Case Report: Perioperative Management of Hyperthyroid Patient with

Rheumatic Heart Disease who Undergoing Partial Isthmolobectomy

Dian Pritasari Jeger1, Wira Gotera1, I Wayan Wita2
1
Department of Internal Medicine, Faculty of Medicine,
Udayana University/Sanglah General Hospital, Denpasar, Bali, Indonesia
2
Department of Cardiology and Vascular Medicine, Faculty of Medicine, udayana
Univeristy/Sanglah General Hospital, Denpasar, Bali, Indonesia
Email: dhie_gee06@yahoo.com

ABSTRACT

Introduction
Diseases of thyroid gland are frequently seen in clinical practice. Two kinds of problems that
encountered with surgical procedure are anatomically-related (goiter) and functionally-related
(hyperthyroidism, thyroid crisis, and hypothyroidism). Surgical procedure of thyroid diseases
almost electively done since it increasing risk of death due to uncontrolled thyroid problem.
Thyroid disease sharing a common relation with various cardiovascular problem, its influence
under anesthetic agents, and volume distribution during hypermetabolic state.

Case Report
A 55-year-old female presented to our hospital with increasing size of thyroid gland and difficult
of swallowing. Patient had history of hyperthyroidism and rheumatic heart disease (RHD).
Work-up revealed solitary nodule in right thyroid gland, irregular heart sound with rumbling
diastolic murmur in apex grade III/IV. On ECG was found atrial fibrillation with normal
ventricular response (AF NVR). On echocardiography were found dilated right and left atrium,
normal levft ventricle ejection fraction (LVEF) 61%, normal tricuspid annulus plane systolic
excursion (TAPSE) 1.8 cm, severe calcification and stenosis on both of mitral valves which is
characteristic of rheumatic, mild tricuspid regurgitation (TR) with intermediate probability of
pulmonary hypertension (PH), mild-moderate aortic regurgitation (AR), and mild pulmonary
regurgitation (PR). From thyroid ultrasound shows the result multiple solid nodule with calcified
and fine needle aspiration (FNA) biopsy shows benign follicular nodule. Patient then was
planned to undergo partial isthmolobectomy.
Pre-operative preparation includes, stop anticoagulation warfarin five days prior to surgery,
enoxaparin bridging, and continues antifailure therapy. It surely can control patient in NYHA
class I-II and did not exacerbate the AF rate becomes rapid. Lee cardiac risk index was used to
assess the risk of cardiac arrest, sudden death, or any occurence of malignant arrhythmia durante
surgery. Patient put on a class II, 0.9% or low-moderate risk. Clinically and laboratories (free
T4/FT4 and thyroid stimulating hormones/TSH) have to be confimed that patient in a euthyroid
state. Venous thromboembolism risk use Caprini score and yield minimal risk. Other preparation
such as, maintenance systolic blood pressure below 160/90 mmHg, creatinine serum below 7
mg/dl, and hemoglobin level ≥ 10 g/dl have already done. Surgery was done successfully and
post-operative care was closely monitored in intensive care unit (ICU). Patient got experience in
shock but well treated by inotropic support. Soon as the condition was stable, patient move to
ward, start early mobilization, resume anticoagulation since no bleeding detected, and discharge
from hospital.

Discussion
Patient with hyperthyroid and RHD have done the surgery. Due to its significant comorbidities,
we have to check complete pre-operative assessment regarding its clinical condition, thyroid
function, rate control, bleeding risk, and thromboembolism risk. Durante operative patient did
not get any significant hemodynamic problem. Post-operative monitoring was continued to
promote patient in early weaning and ambulation. Regarding its complicated condition, we try to
explore how the patient was managed during perioperative since it has major burden and risk of
hemodynamic instability.

Conclusion
Perioperative assessment on this patient was include evaluation and management of
cardiovascular condition, assessment of bleeding and thrombosis risk, and also evaluation of
thyroid condition. This assessment was aimed to minimalize durante surgery risk, reduce
hospitalization time, and improve long term outcome of the patient.

Keywords: hyperthyroid, rheumatic heart disease, mitral stenosis, isthmolobectomy.