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46 year old male with chest pain who presented for evaluation of worsening dyspnea for 2-3 weeks. He reports driving back from Indiana last week for 3 days and since then both his legs got very swollen. "
History:
hypertension, gunshot wound, cerebrovascular accident
Congestive heart failure, severe mitral valve regurgitation, nonischemic cardiomyopathy with estimated ejection fraction of 5-10%
Congestive Heart Failure is a condition in which the heart's function as a pump is inadequate to meet the body's needs.
This occurs when the left ventricle is unable to pump out a sufficient amount of blood during each ventricular contraction.
Tachypnea, Tachycardia, increased blood pressure, Cheyne-Stokes, cyanosis, pink-frothy secretions, increased tactile fremitus, crackles and wheezing
Transesophageal echocardiography (TEE) is a test that produces pictures of your heart. TEE uses high-frequency sound waves (ultrasound) to make detailed pictures of your heart and the arteries that lead to and from it.
1. Severe mitral regurgitation with some improvement with dobutamine infusion consistent with good contractile reserve and dilated cardiomyopathy secondary to mitral regurgitation.
2. Normal RV chamber size
3. Aortic valve appears intact. Mild tricuspid regurgitation.
3/15
" patient underwent left and right heart cathertization by Dr today. No significant coronary disease. Moderate pulmonary hypertension. Patient now is willing to prceed for surgical intervention to help him. Talk with patient regarding weak heart w/ EF about 20% and possibilities of post of complication, long ICU stay, and need for intra-aortic balloon pump.
Mitral valve replacement surgery with post-op intaaortic balloon pump.
Procedure:
1. Mitral valve replacement using tissue valve since you epic valve size 33 mm. With leaflet preservation as well as chordee technique.
2. Ligation left atrial appendage using Atricure clip
3. Mideastinal lumph node biopsy level R4
4. Placement of intra-aortic balloon pump Pre-op.
3/17
“Diagnosis
-status post mitral valve replacement
hx non ischemic cardiomyopathy
-cardiogenic shock, low EF post op, 10-15%
-AKI
Plan
-Mechanical Ventilation, coordinate extubation with anesthesia
aggressive pulmonary hygiene post extubation
pressors, inotropes, IABP, pacing wires, chest tubes – CV surgery managing
Blood sugar control
electrolytes replacement
PUD prophylaxis
DVT prophylaxis
Pain control
3/20
Patient is extubated, awake aleart oriented, status post AIBP balloon was discon. Yesterday still low doses of epi. Status post bronchoscopy. T-max 38.6 current temperature same
all cultures are negative
sternal wound clean
lab results were discussed with patient discussed
Now extubated on NC, no acute distress, PA pressures noted PAS 60s on Milrinone drip, not ready to wean today wean Epi as tolerated.
noted HGB: 7.8 given that HR is good BP is good, being diuresed will hold off transfuse for now.
Chest tube output 70cc/24 hour. Consider remove today.
“Findings: indwelling swanz-ganz catheter indwelling IJ SVC sheath. Mediastinal chest tubes present. Cardiomegaly. Perihilar and bisalar infiltration. ETT above carina. Indwelling atrial appendage done.
Impression: support lines and tubes in good position. Perihilar and basilar subsegmental atelectasis. Small bilateral pleural effusion.
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