ABC | Volume 114, Nº4, Suplement, April 2020

Anatomopathological Correlation Case 1/2020 - A 56 Year-Old Woman Developed Heart Failure after a Presumed Diagnosis of Acute Myocardial Infarction and Mitral Valve Regurgitation with Rupture of Chordae Tendineae Desiderio Favarat o e Luiz Alberto Benvenut i Instituto do Coração (InCor), HC-FMUSP, São Paulo, SP – Brazil Mailing Address: Desiderio Favarato • Avenida Dr. Enéas de Carvalho Aguiar, 44, subsolo, bloco II, 2º andar (Unidade Cínica de ATerosceros) Cerqueira César. CEP 05403-000, São Paulo, SP – Brazil E-mail: dclfavarato@incor.usp.br Keywords Heart Failure/physiopathology; Mitral Valve Prolapse/ surgery; Myocardial Infarction; Sepsis; Postoperative Care; Shock, Cardiogenic; Renal Insufficiency. A 55-year-old female patient, from the municipality of Carapicuiba, state of São Paulo, had arterial hypertension and started having dyspnea on major exertion a year and a half before hospitalization. In September 2016, she started having severe chest pain that felt like tightness, which was relieved a little with rest, associated with nausea. She sought medical care in her city, was medicated and discharged to go home. In the next morning, she had a recurrence of pain and was hospitalized. During hospitalization, she had a cardiac arrest, which was reversed with electric shocks. The patient remained hospitalized for 10 days and was discharged with a diagnosis of acute myocardial infarction and mitral valve disease. After hospital discharge, she developed functional class IV (New York Heart Association) dyspnea, sporadic episodes of paroxysmal nocturnal dyspnea and orthopnea, being referred to InCor-HCFMUSP. She was using ASA 100 mg / day; Furosemide 40mg 3xday; Captopril 50mg 3xday; Clopidogrel 75mg once a day; Simvastatin 40mg 1xd. The physical examination disclosed a heart rate of 102 bpm, blood pressure of 118x86 mmHg, pulmonary auscultation disclosed crackling rales in lung bases, cardiac auscultation showed rhythmic heart sounds with +++ / 6+ mitral systolic murmur; abdominal examination was normal and there was no lower -limb edema. The echocardiogram (09/28/16) showed aortic diameter measuring 28 mm, left atrium 47 mm, diastolic left ventricle 48 mm and systolic 26 mm, left ventricular ejection fraction of 77%, septal thickness 11 mm and posterior wall thickness, 9 mm. The mitral valve showed partially ruptured chordae tendineae, posterior cusp eversion into the left atrium, with coaptation failure between the cusps and marked eccentric reflux. The tricuspid valve also showed marked reflux. The pulmonary artery systolic pressure was estimated at 62 mmHg. Laboratory tests (Nov. 08, 2016) showed 4300000 red blood cells / mm³, hemoglobin 12.3 g / dL, hematocrit 38%, 8110 leukocytes / mm³, creatinine of 1.75mg / dL, sodium 140 mEq / L, and potassium 3.8 mEq / L. The electrocardiogram (11/08/16) showed left atrial overload and final intraventricular conduction delay of the stimulus (Figure 1). Marked cardiomegaly and signs of pulmonary congestion were observed on the chest X-ray (Figure 2). Echocardiogram and cardiac catheterization with coronary angiography were requested. The coronary angiography (02/08/17) showed a 40% left coronary artery trunk lesion, two lesions in the anterior interventricular branch, 50% in the ostium and 90% in mid- third; a 60% proximal lesion in the circumflex branch and 60% lesion in the mid-third of the right coronary artery. (Figure 3) A surgical procedure to correct valve regurgitation and coronary artery bypass grafting (CABG) surgery were indicated. Preoperative tests showed: red blood cells 4300000 / mm³, hemoglobin 12.4 g / dL, hematocrit 37%, leukocytes 13990 / mm³ (2% band cells, 80% segmented, 0% eosinophils, 8% lymphocytes and 10% monocytes), platelets 173000 / mm³; total cholesterol 158 mg / dL, HDL-C 28 mg / dL, LDL-C 109 mg / dL, triglycerides 103 mg / dL, creatine-phosphokinase (CPK) 2938 U / L, glucose 120 mg / dL, urea 310 mg / dL, creatinine 4.79 mg / dL, sodium 136 mEq, potassium 4.9 mEq / L, Alanine aminotransferase (ALT) 988 U / L, aspartate aminotransferase (AST) 681 U / L; uric acid 27.1 md / dL, glycated hemoglobin 5.4%, Urinalysis with proteinuria of 0.38 g / L and sediment with 14000 epithelial cells / mL, 63000 leukocytes / mL and 4290 hyaline casts / mL. TSH was 6.25 µIU / mL, free T4 was 0.98 mg / dL. Thrombin time (INR) was 1.4; activated partial thromboplastin time (APTT) ratio was 0.96. Serology for hepatitis B and C and for HIV were negative. Considering these laboratory alterations, the patient was called to the emergency department of InCor (Feb. 23, 2017). The patient reported that after undergoing cardiac catheterization on February 8, 2017, she received a prescription for atorvastatin and since then she had been progressing with diffuse myalgia and functional class worsening with dyspnea at rest and orthopnea up to 3 days before hospitalization, associated with reduced urinary output and darkened urine. She also reported chest pain in the infra- mammary region, with irradiation to the epigastric region, with worsening at usual efforts, poorly characterized, lasting for hours without improvement factors. She denied fever and cough. She said she had been constipated for 3 days. Editor da Seção: Alfredo José Mansur (ajmansur@incor.usp.br ) Editores Associados: Desidério Favarato (dclfavarato@incor.usp.br ) Vera Demarchi Aiello (anpvera@incor.usp.br ) DOI: https://doi.org/10.36660/abc.20200024 47