November 22nd, 2010

Send Us Your Vexing Cases

No matter how evidence-based we strive to be in our decision making, we all know that the patient in front of us is never exactly like those enrolled in large clinical trials. Thus at CardioExchange, we have highlighted cases where the application of evidence-based medicine and treatment guidelines is not straight-forward. And often, to our delight and to everyone’s benefit, you’ve responded with your views and your questions on how these patients should be treated.

Now, we want to build on that community by turning the tables: You show us the cases, ask the questions, and tell us what happened in the end. Submit a vexing case to us by e-mailing us here.  If your case is selected to be presented and discussed, we’ll edit the content for clarity and HIPPA compliance, and you’ll get a great opportunity to interact with your colleagues.

We hope that these cases will engender exciting and even controversial conversations that will allow us all to learn from each other and ultimately improve the care of our patients.

9 Responses to “Send Us Your Vexing Cases”

  1. Jean-Pierre Usdin, MD says:

    Dear doctor Anju and colleagues what do you suggest in this case?

    This 85 year old still active man lives in Barbados (West Indies) and comes every 12 or 18 months in Paris for his cardiac follow up.

    A cardiac pace maker was implanted in June 2004 because of atrio-ventricular block.
    He has high blood pressure and suffers from a permanent atrial fibrillation.
    He takes Atenolol, Pravastatin and Warfarin with for the most part stable INR.

    The recent evaluation of the battery on May 30th 2011 showed 2.75V, 16.82µA and 1 266 ohms with a mean estimated running time of 2.5 years (range 1 to 3.5 years) The heart rate is totally dependent of the cardiac device.
    Because of his old age, the possible future difficulties in travelling from West Indies to France, the anxiety of suffering from a sudden dysfunction of the pacemaker or whatever unexpected disease, the patient ask me to change now the stimulator. Furthermore his wife has a progressive neurological problem and would probably not be able to travel next year, he said.

    I hesitate in doing such preventive procedure.

    My questions are:
    1: do you think the operative risk in this 85 year old-man under anticoagulant therapy makes acceptable a preventive surgery i.e. before a hypothetical impairment of flying during more than eight hours in the future?
    2: Is it wise to change the long term anticoagulant regimen. Substituting Coumadin by Dabigatran after surgery? (Or before?)
    Dabigatran has not yet the agreement in France in non-valvular atrial fibrillation but in Barbados it may have.

    Thank you for everyone help.
    Jean-Pierre USDIN MD

    Competing interests pertaining specifically to this post, comment, or both:
    no conflicts of interest.

    • Enrique Guadiana, Cardiology says:

      First I would evaluate if is possible to extend the life of the pacemaker. How are the umbral? It is possible to lower the voltage output. I suppose the patient have a unicameral pacemaker if not and the FA is permanent and there is any contraindications I will use the VVI mode. I will evaluate to turn off any unnecessary pacemaker function. Could you lower the base heart rate safely? And if so, calculate with the pacemaker company how much the life of the pacemaker will increase. Then I will present this information to the patient. About the Coumadin if he is stable no history of complications I will not change the treatment.

      • Jean-Pierre Usdin, MD says:

        dear doctor Guadiana
        thank you for your recommendations.
        I already exactly do that and with the help of an ingenior we modify the outpout of the pace maker to the lower safer level concerning vantricular pacing.
        we stopped also some applications and the battery life was increased of 18 months.
        I explain to the patient the pros anc cons and he accepted to postpone the battery replacement.
        as he feels in good condition he will return to see me in one year
        in case of problem he knows that he can go to a closer place to replace the device (other carabeian islands)
        thank you
        dr Usdin

  2. Faiza Hashmi, MD says:

    Hi, I have been a member if this community for a few months now and I find the views, articles and blogs here very informative and interesting. Cardio Exchange is definitely one of the top resources to keep myself updated on the Cardiology front.

    I am writing today because I wanted to submit a very challenging and interesting case of arterial thrombosis (? thromboembolism) and the challenge of anticoagualtion and concomitant GI bleeding as a complication .
    I recently had a 85 year old caucasian female patient with Past medical history of Hypertension and ?Crohn’s disease who was admitted for Left hand pain due to ischemia.On examination the radial pulse on left side was diminished and arterial doppler showed a thrombus in the radial artery.The patient underwent thromboembolectomy via fogarty catheter by vascular sugeon. Further work up for the source of Embolus was negative as a tranthoracic as well as a Transesophageal echocardiogram did not reveal any intracardiac thrombi or valvular lesions.The patient was started on heparin drip post surgery and the aim was to bridge that with warfarin for long term anticoagulation.The twist in the case came when the patient’s primary care physician started her on Dabigatran for anticoagulation instead of warfarin.
    Ten days after discharge from the hospital and being on dabigatran (75 mg PO BID) the patient presented to the ER with LGI bleed and complain of dark bowel movement the day before (?malena) . She was admitted to ICU and dabigatran was discontinued .she recieved 2 units if packed red cells and 4 units of FFP to reverse the coagulopathy and underwent colonscopy with clipping of the bleeding vessel.
    3 days after this episode , on the telemetry floor the patient again complained of Left hand pain alongwith skin mottling/bluish discoloration and feeling cold and numb. A repeat arterial doppler scan showed a thrombus in the Left radial artery and the patient was emergently taken to the operating room for another thrombectomy.
    The question was how to proceed now with anticoagulation given that she had recurrent arterial thrombus and also had recent GI bleeding.

    This case was interesting for multiple reasons:
    1. it poses the dilemma of treating one serious condition i.e limb threatening ischemia, by anticoagulation vs facing another posiibly life threatening condition i.e GI bleed as a consequence.
    2. the role of dabigatran and its off label use in vascualr especially arterial thromboembolism is controversial and potentially risky.
    would it have been better to weigh risks/benfits ratio of warfarin and just follow the conventional traetment instead of jumping on the dabigatran bandwagon just to avoid warfarin and the dreaded monitoring of PT/INR even in conditions when dabigatran is not indicated or approved?
    3.arterial thromboembolism is a relatively uncommon disease and although in the index case the hypercoagulability profile was negative ,even if it were positive it would more likely have led to venous thromboembolism.

    I just wanted to share this case with the community and see what the experts think.

    Thank you,

  3. Bassem Fouad, MD says:

    As the patient is octogenrians and has no history of bleeding tendncy, so i do believe that bleeding mainly due to dabigatran over-response. Shifiting to warfarin I think may be an answer. Importantly to scan Aorta again by different modalities.

    Competing interests pertaining specifically to this post, comment, or both:
    no conflict

  4. Stephen Fleet, MD says:

    One of the radiology residents where I work in Massachusetts told me he has a friend in Philadelphia with coronary stents and Factor V Leiden. The patient’s cardiologist had a stroke and retired. Does anyone know of a cardiologist in Philadelphia who might be interested in following such a patient and would be versed in aspects of intervention as well as coagulation? I don’t personally have any Philly connections or contacts.


  5. Wasim Rashid, MBBS,MD says:

    I had to opine on a call from the neurosurgery ward where a 40 year old woman had developed bilateral femoral vein DVT 10 days after being operated for Aneurysmal subarachnoid haemorrage.What would be the best management plan in this patient?

    Competing interests pertaining specifically to this post, comment, or both:

  6. in my opinion, catheter directed thrombolysis – is the best option.

  7. Thierry Legendre, MD says:

    The risk of pulmonary embolism is very high and intracerebral bleeding could be devastating; I would recommend the placement of a removable inferior vena cava filter for 2 or 3 months and then oral anticoagulation.