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Washington University Experience | VASCULAR | Infarct - Embolic | 6A0 Case 6 History
Case 6 History ---- The patient was a three year old boy with a history of hypoplastic left heart syndrome status post multiple surgical procedures, ECMO, cardiac arrest x2, decompensated heart failure, cardiogenic shock, and recent pulmonary hemorrhage, who was on a quadrox oxygenator. On 3/10 the patient was at home in his usual state of health and suddenly became apneic and pulseless. CPR was performed and continued by EMS. Elevated troponin and CK-MB resulted in ICU admission where troponins and CK-MB began to normalize over the next couple of days with EKG returned to baseline. He was transferred to SLCH for heart transplant evaluation on 3/16 and slowly stabilized. On 3/30 he had several episodes of emesis with feeding and was not moving in his right side. A head CT at that time revealed acute infarct of the left parietal and temporal lobe extending into the basal ganglia in the distribution of the middle cerebral artery. There were several transfers in and out of the cardiac ICU. A head CT on 5/29 revealed multiple infarcts at different ages. Over his course in the ICU, he began to have improved right sided motion and reacquired some language. He went through multiple agents for agitation and comfort. He had tricuspid valve repair and annuloplasty and returned on ventricular assist device support via a CentriMag. He had postoperative significant bleeding and his ventricular assist device support was sequentially weaned. He was found to have dyskinetic wall movement. On 5/14, he had a Berlin ventricular assist device placement as a bridge for transplantation and had multiple episodes of associated clotting issues. During his stay in the ICU, he developed fever. A tracheal aspirate grew Haemophilus influenza. Cefepime and vancomycin were given. He continued to spike fevers and his antibiotic coverage was broadened but no positive cultures were ever found. He underwent CT of his abdomen, chest and head, which revealed multiple areas of infarction including the spleen and both kidneys. He remained in the ICU critically ill with multi-organ failure, supported with the Berlin heart, Nova lung and mechanical ventilation. Overall, he was in persistent respiratory failure on prolonged mechanical ventilation, coagulopathic, with end stage heart failure, status post multiple strokes causing right hemiparesis, and renal failure. Due to his poor prognosis, care was redirected and he died on 7/1. ---- Autopsy showed multifocal infarcts at different stages of resolution in the CNS, kidneys and spleen likely secondary to thromboemboli. In addition, presence of two small subdural hematomas and subarachnoid hemorrhage over the right occipital lobe was noted. Both bleeding as well as coagulopathy (leading to thrombo-emboli), as seen in this particular case, are in fact well-known complications of indwelling ventricular assist devices.
