BACKGROUND, CURRENT ILLNESS AND PHYSICAL EXAMINATION Personal history No known drug allergies. Active smoking 40 pack-years. CVRF: hypertensive, obese. Lumbar canal stenosis. During follow-up, right hypernephroma was diagnosed. IQ: herniated disc L5-S1 in 2006.  Cardiological history Permanent atrial fibrillation Rheumatic valve disease. Double mitral lesion with severe stenosis, severe TR and PHT. Intervention in 2006 by mitral valve replacement with mechanical prosthesis (Sorin Bicarbon no 27) and tricuspid annuloplasty.

Usual treatment: omeprazole 20 mg, spironolactone 25 mg, verapamil 80 mg/12 h, acenocoumarol, oxycodone/naloxone, duloxetine 60mg, gabapentin 300 mg/8 h, naproxen. ʟʟ SFB: active life, functional limitation due to lumbosciatica with neurogenic claudication. NYHA I/IV.  Present illness Admitted to Urology for radical right nephrectomy, scheduled for 6 September. Anticoagulated with enoxaparin 60 mg/24 h for 5 days prior to surgery (1 to 5 September) and with enoxaparin 40 mg/24 h for 5 days after surgery (6 to 10 September). On 10 September she began to experience dizziness, dyspnoea on exertion and hypotension. Initially assessed by Cardiology, it was interpreted as decompensation of heart failure, diuretics were started and anticoagulation was increased to enoxaparin 80 mg/12h. On day 13, sudden respiratory worsening, requiring OTI and profound hypotension requiring noradrenaline in continuous perfusion at increasing doses (up to 1.5 μg/kg/min). A CT angiography was performed, without finding PET, showing left renal and splenic infarctions. The patient was transferred to the resuscitation unit and on-call cardiology was notified for assessment.

PHYSICAL EXPLORATION (on admission to the Coronary Unit)
BP 106/49 mmHg (IABP + noradrenaline); PAP 63/45 mmHg; PCP 50 mmHg; HR 145 bpm; SatO2 97 % (FiO2 80 %); central temperature 38.7°C. Sedated, well adapted to the ventilator. Peripheral lividity, with acral coldness. Cardiac auscultation: arrhythmic heart at 120 bpm, gallop. Pulmonary auscultation: scattered rhonchi and universal crackles. Abdomen: soft and depressible, no defence on palpation. Lower extremities: lividity, no oedema.


COMPLEMENTARY TESTS
Chest X-ray: cardiomegaly, perihilar alveolar infiltrates, compatible with acute pulmonary oedema. Swan-Ganz catheter in pulmonary branch, counterpulsation balloon at the level of the tracheal carina, orotracheal intubation tube in normal position. Mechanical prosthesis in mitral position. Angio-CT scan: ruled out PTE. Data of heart failure and renal and splenic infarcts. ECG: AF with ventricular response at 130 bpm, axis at 0o. No repolarisation alterations. Analysis on admission to the Coronary Unit: PO2 65 mmHg. PCO2 44 mmHg. pH 7,22. HCO3 18 mmol/l. SaO2 92 %. Lactate 24 mg/dl. Glucose 287 mg/dl. Urea 72 mg/dl. Creatinine 2.45 mg/dl. GPT 55 U/L. CK 89 U/L. LDH 519 U/L. Corrected calcium 8.56 mg/dl. Sodium 133 mmol/L. Potassium 5 mmol/L. C-reactive protein 13.09 mg/dl. Haemoglobin 14.4 g/dl. Haematocrit 44 %. Platelets 227.000/μL. Leukocytes 16,500/μL (neutrophils 83 %). Prothrombin index 70 %. INR 1.28. TTPA 41.3 s. Transthoracic echocardiogram: left ventricle neither dilated nor hypertrophic, with moderate global dysfunction (estimated LVEF 35-40 %), without clear asynergies. Trivalve aortic valve, without functional alterations. Metal prosthesis in mitral position with restriction of the opening of the antero-medial disc, leaving the postero-lateral disc fixed. Maximum velocity across the valve 230 cm/s, mean gradient 16 mmHg. Severely dilated left atrium. Poor access to right chambers. No pericardial effusion. Transesophageal echocardiogram: metallic prosthesis in mitral position with restriction of the opening of the antero-medial disc and absence of movement of the postero-lateral disc; leading to an acceleration of flow in systole with maximum velocity and mean gradient coinciding with the TTE. An attempt is made to measure the thrombus, with an approximate diameter of 21.7 mm. Severely dilated left atrium with smoke inside. Left atrial appendage with an image suggestive of thrombus inside.


EVOLUTION
On arrival at the resuscitation department, the patient was sedated and intubated, well adapted to the ventilator. Haemodynamically unstable, requiring increasing doses of noradrenaline in continuous perfusion (up to 1.5 μg/kg/min) to maintain TAS 80 mmHg, in atrial fibrillation at 140 bpm. Transthoracic echocardiography (V-Scan) was performed, which showed moderate LV dysfunction, with obstructive thrombus on the mitral prosthetic valve, limiting the opening of the discs. Given the poor clinical and haemodynamic situation, intra-aortic balloon counterpulsation was implanted and the patient was transferred to the Coronary Unit, where right pressures were monitored using a Swan-Ganz catheter. The patient has been in anuria since the onset of the condition. Given the history of major surgery in the previous 8 days, the size of the thrombus, the presence of systemic embolisms and the presence of a thrombus in the atrial appendage, fibrinolysis was rejected and the cardiac surgeon on duty was notified, who agreed to perform urgent surgery. Valve replacement with a biological mitral valve prosthesis (Perimount plus no. 27) was performed. During the postoperative period, in the Coronary Unit, he developed septic shock secondary to pneumonia, without any germ being isolated in the cultures. He was treated with intensive antibiotic therapy, with good evolution. Two weeks later he was transferred to the hospital ward. She was finally discharged from hospital one month after cardiac surgery.

DIAGNOSIS
Right radical nephrectomy for hypernephroma. Thrombosis on mechanical mitral prosthesis in relation to perioperative bridging therapy with enoxaparin. Secondary cardiogenic shock. Mitral valve replacement with biological prosthesis. Septic shock due to right basal pneumonia, resolved.
