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Washington University Experience | VASCULAR | Infarct - Remote | 16A0 Case 16 History
Case 16 History ---- The patient was an 81-year-old woman with a medical history of coronary artery disease s/p coronary artery bypass graft, myocardial infarction, mitral valve valvuloplasty, atrial fibrillation, chronic obstructive pulmonary disease, and osteoarthritis. She presented to the BJH ED in August 2010 after having an acute episode of near syncope, fell and hit/landed on her head. Initial EKG showed a sinus bradycardia (rate in the mid 40s) with a left bundle branch. Non-contrast head CT showed tissue swelling overlying the skull in the anterosuperior region without fracture, no acute intracranial abnormality, old left cerebellar and right caudate infarcts, and periventricular white matter changes consistent with chronic small vessel ischemic disease. Transthoracic echocardiography showed severe global left ventricular dysfunction, moderate left ventricular ejection, moderate left atrial and right atrial enlargement, mild mitral regurgitation, and multiple (at least 3) large (1-2 cm) echogenic rounded structures in the left atrium most consistent with thrombi. She was admitted to the cardiac care unit and also placed on a heparin drip for anticoagulation. On one afternoon in August 2010 the patient developed a sudden onset of abdominal pain. Non-contrast abdominal and pelvic CT showed multiple mildly dilated loops of small bowel in the lower abdomen concerning for small bowel ischemia in the setting of left atrial thrombus. The overall findings were interpreted as being most consistent with mesenteric ischemia and surgery was consulted. Emergent surgical intervention was offered to the family. However, in keeping with the patient's wishes, the family declined. The patient was placed on comfort care and passed away.
