Question

A 35-year-old woman presents with fatigue and yellowish coloration of her eyes and skin that started several weeks after noneventful implantation of the prosthetic mechanical heart valve. Physical examination reveals the presence of regurgitant murmur and subicterus. Laboratory results are: hemoglobin 7.0 g/dL; reticulocytes 21%; white blood cells 11,500/µL; platelets 80,000/µL; and undetected levels of haptoglobin. In lactate dehydrogenase, the direct and indirect bilirubin levels are all elevated (3,100 U/L, 2.1 and 1.2 mg/dL, respectively). Peripheral blood smear shows burr and helmet cells (schistocytes) and polychromasia. Both direct and indirect Coombs' tests are negative. You suspect microangiopathic hemolytic anemia.

What is the next step in management??

1. Hemoglobin electrophoresis
2 Glucose-6-phosphate dehydrogenase deficiency
3 Echocardiography
4 Hepatitis B panel
5 Direct agglutination test

Answer 1

The next step in managing a patient suspect of microangiopathic hemolytic anemia after mechanical heart valve implantation is to perform an echocardiography to evaluate the valve function and look for the source of hemolysis.

Step-by-step explanation:

The patient's presentation indicates microangiopathic hemolytic anemia (MAHA), which could be related to her mechanical heart valve. The presence of schistocytes (burr and helmet cells) on the peripheral blood smear, the elevated lactate dehydrogenase (LDH), and the decreased level of haptoglobin are all suggestive of hemolysis, with the latter indicating the destruction of RBCs. Considering that both direct and indirect Coombs' tests are negative, an immune-mediated process is unlikely. Given the recent history of prosthetic mechanical heart valve implantation and the clinical signs of MAHA, the next step in management would be to perform an echocardiography (Option 3). This would help assess valve function, the presence of any vegetations or thrombi, and any other potential cardiac sources of hemolysis.