Optimal therapeutic attitude in a complex pacient (Heyde Syndrome with severe anemia and multiple comorbidities)

Introduction: Heyde syndrome represents the association between severe aortic stenosis and intestinal angiodysplasia with gastrointestinal bleeding. It has an increased incidence in the past decade in the population over 70 years old in Romania. The most incriminated pathyphysiological mechanism involved is Von Willebrand type A disease (by depletion of Von Wil-lebrand factor in blood flowing through the narrowed valvular stenosis).
Case presentation: We present the case of a 79 years old pacient, former athlete, diagnosed a year previous with severe aortic stenosis and anemia (5 g/dl). The etiology of anemia, long sought by many doctors has not been elucidated (repeated colonoscopies and superior endoscopies were negative for bleeding sources). The pacient had multiple hospitalizations for decompensated heart failure and blood transfusions. From the associated comorbidities we wish to mention obesity, ischemic heart disease with severe cardiac angina, severe aortic ateromatosis, fusiform aneurysm of infra-renal aorta, with partial thrombosis (D-45mm), colon diverticulosis, gastrointestinal erythematous gastritis, chronic kidney disease stage IV, vestibular syndrome, disc herniation L5-S1 with medular compression highly symptomatic. All these have represented a challenge for the multidisciplinar team who took care of the pacient, both medically and logistic.
The reasons for the current hospitalization were re-presented by severe dyspnea with orthopnoea, extreme fatigue at mild-minimum efforts, recurrent lipothymia and angina pectoris, in spite of an almost comple-te treatment previously given at home (betablockers, diuretics, statin, ACE inhibitor, neurotrophics), all in minimum doses and without antiplatelet drug. Blood tests show severe anemia with 6 g/dl hemoglobin with iron deficiency due to blood lost, increased creatinine serul levels with Creatinine Clearance 29 ml/min/1,73 mp. Heart ultrasound presents non dilated left ventricle with preserved systolic function, mild mitral regurgita-tion and severe aortic stenosis with mild regurgitation.
The pacient benefits at first of correction of anemia with red blood cell transfusion and compensation of heart failure through standard treatment. Repeated colonoscopy and superior endoscopy show no signs of blood loss, but with persistent fecal occult blood test positive. The CT enterography does not reveal new in-formation about the pacient’s source of bleeding, while the aortic aneurysm remains stationary between evaluations with the fake lumen with partial thrombosis. Along with the gastroenterological team it is decided to evaluate the pacient through wireless videocapsule endoscopy where there are noticed a number of 15 angiodysplasic lesions at the level of duodenum and jejunum. The pacient is then transferred to another clinic where he benefits from crioablation of seven lesions (the only ones seen at that time), followed by a relative stationary levels of hemoglobin between 8.1-8.5g/dl. It is then when angiography is performed with evidence of severe bivascular coronary heart disease with recommendation of interventional miocardial reperfusion. The pacient receives aspirin for 14 days, subsequent benefitting from elective angioplasty with stent in right coronary artery and left circumflex artery, with good results, without complications. All this time the hemoglobine maintaines values between 7.5-8g/dl.
A week later Heart Team decides and practices trans-catheter aortic valve implantation with no complication and very good results, with favorable outcome for the pacient who shows obvious amelioration of heart failure and with the increase of hemoglobin up to 10g/ dl, with no further decrease. We mention that this time the pacient received nonsteroidal anti-inflamatorry drugs for the lumbago, a pain that prevented pacient’s mobilization in the last sixs weeks of hospitalization.
The particularity of the case: The particularity of the case is represented by the correction of the severe anemia due to difuse gastrointestinal bleeding, after TAVI. Another special element is represented by the very good cooperation between five medical specialties (cardiology, interventional cardiologist, cardiothoracic surgeon, gastroenterology and anesthesiologist) which led to treating a complex pacient with multiple comorbidities.
Conclusions: To conclude, as it is noted in the literature, Heyde syndrome (aortic stenosis associated with intestinal angiodysplasia) represents a rare association and very difficult to treat. Many times we tend to be reserved in the outcome of such a pacient (obese, bed bound by spine pathology, severe angina, bivascular coronary heart disease, severe aortic stenosis and above all severe anemia who prevents administration of optimal therapy), but persistent team work, with pacience, meticulosity and devotion can return to the family a pacient that has never ceased to hope.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)