Curious Case of Anaemia

I was relaxing on a Saturday evening making plans for spending time with my family on Sunday when I received a call from our cardiology colleague regarding a sick young lady who had been received in ER. Briefly she had been having trouble since last six months and had been consulting various doctors in Rajasthan for long standing anemia. Her Hemoglobin persistently stayed around 7-8 gm% and she had undergone extensive investigations for ruling out blood malignancies and had even been seen by oncophysician.

On her arrival in ER simple clinical examination revealed a murmur in the precordial area and a Cardiologist was asked to evaluate her. The subsequent echo images which my colleague sent me on whats app was something which I had never seen.

There was a ventricular septal defect ( a hole in the heart ) which is not unusual to see sometimes in young adults. To my horror there were huge ball of infection ( vegetation’s ) surrounding the VSD. Briefly I told the cardiologist that she would need surgery and that I would assess her the next morning and do the needful.

Next 24 hours had however something else in store for us. She deteriorated overnight and went into shock due to infection and had low blood pressure She landed up on ventilator and by next day needed lot of medicines to support her blood pressure. In view of the critical status her other organs like kidney and liver were also showing signs of decompensation.

Clearly surgery was the only alternative and it would have been very high risk with the possibility of death on table itself.

With understandable reluctance the relatives did give consent for surgery. She was taken up for open heart surgery and I too was shocked to the findings which I saw intra operatively.

The vegetation’s were so extensive that they occupied the entire right side of the heart. They had also invaded onto the left sided heart valves(both mitral and aortic.)

With great difficulty and meticulous dissection, I could clear the vegetation’s and close the VSD.

While removing the vegetation’s on the aortic valve I landed up with a hole in the leaflet of the valve and now was left with two choices ; either to replace it with a metal valve or to try and repair it. Replacing would not only be technically challenging but also in a young girl would mean lifelong anticoagulation with its own set of problems. So I decided to give it a try with repairing it. I took a patch from the patients own pericardium and repaired the hole and after testing it seemed that we had got it right.

Postoperative echo showed a perfect repair. She made a excellent recovery and was discharged subsequently. At follow up of three months her hemoglobin had climbed up to 13 and her cheeks were blushing pink and she was full of energy. All her organs were working normally now.

It has been almost a year now and she continues to do well. Sometimes in the era of technology and fast paced life we all forget to do the basic things like clinical examination which leads to patient being labeled as a diagnosis and everyone else subsequently works around the same.. a simple thing here would have saved her so much trouble but we are happy that eventually all is well that ends well especially for our young lady who has a whole life in front of her.

By : Dr. Sandeep Agarwala

Sr. Consultant Cardio-thoracic Surgery