Cardiology>>>>>Adult Congenital Heart Disease and Pregnancy
Question 7#

You are asked to review a 27-year-old female with complex congenital heart disease. She is normally managed at another centre, and limited information is available. She has had a number of operations in early life but has recently been well. Her parents tell you that she has ‘one main pumping chamber’. The history is of deterioration over the last week with fevers and headache. On examination the patient is cyanosed (baseline saturations 85% on room air) and agitated with GCS 13–15. Temperature is 38.4°C, BP is 120/80 mmHg, and heart rate is 100 bpm (regular). A bedside echocardiogram is attempted but the image quality is very poor. The ED team have initiated supportive treatment with high-flow O2 and IV fluids. Blood cultures have been taken. The chest X-ray is suspicious for right basal consolidation.

What would you advise?

A) There is evidence of severe sepsis with compromise; in view of the complex congenital heart disease there is a risk of rapid decompensation and the patient should be moved to the ITU with a view to intubation if the hypoxia deteriorates
B) The patient requires an immediate TOE as she is in a high-risk category for concomitant endocarditis and TTE is non-diagnostic
C) In view of the temperature and reduced GCS she should have an urgent CT head
D) After adequate blood cultures have been taken, initiate empirical antibiotics for pneumonia and move to CCU for supportive treatment; involve the ITU team in case of deterioration; aim for saturations >93% and plan for TOE when stabilized to rule out endocarditis
E) Urgently contact the team she is under to establish the underlying diagnosis; aim for transfer if stabilized with supportive treatment

Correct Answer is C

Comment:

This question emphasizes the risk of cerebral abscess in patients with cyanotic heart disease. Patients with cyanotic heart disease and evidence of sepsis with neurological deterioration require urgent investigation for cerebral abscess. This patient has no evidence of significant haemodynamic compromise. Saturations of 85% may be normal for a patient with univentricular physiology (mixing of systemic and pulmonary blood) and balanced pulmonary and systemic circulations. Clearly it would be important to treat potential chest sepsis and rule out endocarditis.