A 56 year old man, no previous co-morbidities, is shifted to our tertiary care centre from a nursing home, where he was admitted the evening prior with chest pain of 2 hours duration, sweating and low BP = 80/45 mmHg. ECG demonstrated anterior ST elevation for which he was given aspirin, r-TPA, heparin. His symptoms resolve. Serum chemistries reveal a peak CPK of 1800 and a CK-MB fraction of 15%. He continues to be hypotensive, and his examination reveals a holosystolic murmur. 2D Echo shows a large VSD.
On arrival to our centre, he is conscious, oriented, appears mildly dyspnoeic and BP is recorded 60/35 and his pulse is 112 and regular.
We intubated and ventilated him. Put an Intra-aortic balloon pump, and started ionotropic support at moderate doses and could get the BP up to 72/40 mmHg.
Please give your suggestions. How do you manage this case?
Post your comments and suggestions in the comments below.
On arrival to our centre, he is conscious, oriented, appears mildly dyspnoeic and BP is recorded 60/35 and his pulse is 112 and regular.
We intubated and ventilated him. Put an Intra-aortic balloon pump, and started ionotropic support at moderate doses and could get the BP up to 72/40 mmHg.
Please give your suggestions. How do you manage this case?
Post your comments and suggestions in the comments below.
Is this VSD acquired? He would need a definitive surgical repair at some stage after stabilisation. Steps to prevent increase in right sided pressures should be taken in the meantine (avoiding hypoxia/hypercarbia/ acidosis)and also avoid increase in afterload. I wonder whats the role of inodilators to reduce shunt fraction here...
ReplyDeleteYeah. He was planned for surgery...but a BP of just 70 mmHg systolic was the reason for the delay. Books say that vasodilators like NTG and SNP decrease the shunt fraction...but couldnt be given again due to hypotension. Increasing the ionotropes were of no real benefit.
ReplyDeleteHe mus b having a Large VSD wid Lt-->Rt shunt...He needs IABP,,,Levosimendon,,,and Urgent surgery,,,Putting IABP wont help him out immediately,,wil take some time,,Need to correct Acidosis due to Cardiogenic shock,,,n emergency Surg,,he wont Improve b4 Surgery,,,and intraop TEE for sure,,,,
ReplyDeletei wud think that surgery wud be the answer.The mortality following an acquired VSD is quite high.
ReplyDelete