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Washington University Experience | VASCULAR | Small Vessel Disease | 17A0 Case 17 History
Case 17 History ---- The patient is a 72-year-old man with past medical history of hypertension, type 2 diabetes, hyperlipidemia, and tri-vessel coronary disease with 95%, 70% and 60% occlusion of right coronary, left circumflex and left anterior descending arteries, respectively. Other past medical history includes 50-70% occlusion of right internal carotid, obstructive sleep apnea and history of smoking. In April 2014, the patient was hospitalized for acute congestive heart failure from complete heart block with ejection fraction of 47% and treated with a dual permanent pacemaker. He was found to have heparin-induced thrombocytopenia and multiple deep vein thrombosis and pulmonary emboli. Anticoagulation with warfarin was initiated. A few days before his current admission, the patient had been admitted to an OSH for fatigue and chest pain. Atrial fibrillation with rapid ventricular response developed; on imaging he was found to have a 5x3 cm ventricular pseudoaneurysm. He was transferred to BJH for coronary artery bypass surgery and left ventricle aneurysmectomy. Because of heparin-induced thrombocytopenia, plasmapheresis was started on 7/15; his only complication was hypotension on 7/18 which was treated with fluid resuscitation. Because of high titer of antibody for anti-heparin platelet factor 4, plasmapheresis was continued and surgery was scheduled for 7/25. However, on 7/24, the patient had an uncomfortable abdomen, shortness of breath and appeared acutely ill with diaphoresis and mottled skin. He developed hypotension with EKG which initially showed right bundle branch block, then later ST elevation in V2-3. Hypotension worsened and patient eventually developed pulseless electrical activity. He could not be resuscitated. ---- At autopsy the weight of the unfixed brain was 1330g. Several subacute infarcts involved the periventricular right parietal and occipital lobes.
