Delayed Recognition Of Left Atrial Injury
Sudhan Nagarajan, Elbert Williams, Amit Pawale, MD, Ramachandra Reddy.
Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA.
OBJECTIVE: A 71 year old lady, with past medical history of hypertension, presented with exertional dyspnea worsening over a year. Transthoracic echocardiogram and Coronary angiogram revealed severe aortic stenosis and two vessel coronary artery disease respectively. She underwent elective Aortic valve replacement and coronary artery bypass grafting. Tricuspid annuloplasty was done for severe tricuspid regurgitation detected on intraoperative transesophageal echocardiogram (TEE). After weaning off from cardiopulmonary bypass, moderate right ventricular dysfunction and massive airway bleeding were noted. Extracorporeal membrane oxygenation (ECMO) with central cannulae was initiated and chest left open. Postoperative bedside TEE showed severe right pulmonary artery narrowing. Mediastinal exploration and pulmonary arteriotomy the following day showed no embolus. A large hematoma adjacent to the right pulmonary artery was evacuated and a tear in the dome of the left atrium was identified and repaired. Subsequent hospital course was complicated by acute kidney injury followed by multiorgan failure and failure to wean off from ECMO. Patient care was withdrawn on sixth postoperative day after discussing poor prognosis with the family.
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