5^th World Heart and Brain Conference

Biography

Biography: Sherien Abdelsalam

Abstract

We report the case of a 36 year old woman, diagnosed with arterial hypertension at the age of 34, with difficult control of blood pressure values under treatment with beta-blocker, ACE and diuretics. She was referred to us for evaluation. No history of cardiac problems or family history of hypertension. The clinical examination showed an overweight woman, a blood pressure of 165/80 mmHg in the right arm and 100/60 mmHg in the left leg, large pulsations in the suprasternal notch, normal heart sounds, 60 bpm. A systolic murmur was audible at the parasternal right and left area and at the paravertebral interscapular area bilaterally. The radial pulses were palpable but femoral pulses were extremely weak and at transthoracic echocardiography, showed mild LVH. From the suprasternal view, we found the signs of an aortic coarctation, without significant systolic gradient but diastolic run-off at Doppler evaluation. Confirming the diagnosis CT angiography examination showed very tight coarctation with interruption just distal to the left sub clavian artery, with post-stenotic dilatation of the descending aorta, with some collateral vessels. After multiple trials to cross retrograde the trials of antegrade, recanalization of the interrupted aorta was performed using a rigid coronary wire and we managed to cross the lesion. The guide wire was captured with a snare and kept fixed. This allowed crossing with MP4 F catheter was interchanged and angiography was performed in the proximal arch of the aorta. Measurements were confirmed and a rigid guide wire was used to allow interchanging the angiographic catheter to 14-F Cook sheath (Cook Medical, Bloomington, Indiana). A covered Cheatham was implanted. Angiography post stent showed successful stent of the COA and the residual gradient of 2-3 mm across the stent. The patient was transferred to the CCU, she was stable clinically. Next morning, pallor was observed and we asked for urgent blood picture which showed hemoglobin dropped 2 grams compared to before the procedure and follow up after 2 then 4 hours showed continue of the dropping in the blood hemoglobin. Blood replacement and urgent CT thoracic and abdominal showed a nice stent without dissection or aneurysm but a large left perinephric hematoma (7×8 cm) was detected. That has put us in a conundrum since the procedure was smooth and there was no apparent injury to any renal vessel; on asking the patient gave history of falling down in the toilet on her side without telling someone or asking for help. After discussing with the surgical team, she was managed conservatively and she was safely sent home after 7 days. Dropping hemoglobin after stenting COA has many causes which include dissection, aortic rupture, bleeding during the procedures and injury of vascular structure. Meticulous history taking, careful examination and multi-disciplinary imaging modalities would pretty much help detect the cause of the bleeding early and prevent its incidence in future cases.