Intestinal Ischemia Following Cardiac Surgery: An Unusual Clinical Presentation

1. Abstract Mesenteric ischemia is a dreadful complication with a high mortality rate. Early diagnosis and management is mandatory to improve prognosis. We report a 72-year-old woman who has undergone a bioprosthetic aortic valve replacement. She presented an abdominal pain associated to an occlusive syndrome. Angio-CT scan has found initially a functional bowel obstruction without mesenteric ischemia. 3 days later, she became febrile and her abdominal distension increase. The fellow up Angio-CT scan revealed a pneumoperitoneum suggestive of a bowel perforation. A diagnostic laparotomy had found two ischemic ileal perforations. The ischemic origin was confirmed by histo-pathological examination. She underwent segmental ileal resection with end-to-end anastomosis. The follow up was favourable. 2. Introduction Gastrointestinal complications after cardiac surgery are rare, but are associated with significant morbidity and mortality witch varies between 13,9 and 63% [1-3]. Mesenteric ischemia accounts for approximately 14% of post cardiac surgery gastrointestinal complications with a mortality rate of 50-100% in some studies [3]. Early diagnosis allows timely management to improve patient prognosis. However, definitive diagnosis remains difficult in most cases because of the variety and non-specificity of clinical presentations. We presented a case of a non-specific clinical presentation of a postischemic bowel perforation, revealed by an occlusive syndrome after biological aortic valve replacement. She was successfully undergone a surgical resection of the ischemic bowel. 3. Observation A 72-year-old woman was admitted to our department for a severe symptomatic aortic valve stenosis. Her medical history included diabetes mellitus, hypertension, osteoporosis and a primary thrombocytopenia. The left ventricular ejection fraction was normal (63%) and coronarography revealed atherosclerosis without significant stenosis. She underwent a bioprosthetic aortic valve replacement. The cardiopulmonary bypass (CPB) and cardiac ischemic times were 84 and 55 minutes, respectively. She was extubated 4 hours after surgery and unfractionated heparin was started at 6th hours, replaced by a low molecular weight heparin after drains removal. At postoperaive day (POD) 5, she presented a diffuse abdominal pain associated with an abdominal distension. The clinical examination was unremarkable. Laboratory parameters revealed elevated white blood cell (WBC) count (16,000/μl) and C-reactive protein (CRP) level (27 mg/dl), but a normal lactate rate (1.2 mmol/L). Abdominal angio-CT scan was performed, it showed a functional bowel obstruction with a normal mesenteric vascularization (Figure 1). The general surgery recommended a simple observation. Three days after (at POD 8) she presented fever (38°C) and an increase of abdominal distension with persistent of abdominal pain. At the examination right lower quadrant tenderness developed. Laboratory exams revealed persistent of a high WBC and CRP with a normal lactate. A control angio-CT scan found a significant pneumoperitoneum with air bubbles in bowel wall, suggestive of