A 34-year-old male presented to the emergency room with melena, gum bleeding, and nosebleeds for 2 hours. He has a history of severe mitral regurgitation status post mechanical mitral valve replacement in 2017, with subsequent hyperthyroidism. At presentation, he was found to have thyroid storm, acute heart failure exacerbation, anemia, prolonged INR, and suspected infective endocarditis. He was treated aggressively with antibiotics, anticoagulation reversal, heart failure medications, anti-thyroid drugs, and supportive care. His condition gradually improved with normalization of thyroid function and hematologic parameters. Further cardiac evaluation was planned as an outpatient after stabilization.

1. CASE I
TN AH (61 th)

2. RiwayatPenyakit Sekarang
Keluhan Utama:
Cepat lelah (ngos-ngosanpada saat aktivitas)
Dada terasa tidak nyaman, cepat lelah dan
rasa agak berdebar sejak 1 tahun lalu
Tidur dengan 1 bantal, pasien menyangkal
terbangun pada malam hariakibat sesak
Keluhan cepat lelah masih dirasakan walau
sesudah CABG

3. RiwayatPenyakit Dahulu
2/2/2016
Kontrol Poli:
Cepat lelah
pada saataktivitas
19/1/2016
CAD3VD
Anjuran:
-. CABG
-. Staging PCI
17/10/2016
Rawat untuk dilakukan CABG:
Nyeri dada
pada saataktivitas
Direncanakan CABG
Terapi:
-. Ramipril 1x5 mg
-. Bisoprolol 1x5 mg
-. Simvastatin 1x20 mg
-. Aspilet 1x80 mg
Terjadwal operasi
17/10/2016
3/10/2016
Echo pre CABG
LVEF = 79%
Global normokinetic
RV normal
DisfungsiLV diastolik, relaksasiabnormal

4. PemeriksaanPenunjang
Cath19/1/2016
RSUP Fatmawati
LM:normal
LAD:Total
oklusiproksimal
D1: subtotaloklusi
Ostial
LCX: Total oklusisetelah OM1
Distal mendapat aliran dari bridging collateral

5. PemeriksaanPenunjang
Echo 3-10-2016
Dimensi ruang jantung dalam batas normal
LVH –
Kontraktilitas LV normal (EF 79%)
Kontraktilitas RV normal (TAPSE 2.2 cm)
Analisa segmental: global normokinetik
Katup aorta: 3 cuspis, kalsifikasi -, AR –
Katup mitral: dalam batas normal
Katup trikuspid: dalam batas normal
Katup pulmonal: Dalam batas normal, PVAcct 107 ms
Doppler E/A<1, DT 194 ms, E/e’ 8 cm/s
AoVmax 1 m/s
LA volume Index 15 ml/m2
FungsiLV sistolik normal EF 79%
Global normokinetik
DisfungsiLV diastolik, relaksasiabnormal
Kontraktilias RV normal
Katup-katup normal

6. TindakanCABG(17/20/2018)
Tindakan pembedahan:
CABG x3:
-. LIMA – LAD
-. SVG-LCx distal
-. SVG-RCA distal
Penemuan:
Jantung ukuran normal, kontraktilitas cukup
SVG tungkaikanan dan kiri baik
LIMA bak
Stenosis di LAD, LCX, RCA

7. Followup paskaoperasi
S: Terintubasi
O = KU: CM
TD 99/64 mmHg, nadi 110x/menit, rr 24x/menit
Tanpa inotropik/ vasopresor
18/10/2018
19/10/2018
S: Ekstubasi- Tidak ada keluhan
O = KU: CM
TD 107/64 mmHg, nadi 102x/menit, rr 22x/menit
Start Bisoprolol 1x2.5mg; → 5 mg
ramipril 1x2.5 mg
furosemid 2x2 ampul iv
S: Mobilisasi mulai dilakukan, masihcepat lelah
O = KU: CM
TD 109/65 mmHg, nadi 99x/menit, rr 24x/menit
Bisoprolol 1x10 mg
Ramipril 1x5 mg
Furosemid 3x2 ampul iv
20/10/2018

8. Followup paskaoperasi
Ronki (-)
nadi 99x/menit → Walau sudah diberikan beta blocker,
Furosemide, dan ACE i
20/10/2018
CekMarker Tiroid
TSH 0.07
FT4 1.22
T3 0.53
Hipertiroid subklinis
Terapi : Metimazole
Kontrol poli
21/7/2019 Keluhan ngos-ngosan masih ada
TD: 142/83; nadi 94x/menit; rr 24x/menit
20/8/2019
Keluhan ngos-ngosan sudah tidak ada
TD: 123/83; nadi 73x/menit; rr 18x/menit
TSH 1.51
FT4 0.99

9. Followup paskaoperasi
8-8-2020
DOE: Tidak ada
TD : 120/72; nadi70x/menit
Echo evaluasi:
echo : EF 63 %, TAPSE 2, globalnormokinetik E/A < 1

10. • A 34 y.o male came to ER on 12 Feb 2020
Case II
Chief
complaint
Melena and gum bleeding since 4 days,
nosebleeds since 2 hours
1 week before
• Fever, palpitations, increased appetite, and heavy
sweating
• Fatigue, progressive DOE, OP, PND
• Cough progressed to more productive yellowish sputum
• Distended stomach, swollen legs, urine <<

11. Previous Medical History
10 Agt ‘17
Patient with
Severe degenerative
MR Fc II ec and stretch
PFO
Admitted for
MVR withmechanical
prosthetic On-Xvalve
and PFO closure
pre-Op: BP 141/67, HR
117x
ICU
BP 130/66
HR 120
Initial
heparin
GP
BP 115/58, HR98
INR1.49
Start Warfarin 1x1 mg
Bisoprolol1x5mg
Captopril 3x6,25mg
PTU 3x200mg
IWB
BP 133/70,
HR 108
Warfarin
initiation→
INR 10, SAH
TSH < 0.05, FT4 3.1
Stop Warfarin, Vit K
IV, PTU
10-11 Agt ‘17 11-16 Agt ‘17 16-18 Agt ‘17

12. Riwayat Penyakit Dahulu
August 2017
Outpatient clinic
Simarc 1x 2 mg → INR 3.34 → Simarc 1x 1
mg
PTU 3x 100 mg
Bisoprolol 1 x 5 mg
Ramipril 1x 5 mg
Lasix 1x 40 mg
November 2017

13. Riwayat Penyakit Dahulu
2018 2020
Loss-to-follow up
Visited ER twice
Agitation,
palpitation
•Discharged against
medical advice
Prolong INR, nosebleed,
gum bleeding
•“ran away” w/o
therapy
Jan 2018 Jan 2020
ContinuedWarfarin1x2 mg irregularly
anti heart failure, anti thyroid discontinued

14. • Agitation, anxious
• BP 142/62 mmHg
• HR 120x/min
• RR 24x/min
• Temp 38.2o C
Physical Examination at ER
(12.02.2020)
Eyes : Proptosis (+)
Anemic, subicteric
Neck: JVP distension(+)
Diffuse Struma5x5 cm
Abdomen: Ascites(+)
Hepar ballotement (+)
Cardiac : S1 N, S2 mechanic sound
Lung : Rhales +/+ 1/3 basal
Lower extremities: Pitting edema(+)
Hands : Tremor (+)

15. • Sinus tachycardia
• Rate 121x/min,
• Normal Axis and P
wave
• Pattern of incomplete
RBBB and LVH
Electrocardiogram at ER

16. • CTR 70%
• Normal aortic and pulmonal
segment
• Flattening of cardiac waist(+)
• congestion (+)
• Infiltrate (+) parahilar dextra.
Chest X-ray at ER

17. Laboratorium at ER
Hb(g/dL) 10.6
Ht (%) 32.1
Leuco (/uL) 6890
Segment 69.6%
Trom (/uL) 129.000
Ureum(mg/dL)/ Cr (mg/dL) 25.3 / 0.46
eGFR 157
RBG (mg/dL) 122
Na (mmol/L) 134
K (mmol/L) 3.7
Cl (mmol/L) 100
Ca T (mmol/L) 1.89
Mg (mg/dL) 1.5
TSH (ref 0.27-4.2 uIU/mL) 0.116
FT4 (ref 0.93-1.7 mg/dL) >7.77
INR 15.83
PT 169.4
CRP (mg/L) 5
LED (ng/mL) 31
PCT 0.09
SGOT(0-41 U/L) 39
SGPT (0-50 U/L) 60
Total Proteing/dL
(ref 6.6-8.7)
7.9
Albumin (ref 3.5-5.2 g/dL) 2.7
Globulin (ref 3.1-3.5 g/dL) 5.2
Total Bil (0-1.4 mg/dL) 4.69
Direct Bil (0-0.3 mg/dL) 3.38
Indirect Bil (0-0.75 mg/dL) 1.31
Lactate (mmol/L) 1.8

18. Burch-
Wartofksy Index
• Score 75
• Highly
suggestive of
thyroid storm

19. Gastrointestinal bleeding ec prolonged INR
Thyroid storm
ADHF ec Thyroid storm in Severe MR Post Mechanical prosthetic MVR (2017)
Anemia, Thrombocytopenia, Hypoalbuminemia
Hypomagnesemia, Hypocalcemia
CAP
IE couldn’t be ruled out→ perform blood culture for IE
Diagnosis

20. Initial Treatment at ER
• Rehydration 1-2 cc/kg in 10 min→
1500 cc/24 hrs
• Vitamin K 1 mg IV + FFP 2 unit
• Pantoprazole bolus 80 mg IV
• then drip 8 mg/jam IV
• Sucralfate 4x1 C PO
• Paracetamol 4x 500 mg IV
• PTU loading dose 600 mg PO
• → 4x200 mg
• Dexamethasone 3x 10 mg IV
• Propranolol 2x 10 mg PO
• Ceftriaxone 1 x2 gr IV
• Correction for electrolyte imbalance :
• MgSO4 2 gram
• Ca gluconas 1 gram
• Furosemide 40 mg Extra IV

21. ICVCU
14-18 Feb 2020
S: Fever,
dyspnea,cough
(+)
O : CM
Agitation (-)
BP 102/56
HR 101-108x
Rh +/+ 1/3 basal
T 37.6 C
Problems Plan
Prolonged INR
GI tract Bleeding
Re-check INR → 1.88
Re-check Fecal occult blood test → (+) →continue
Pantoprazole drip
Thyroid storm ->
hyperthyroid
Propranolol switched to concor 1x 2.5 mg, PTU
4x200 mg, Dexametason3x10 mg, paracetamol
4x500 mg IV
CongestiveHF Furosemide 3x20 mg IV
Electrolyte imbalance Electrolyte correction
Suspect IE Followup blood culture, TTE full diagnostic
CAP Empirical AB ceftriaxone 1x 2 gr
Follow Up

22. IWM
18-21 Feb
2020
S:
dyspneau↓
O:
BP 100/62
HR 80-105
Rhales +/+
decreased
Masalah Tatalaksana
GI tract bleeding Re-check fecal occult blood test → (-)
Pantoprazole ↓2x 40 mg IV
Post mechanical MVR Re-Start Simarc 1x 2 mg
Hyperthyroid Dexamethasonstop,othertherapy
continue
CongestiveHF Lasix 3x 20 mg IV
Electrolyte imbalance Electrolyte correction
Suspect IE 1st Blood culture (-)
Repeat Blood cultureafterwash out
antibiotic
TTE
TTE 19/2/2020
• EccentricLVH, LVEF 64%
• TAPSE 1.7cm
• Prostheticmitral valve
gradient 8-12mmHg
• MVA VTI 1.9 cm2
• Minimal Pericardial
Effusion at posterior LV
• Continue with TEE

23. GP2
21-25 Feb 2020
S: OP(-), cough(+)
O: rhales +/+,
edema+/+ minimal
Pre-discharge :
S : Dyspneau (-)
TD 115/52, nadi 80-
90x
rhales -/-
Edema -/-
Problems Plan
Hyperthyroid Re-check TSH FT4 → TSH 0.019, FT4 0.35
PTU ↓ 2x 100 mg
CongestiveHF Lasix ↑ 5 mg/jam
→ 10 mg/jam IV → improvement in congestion
→ Switch to intermittentoral furosemide
Ramipril 1x2.5 mg and Spironolacton1x 25 mg
Hypoalbuminemia Check for microalbuminuria→ negative
Suspect IE 2nd Blood culture→ negatif
→ Rejected IE
Suspect Prostheticvalve
dysfunction
TEE → stopped halfwaybecause patientscoughed
and anxious

24. Therapy at discharge
• Furosemide 1x40 mg
• Ramipril 1x2.5mg
• Metimazole 10 mg
• Bisoprolol 1 x 2,5 mg
• Spironolactone1x25 mg
• Warfarin 1x2 mg
• Sucralfate3x 1 C
• Cefixime 2x200mg
Follow Up after
discharge
(2 March 2020)
No complaint ofdyspnea,palpitation,bleeding.INR 1.2
Schedule for repeat TEE, check for INR & thyroid function regularly
Conditionnow:still continuingall medication, delayed outpatient
schedule because of Cov - 19 pandemic

25. Item 12/2 14/2 15/2 16/2 17/2 18/2 19/2 20/2 21/2 22/2 23/2
Hb(g/dL) 10.6 9.7 9.1 9.2 9.2 9.8 11.1
Ht (%) 32.1 29.6 26.6 27 26.8 28.3 33.8
Leuco (/uL) 6890 1950 3830 6220 9820 13760 12050
Segment 69.6% 84.2%
Throm (/uL) 129.000 87.000 61.000 59.000 69.000 110.000 175.000
Ur (mg/dL)/ Cr (mg/dL) 25.3 / 0.46
Na (mmol/L) 134 134 132 134 137 135
K (mmol/L) 3.7 3.8 2.7 3.6 3.7 3.6
Cl (mmol/L) 100 96 97 100 102 89
Ca T (mmol/L) 1.89 2.11 1.8 1.84 1.92
Mg (mg/dL) 1.5 2.1 1.4 1.7
TSH (ref 0.27-4.2 uIU/mL) 0.116 0.019
FT4 (ref 0.93-1.7 mg/dL) >7.77 0.35
INR 15.83 1.88 1.66 1.82 1.73 1.75
Albumin (ref 3.5-5.2 g/dL) 2.7 2.6