Question

A 64-year-old man had calcific mitral and aortic valve disease with stenosis and insufficiency of both valves. Because of the severity of the aortic and mitral regurgitation, he underwent aortic and mitral replacements. Postoperatively, he developed cardiac arrhythmias and signs of acute renal failure, but this cleared and he was improving. On the 20th post-op day, however, he developed acute pulmonary edema, and was transferred to the coronary care unit. He was treated vigorously for pulmonary edema and this cleared in approximately four hours. He was considered stable after 4 days. His serial enzyme studies are shown below.

Lab data:

	Episode	Day1	Day2	Day3	Reference
Total CK	76	84	37	28	50 U/L
%CK-2	0	0	0	0	0%
Total LD	1156	1048	896	936	200 U/L
% LD1	20	32	40	23	25%
% LD2	39	30	35	37	35%
% LD3	19	17	15	17	20%
% LD4	7	7	4	7	10%
% LD5	15	14	6	16	10%
AST	98	122	92	103	50 U/L
AST	0	116	119	137	50 U/L

1. What is going on in this patient?

2. Why are the CK-2 levels never increased?

3. Why is total LD increased? What caused the LD-1>LD-2 flip?

4. Why are AST/ALT increased?

5. What could have caused his acute renal failure? Describe the urine he would have produced during this time?

Answer 1

1) In this patient the post operative he faced cardiac arrhythmias, abnormal renal failure and on the 20th post op day he had suffered with pulmonary edema, these are some complications of the mitral and aortic valve replacement surgery, 2)Creatine kinase 2 enzyme is the increases when there is damage to the myocardial muscle damage , and its normal range is 0 to 6% . 3) Total lactate dehydrogenase increases because the by insertion of prosthetic valves causes chronic hemolysis with results in the increase of total lactate dehydrogenase, and LD1/LD2 ratio flipped occurs in the hemolysis. 4) AST/ALT increases because of the acute liver failure, it may be due to the complications of valve replacement surgery, 5)renal failure is due to clinical complications because glomerular filtration rate is altered , the urine output after the mitral and aortic valve replacment is oliguria is seen.