge medications: warfarin , ASA, atorvastatin, metoprolol, omeprazole • Follow up with Internist/Cardiology

  13. Two weeks later…. • Two hours of crushing substernal CP • Respiratory distress, profuse diaphoresis • Afebrile, B/P 88/60, 80, 30, 94% on RA • Lungs clear, JVP slightly elevated • EKG was obtained……….

  14. EKG: new left axis deviation and t wave inversions in the lateral leads • Troponin <.03, CK 146, INR 2.2 • All other labs normal • CXR unremarkable

  15. Management • IV nitro, metoprolol, MSO4 and heparin with some resolution of pain • TTE 35-40%. Eccentric titling of aortic valve. Hypokinetic lateral wall • Pt given FFP and emergently sent to the cath lab.

  16. Interventions • Cardiac cath showing showing occluded Cabrol limb to LM • IABP/Swan placed in the lab • Pt emergently taken to surgery • Off pump coronary bypass performed: LIMA to LAD

  17. POD #0-1 • Dopamine/Neo/Epi/Milrinone gtt • Pt remained intubated (PEEP of 7.5) • Tmax 38, HR 90’s, MAP 60’s • CVP 17, PA 58/30, CO/CI: 4.1/2.0 • BUN/Creat 15/1.1, good urine output • SVT amiodarone started • IAPB maintained at 1:1

  18. POD #2 • Spiked temp to 38.9, WBC 15.6, pan cultured • Vitals: B/P 90’s/40’s, HR 90’s • ABG: 7.44/34/76/90% on 60% and PEEP 7.5 • CVP 14, PA 55/30, SVR 1058, CI 2.0 • CXRopacity right base, increased vascular markings bilaterally • Cefuroxime IV • Furosemide gtt

  19. POD #3, CT/ICU Day #4 • IABP d/c’d • Pulmonary status worsening • ABG: 7.33/39/49/92% on 80% FiO2 • IV vecuronium started • CXR showing worsening infiltrate/pulm. edema • Cefuroxime changed to pip/tazo • Transferred to CCS team • Trial of IV alprostadil

  20. POD #4 • ABG: 7.33/39/49/92% on 100% Fio2 PEEP increased to 12.5 • Temp 39, WBC 17.7 • Pip/tazocefazolin/aztreonam • CVP 20, PA 64/31, CI 2.0, MAP 60s’, HR 80’s • Echo: EF 25-30%, restrictive filling pattern, extensive WMA’s in the distribution of the LAD • IABP placed

  21. Febrile, WBC 17.7 MAP 60’s, HR 100’s SVR 850 CXR without change PEEP increased to 15, FiO2 down to 60% Creat 1.82.0 Medications: Milrinone gtt Phenylephrine gtt Epinephrine gtt Dobutamine gtt Furosemide gtt 6. Amiodarone gtt 7. Heparin gtt 8. Vecuronium gtt Midazolam gtt Fentanyl gtt Insulin gtt Cefazolin/Aztreonam IV Famotidine/ASA POD #5-6

  22. POD #7-10 # CV: -V-Tach lidocaine gtt - Repeat echo showing EF of 25% (CI 2.4) # Pulmonary: - Increasing FiO2 requirements (100%) # ID - Persisting leukocytosis, abx adjusted # FEN - Worsening renal function CVVH - New coagulopathy, elevated LFT’s

  23. POD #11 • Worsening acidosis (ph 7.197.02) • Increasing pressor requirements • V-fib arrest • Pt pronounced dead at 1:30 am • Autopsy granted

  24. A-02-09

  25. A-02-09

  26. Final Autopsy Diagnosis I. Coronary artery atherosclerosis, severe. A. Acute myocardial infarction, anteroseptal myocardium (days). 1. Status post CABG with LIMA to LAD (days). 2. Reperfusion hemorrhage in myocardium. 3. Cardiogenic shock as evidenced by: a. Acute infarction of large bowel. b. Acute tubular necrosis. c. Acute hepatic passive congestion and centrilobular necrosis. d. Focal infarction of the spleen. 4. Biventricular hypertrophy. 5. Bilateral pleural effusions. B. Healing myocardial infarction of posterolateral left ventricle (weeks).

  27. Final Autopsy Diagnosis II. Status post Bentall procedure for repair of idiopathic dilation A. Status post aortic valve replacement. 1. Status post Cabral graft from ascending aorta to left main coronary artery and reimplantation of right coronary artery into ascending aorta. III. Cerebral atherosclerosis by history. A. History of transient ischemic attacks, with known 50% narrowing of basilar artery by angiogram (weeks). IV. Idiopathic hypercalcuria (years). A. Interstitial nephritis, mild. B. Nephrolithiasis not identified at autopsy.

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