Trial Short Case 2 April 2021

Case Summary

28 year old female – admitted increased shortness sudden visual loss which resolved with 24 hours under neurology services. Husband Reports having additional short-lived episode of slurred speech 3 weeks prior to hospital admission.  Had a second episode of visual loss on the morning of referral the cardiothoracic service to hospital.

Developed a DVT in hospital while receiving appropriately prescribed DVT prophylaxis

No fevers or septic symptoms

CT and MRI confirmed several small posterior circulation embolic infarcts

Referred 1 week after admission after work up for stroke

Background

No prior medical issues

Limited English – Nepalese background

Lifelong non-smoker, nil ETOH, never IVDU, no previous operations/blood transfusions

Unknown family history

Married, nulliparous, expresses strong desire to have children

Medications

Nil

Nil known Drug Allergies

Examination

Weight 39kg,

Height 151cm

BMI 17.1 kg/m^2

HR 60 Regular

BP 105/50

JVP not elevated

Vesicular breath sounds throughout chest with no added sounds

HS Soft S1, normal S2, high pitched, early diastolic murmur heard maximally at the 2rd interspace parasternally on the left side, accentuated on sitting the patient forward and listening at end expiration.

No palpable lymphadenopathy

No peripheral oedema

No stigmata of IE, no clubbing

No fevers in hospital

Investigations

ECG – normal sinus rhythm, bradycardia, no conduction delay

CT brain – no evidence of infarct no bleed

MRI – multiple small subacute occipital infarct evident on diffusion weighted imaging, no evidence of haemorrhage

Bloods:

Blood cultures – 7 X sets of blood culture taken, so far all -ve (3 X sets have been cultured for 5 days)

Hb 93 g/L

WCC 9.3 X 10^9/L (normal 4.0-11.0 X 10^9/L

RCC 3.8 X 10^12/L (normal 3.8-5.8 X 10^12/L)

MCV 86 (normal 80-100fl)

MCHC 27 (normal 27-32 pg)

Hct 0.32 (range 0.32-0.46)

Plt 560 X 10^9/L (normal 150-400 X 10^9/L)

Na 136 mmol/L

K 3.8 mmol/L

Cl 100 mmol/L

HCO3 38 mmol/L

Cr 40 umol/L

Ca 2.1 mmol/L

Corr C 2.3 mmol/L

Po4 1.0 mmol/L

Mg 0.9 mmol/L

LDH 140 U/L

AST 35 U/L (normal <45U/L)

ALT 37 U/L (normal <55 U/L)

Total protein 60 g/L (normal 65-85 g/L)

Albumin 32 (normal 34-48 g/L)

ALP 115 (normal 30-110 IU/L)

Bili 9 umol/L (normal 2-24 umol/L)

GGT 42 U/L (5-35U/L)

CRP 60 mg/dL

ESR 40mm/hr (normal 0-15ml/hr)

INR 0.8

TT 9s (range 10-15)

APTT 24

PT 10

INR 0.9

D-Dimer 2.8mcg/ml (normal <0.4 mcg/ml)

Fibrinogen 5.3

Protein C -  90%  normal activity (normal range 60%-150%)

Protein S – 70% normal activity (normal range 60%-130%)

Factor V Leiden  - screen -ve

Factor VIII level - 70% normal (normal range 50-150%)

Factor XI level – 80% normal (normal range 65% to 130%)

Auto- immune screening

dsDNA normal

Anti-cardiolipin IgG antibody <15U/ml (-ve)

C3 level 16 mg/dL (normal)

C4 level 16mg/dL (normal)

Lupus anticoagulant +ve

Beta 2 glycoprotein antibody IgG -ve

Beta 2 glycoprotein antibody IgM -ve

ENA -ve

ANA titre 1:20 (-ve)

ANCA screen -ve

Rheumatoid factor -ve

Anti-CCP antibody -ve

Tumour markers:

CA 19-9 - ve

CA 125 -ve

CEA -ve

B-HCG -ve

AFP -ve

TOE – 13mm mobile vegetation on aortic surface of right coronary cusp of aortic valve

AV Vmax 1.9, VA 1.7 cm^2 mean V gradient 14mmHg

Mild AR

No LV and RV size and systolic function

No other valvular pathology

No other structural heart pathology

No pericardial effusion/obvious pericardial abnormality

CT PET – No evidence of disseminated malignancy, no evidence of FDG avidity around the aortic valve or aortic annulus, no evidence of FDG avid emboli

CTCA – calcium score 0, normal coronary anatomy

Questions:

1.      What are the possible aetiologies for this case, how will these impact your decision making, and what do you think would be the most likely in this circumstance.  

2.     The patient and family would like to discuss the risk and benefits of surgery, prosthesis types and impact on future life and health in particular with regards to raising a family. What are the indications to operate in this circumstance

3.     You decide to operate, what factors will influence you operative plan and how will you address these factors in particular.