Male patient, 42 years old, with a history of HIV diagnosed 3 years earlier, with a final CD4 count of 341 x mm3 (10%), without antiretroviral therapy.
The patient presented with dyspnea on exertion for two months.
Three days prior to admission she suffered from dyspnea at rest, fatigue and dizziness, without cough or fever.
She was admitted to the emergency department with sudden compromise of consciousness with rapid recovery.
We found one hypotensive patient presenting with tachycardia (50 mmHg), tachycardic (146 bpm) and high oxygen requirement (SO2 94% with 50% O2).
Physical examination revealed a large jugular engorgement, with prominent wave V (20 cm H2O), right gallope examination due to third heart sound with systolic murmur IV/VI without focuscusp.
Abdominal examination revealed a tender liver, 4 cm below the costal, pulsatile edge.
Her extremities showed signs of poor perfusion, with no evidence of edema.
The electrocardiogram showed sinus tachycardia, arrhythmia and signs of right overload.
Portable chest X-ray showed no cardiomegaly or signs of pulmonary congestion, but marked hylium and prominent pulmonary artery silhouette were observed.
The surface echocardiogram showed a left ventricle of normal size and systolic function, dilation of the right cavities with a left preserved septum bulging (TAP). The function of the right ventricle was assessed by tricuspid annular plane systolic excursion.
The tricuspid valve showed hypermobile, with severe regurgitation associated with severe pulmonary hypertension (75 mmHg).
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The patient remained hypotensive and dyspneic so he was connected to non-invasive mechanical ventilation (NIV) and hemodynamic support was started with volume contribution, noradrenaline up to 0.1 μg/kg/min, milbut.
Pathologic response was achieved when iloprost was started (5 μg nebulized every 4 h) and vasoactive support was reduced and NIV was withdrawn.
Chest CT angiography showed dilatation of the pulmonary artery and main arteries, which were permeable, associated with cardiomegaly of the mid-vessel reflux into the right cavities, with supra- and steepening of the septum.
Transesophageal echocardiography corroborated the surface examination findings.
A massive tricuspid regurgitation was observed, with hypermobilized valve, caused by "failure" of the anterolateral and septal leaflets.
Severe impairment, with persistent need for vasoactive drugs (VAD), despite iloprost and sildenafil therapy.
Having decided to surgically resolve his condition, a broken tendinous cord was found in the operation in its insertion into the papillary muscle.
A tricuspid valve replacement was performed with a biological prosthesis and ICD discharge.
Intraoperative biopsy revealed a chordae tendineous cord with extensive hemorrhage, necrosis, and erythema without signs of endocarditis or tumor.
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In the postoperative tolerance severe nitric oxide decreased to PSA, with systolic pressure of suprasystemic pulmonary artery (PASP 82 and SBP 76 mmHg), with normal filling pressure (AI pressure of 14 mmHg), so high doses of decoupling began.
Iloprost and sildenafil were restarted.
Evaluated by an infectologist, it was decided to start antiretroviral therapy (HAART) (Truvada® and Stocrin®).
The control echocardiogram showed LV with preserved systolic function and abnormal septal motion.
RV with signs of overload and systolic dysfunction, normal functioning biological prosthesis, PSAP 40 mmHg and IAC with bidirectional flow.
Subsequently, the patient progressed, being discharged on the sixteenth day post-surgery, receiving sildenafil 75 mg/day, 10 μg in nebulized ilopro, 5 times in nebulized propylene, Neointlo therapy and 25 μg.
After 3 years of follow-up, the patient is in good general condition, functional capacity I, with negative viral detection and general tests in normal ranges.
The patient discontinued iloprost after 2 years for economic reasons.
The control surface echocardiography showed a PASP of 50 mmHg, tricuspid prosthesis with moderate central insufficiency, dilated and hypertrophic RV with preserved systolic function.
A plate count test of 6 min was performed where a covered distance of 402 m was achieved.
Despite good functional capacity, due to persistent PH in the presence of prosthetic valve insufficiency, it is considered to restart iloprost therapy in nebulizations.
