Rare cause of repeated cardiac decompensation of a patient with multiple comorbidities

Objective: We present the case of a 65-year-old patient, hypertensive, diabetic insulin-treated, known for chro-nic renal disease stage 3, major left ventricular block and coronary artery disease, treated with pharmaco-logically active stent angioplasty on the right coronary artery and circumflex artery (2015) . Subsequently, the patient was diagnosed with erosive gastritis with supe-rior digestive haemorrhage, operated colon neoplasm and anemia with mixed etiology. In february 2019, resuming angina pain, angioplasty with a metal stent was practiced on the proximal segment of the right coronary artery. In this context, it presented sustained ventricular tachycardia electrically reduced, then per-sistent atrial fibrillation electrically cardioverted and treated with amiodarone. In the last year, the patient experienced multiple cardiac decompensations, cur-rently presenting another episode of decompensated heart failure.

Methods: Clinically on admission: patient in acute pulmonary edema, TA=210/120 mmHg, rhythmic, 89/ min, oxygen saturation=75% in atmospheric air. ECG: sinus rhythm, 100/min, major left ram block with ter-minal phase changes. Biological: Nitrogen retention syndrome, hypokalaemia, severe anemia. Echocardio-graphic: Normal-sized cardiac cavities, left ventricular concentric hypertrophy, normal left ventricular systo-lic function (LVSF), restrictive diastolic dysfunction, moderate pulmonary hypertension, bilateral pleural effusion in small amount. Although initially the patient responded to treatment, several hours after admission, she installed atrial fibrillation with rapid rhythm and and acute pulmonary edema requiring orotracheal in-tubation and mechanical ventilation. After electrical cardioversion, the patient installed a total atrioventri-cular block maintained for several hours.

Results: Due to hemodynamic instability, LVSF being moderately diminished, positive inotropic support was initiated and temporary electrical cardiostimulation was performed. Under treatment with intravenous diuretic, high dose potassium chloride, inotropic support, clopidogrel and erythrocyte mass transfusion, the patient remained stable, with negative hydroelectric balance and stationary glomerular filtration rate, but continued to accumulate pleural fluid what required fitting a straight pleural drain tube and multiple pleu-rocentesis. During hospitalization, the patient maintai-ned rapid atrial fibrillation without repeating atrioven-tricular block periods; the temporary stimulation was suppressed and the beta-blocker therapy was started. LVSF normalized and allowed the suppression of the inotropic support, after that the blood pressure valu-es remained high under treatment with alpha blocker and calcium blocker. Abdominal ultrasound revealed the presence of a tumor on the left adrenal gland and the biological tests collected showed an elevated plas-ma aldosterone/renin ratio. Later, control of blood pre-ssure with treatment was performed, and the pleural and pericardial effusion resolved after steroidal anti-in-flammatory treatment and colchicine, and on the 11th day of hospitalization the patient was detubbed.

Conclusions: After confirmation through compu-ted abdominal tomography of the left adrenal tumor (37.7 mm homogeneous, hypodensal, 50% suggestive of adenoma), an endocrinological consultation was performed that concluded for primary hyperaldost-eronism with indication of surgery. The patient being hemodynamically stable was transferred to a general surgical department where tumor resection surgery was performed, the ulterior evolution being favorable.

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