SFEBES2022 Poster Presentations Neuroendocrinology and Pituitary (72 abstracts)
The heart bleeds – complex management of a patient with acromegaly, cardiomyopathy and mechanical mitral valve
Aditi Sharma 1 , Sandhi Nyunt 1 , Kavita Narula 1 , Catherine Mitchell 2 , Nigel Mendoza 1 , Yong Yong 2 , Emma Hatfield 1 , Karim Meeran 1 & Niamh Martin 1
1Imperial College NHS Trust, London, United Kingdom; 2Hillingdon Hospital NHS trust, London, United Kingdom
A 44 year old gentleman presented to his local hospital with a two week history of fevers and rigors. Blood cultures were positive for Streptococcus oralis, and an echocardiogram confirmed new diagnosis of hypertrophic cardiomyopathy (HCM) complicated by mitral valve infective endocarditis (IE). Unfortunately, this required a mechanical mitral valve replacement (MVR) and he started warfarin (INR target 2.5-3.5). During his admission, he reported chronic headaches. An MRI brain showed a 3.8 by 1.9 cm pituitary macroadenoma extending into the right cavernous sinus. On closer review, he had clinical features consistent with GH excess, with a significantly elevated IGF-1 (140.3nmpol/l (range 8.5-31) and unsuppressed GH during an OGTT, consistent with a diagnosis of acromegaly. He was subsequently discussed in the Pituitary MDT and started Lanreotide to attempt pre-operative tumour shrinkage. Biochemical and radiological response were limited so cabergoline treatment was added with minimal improvement in IGF-1 levels. During this period of medical therapy, multi-disciplinary discussions occurred for peri-operative anticoagulation plans, balancing the risk of pituitary haemorrhage and prosthetic valve thrombosis. Trans-sphenoidal pituitary surgery achieved a good resection and histology confirmed a sparsely granulated somatotroph pituitary adenoma (Ki67 1%), which may explain the poor response to somatostatin analogues. 3/12 post-op IGF-1 is awaited to determine remission. HCM is a known sequelae of acromegaly, contributing significantly to mortality of this disease. Successful control of GH excess is essential to improve cardiac function. Furthermore, patients with HCM are predisposed to IE and mechanical valve replacements requires appropriate anticoagulation. However, balancing the risks and benefits of peri-operative and post-operative anticoagulation in this patient with a mechanical MVR required complex and coordinated multidisciplinary decision making. Despite best collaborative efforts, this gentleman has had a prolonged post-operative inpatient stay due to recurrent epistaxis requiring tranexamic acid and ENT procedures to achieve homeostasis with closely supervised re-warfarinisation protocol.
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Endocrine Abstracts
ISSN 1470-3947 (print) | ISSN 1479-6848 (online)
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