ABC | Volume 114, Nº4, Suplement, April 2020

Anatomopathological Correlation Favarato & Benvenuti Heart failure after myocardial infarction an rupture of chordae tendineae Arq Bras Cardiol 2020; 114(4Suppl.1):47-56 On physical examination, the patient was in regular general condition, 2+/4+ skin pallor, hydrated, +/4+ icteric skin, acyanotic and afebrile. Heart rate was 65 bpm, blood pressure was 70x50 mm Hg, oxygen saturation was 90%, with fine crackles in lung bases; auscultation disclosed rhythmic heart sounds, and 3+ / 6+ regurgitation holosystolic murmur in mitral focus; the abdomen was flat and intestinal sounds noises were present, with a palpable liver at 2 cm from the right costal margin; there was no edema or signs of deep vein thrombosis in the lower limbs. The diagnoses of cardiogenic shock and rhabdomyolysis, acute renal failure, ischemic hepatitis and possible infective endocarditis were made. Norepinephrine, intravenous furosemide 40 mg every 8 hours, and ceftriaxone and oxacillin antibiotics were prescribed. Laboratory tests (23 Feb 2017) showed hemoglobin 12 g/dL, hematocrit 35%, leukocytes 14230/mm³ (82% neutrophils, 8% lymphocytes and 10% monocytes), 147000 platelets/m³, CK-MB mass 54.5ng/dL, troponin I 0.349 ng/ mL; urea 313 mg / dL, creatinine 4.94 mg/dL, AST 938 U / L, ALT 746 U/L, gamma glutamyl transferase (Gamma-GT) 473 U/L, alkaline phosphatase (AP) 279 U/L, total serum proteins 7 g/dL, total bilirubins 1.67 mg/dL, direct bilirubin 1.15 gm/dL, lipase 799 U /L, C-reactive protein (CRP) 98.69 mg/L. Prothrombin time (INR) was 1.4 and the activated partial thromboplastin time (APTT) ratio was 0.96. Urinary analysis showed free hemoglobin ++, leukocytes 32000/mL, erythrocytes 13000/mL, without casts. Gasometry showed a pH of 7.40, pCO 2 of 18.7 mm Hg, pO 2 of 99.9 mmHg, O 2 saturation of 99.9% and bicarbonate level of 11.2 mmol/L. The lactate level was 49 mg / dL. Blood culture was positive for Staphylococcus hominis , sensitive to oxacillin and the urine culture was positive for multisensitive E.coli . The antibiotics were then switched to vancomycin, piperacillin and tazobactam on March 3, 2017. In addition to vasoactive drugs, hemodialysis was performed. The transthoracic echocardiogram did not disclose vegetations, the left ventricular ejection fraction was estimated at 65%, with no change in segmental motility. The mitral valve showed posterior leaflet prolapse, with signs of associated rupture of chordae tendineae. The Doppler study and color flow mapping showed eccentric regurgitation jet of marked degree. Laboratory tests (March 02, 2017) showed: hemoglobin 9.2 g/dL, hematocrit 28%, leukocytes 12220 / mm³ (1% band cells, 88% segmented, 5% lymphocytes and 6% monocytes), platelets 123000 / mm³, urea 54 mg/dL, creatinine 1.68 mg / dL, sodium 139 mEq / L, potassium 3.0 mEq / L, AST 44 U/L, ALT 160 U/L. The patient underwent surgery (March 03, 2017) with mitral valve repair and reconstruction and commissurotomy without annuloplasty (quadrangular resection), atrial septal defect closure and left internal mammary artery bypass grafting to the anterior interventricular artery and saphenous vein grafting to the right posterior descending artery, in addition to atrial septal defect closure. The echocardiogram in the immediate postoperative period (March 03, 2017) disclosed mild mitral regurgitation. Chest x-ray (March 03, 2017) at the bedside in the immediate postoperative period showed cardiac monitoring electrodes, central venous catheter, pleural drain in the left hemithorax, sternal metal suture, clear lung fields and normal cardiac area. Biopsy of the mitral valve posterior leaflet showed fibrosis and marked mucoid degeneration of the cusp stroma (B17-0412) She had a seizure on March 4, 2017 and started treatment with lamotrigine. The cranial tomography showed no alterations. The echocardiogram (03/20/17) disclosed mitral valve with reduced cusp coaptation, posterior cusp with mild calcification and reduced mobility, and mild regurgitation. There were no images of thrombi in the atria and their appendages or images suggestive of vegetation. She was discharged on March 29, 2017 and three days later she came to the emergency department complaining of feeding problems, with vomiting episodes, despite the use of ondansetron and diarrhea. She also complained of hoarseness and tinnitus in both ears. She denied dizziness, vertigo, and fever, but reported dyspnea at rest for 1 day. She was using Amiodarone 200mg 1x /day, AAS 100mg / day, Lamotrigine 25mg / day, Furosemide 40mg 1x / day, Ondansetron 8mg 3x / day, Omeprazole 20mg 1x / day, and Dipyrone 500mg 4x / day. On physical examination, she showed 3+/ 4+ skin pallor. Blood pressure was 94x68 mmHg and heart rate was 64 bpm; pulmonary auscultation was normal, and the cardiac auscultation disclosed a 2 + / 6 + mitral systolic murmur; abdomen and lower limbs showed no alterations. Chest x-ray (Apr. 01, 2017) showed para-hilar and right cardiac border condensation foci and blunting basal pleural effusions of the and global +++ cardiomegaly, with unfolding of the left middle arch and dislocated left main bronchus (Figure 4). The ECG (Apr. 02, 2017) disclosed sinus rhythm, left atrial overload, right bundle branch block and changes in ventricular repolarization (Figure 5). Laboratory tests disclosed hemoglobin of 12.3 g / dL, hematocrit 37%, leukocytes 4980 / mm³, platelets 213000 / mm³, C-reactive protein 23.87mg / L, creatinine 1.56 mg / dL, urea 107 mg / dL, sodium 134 meq / L and potassium 3.4 mEq / L. The echocardiogram (Apr. 04, 2017) disclosed a left ventricle with preserved systolic dimensions and function, without segmental alterations. The mitral valve showed marked regurgitation with reduced posterior cusp mobility, albeit without stenosis. Filamentary structure was observed at the base of the posterior cusp. The tricuspid valve showed marked regurgitation, with alterations of the valve cusps. Pulmonary systolic blood pressure was estimated at 75 mmHg. Chest tomography showed a condensation focus in the anterior segment of the right upper lobe and areas of atelectasis and pleural effusion in both lung bases. The transesophageal echocardiogram (Apr. 07, 2017) was similar to the transthoracic echocardiogram performed on April 04, 2017. 49