2024 FSA Podium and Poster Abstracts
P040: A SUSPICIOUS CASE OF HEYDE SYNDROME: PRESENTATION AND PERIOPERATIVE CONSIDERATIONS
Diane B Choi, MD; Cosmin G Guta, MD; University of Miami/Jackson Health System
Introduction: Heyde syndrome is a multisystem disorder typically presenting as a triad of aortic stenosis, gastrointestinal bleeding, and acquired von Willebrand syndrome. It is suggested that increased circulatory shear forces due to the stenotic aortic valve lead to hematologic dysfunction in addition to cardiovascular dysfunction. Primarily affecting the elderly, it may be underdiagnosed and underreported.
Methods: This case report presents an 82-year-old woman with suspected Heyde syndrome who underwent an emergent procedure requiring anesthetic monitoring. Her medical history was significant for atrial fibrillation, severe aortic stenosis (HFpEF, LV EF 60-65%), obesity, cervical cancer (s/p chemo and hysterectomy 20 years ago), and gastrointestinal bleeding presented to the hospital on her primary care physician's advice due to low hemoglobin. Upon arrival, her hemoglobin was 4.7, necessitating transfusion. Three months prior, she had been hospitalized for GI bleeding, the source remaining unidentified by colonoscopy and CT imaging. Outpatient capsule endoscopy was recommended.
Results: Approximately six months before this admission, cardiac workup revealed an aortic valve area (AVA) of 0.8 cm². Three months later, the AVA had progressed to 0.6 cm² and, at the time of this admission, to 0.3 cm². This admission aimed to manage the above issues, particularly further investigating the GI bleed, before further transaortic valve replacement workup.
Due to active lower GI bleeding, her anticoagulation (Eliquis) was withheld upon admission. On day four, she became obtunded and a rapid response was activated. A CT brain revealed a right M1 hyperdensity, prompting a stroke alert. CTA showed a right internal carotid artery terminus filling defect extending into the right M1. The patient then underwent endovascular thrombolysis under moderate anesthesia care (MAC). On arrival to OR she was alert but not following commands. An a-line was placed in the beginning of the case. She received 0.5 mg midazolam and 20 mg ketamine in the beginning of the case and during the procedure, her systolic blood pressure (SBP) was maintained above 160 by using a phenylephrine infusion. After a successful thrombectomy the phenylephrine infusion was stopped and her SBP returned to baseline values. She was transferred to the neuro ICU for post procedure management, Due to complications related to the stroke, the patient expired 3 days later.
Discussion: This case presented technical challenges due to the patient's atrial fibrillation, severe AS with AVA of 0.3 cm², and concomitant GI bleed with indeterminate source. Given the emergent procedure's nature, balancing the patient's hemodynamic status was crucial. This case underscores the importance of expeditious workup for potential transcatheter aortic valve replacement. Although not formally diagnosed, the patient’s presentation with severe aortic stenosis and multiple admissions with GI bleeding make this a highly suspicious case of Heyde syndrome.