Severe aortic stenosis and acute coronary syndrome in an elderly patient with idiopathic thrombocytopenic purpura: a therapeutic challenge

S evere valvular aortic stenosis is a commonly encountered disorder in the elderly, and the intervention is indicated when the patient is symptomatic. Transcatheter aortic valve implantation (TAVI) is a safer therapeutic option in symptomatic patients who cannot undergo surgery or who have high, intermediate, or even low surgical risk. Idiopathic thrombocytopenic purpura (ITP) is acquired thrombocytopenia caused by autoantibodies against platelet antigens. Herein, we report an 81-year-old patient, who was diagnosed with primary ITP two years ago, was admitted to the hospital for heart failure with acute coronary syndrome and severe aortic stenosis. We describe our experience in the peri-operative management of the case of coronary and structural intervention in a patient with ITP. An 81-year-old lady presented with shortness of breath and chest pain to the emergency room. Her medical history included hypothyroidism and primary ITP, which was diagnosed two years ago, and she wasn’t taking any medication for it. She had a temperature of 36.5 °C, a pulse rate of 105 beats/min, a respiratory rate of 30 breaths/min, and a blood pressure of 110/60 mmHg. Physical examination revealed pretibial edema with godet leaving on both legs, 3/6 systolic murmur on all cardiac auscultation sites, left-sided S4, tachypnea and bibasilar crackles. Electrocardiogram was consistent with sinus tachycardia and anterior negative T waves. Chest X-ray demonstrated increased cardio-thoracic index and interstitial pulmonary edema with bilateral pleural effusions. Complete blood count demonstrated mild anaemia with a haemoglobin level of 12.2 g/dL. The white blood cell count was normal. Platelet count was 122 × 10/μL. Liver function tests demonstrated elevated levels of aminotransferase (AST) 44 U/L, alanine transaminase (ALT) 62 U/L, and alkaline phosphatase 117 U/L, with slightly elevated levels of total bilirubin at 1.7 mg/dL and direct bilirubin at 0.7 mg/dL. Kidney function tests demonstrated elevated levels of creatinine 1.35 mg/dL. Additional test results included pro-BNP 25 770 pg/mL and high sensitivity troponin T 105 pg/mL. Her transthoracic echocardiogram disclosed severely reduced left ventricular systolic function (ejection fraction (EF) measured as 30%), left ventricular hypertrophy, akinesia in anterior wall and severe aortic stenosis with a mean gradient of 41 mmHg, transaortic velocity of 3.95 m/s and valve area of 0.82 cm (Figure 1). She was treated with intravenous furosemide. Within days, her signs and symptoms of congestion resolved. Acetylsalicylic acid 100 mg and clopidogrel 75 mg were initiated orally. A blood smear showed decreased platelets. She underwent invasive coronary angiography while having a platelet count of 40 × 10/ μL (Figure 2 and 3). There was stenosis of 90% in the proximal left anterior descending artery. We implanted a sirolimus eluting stent into the lesion (Biomime 30 × 16 mm) on 20 May. The patient was continued on steroids for four days (dexamethasone 40 mg q.i.d.). The patient received multiple platelet transfuJournal of Geriatric Cardiology