[HSF] TVR with liver failure

[Michael Firstenberg]

I know we talk about this frequently - and the key is congestion vs
cirrhosis and usually we see TR....but

I am seeing a 51 woman tomorrow who while getting worked up for a liver
transplant was found to have tricuspid prosthetic valve stenosis (dont know
anything about when/where/type/etc but probably remote IVDA).

TV gradient of 14mmHg, stenosis, with enlarged RA on echo.
min CAD on cath from 2006
Recent admission for liver encephapathy (Ammonia 85!)
Hep C
EGD recently shows mild varices (and gastric ulcers)

Creatinine: 1.3-2.2
Bili 2.5/1.0
Albumin: 2.7
Alk Phos: 62
ALT/AST: 107/188 (give or take over multiple tests)
INR: 1.4 (was 2.2, but I think she was on Coumadin for afib/flutter)

ANA positive
CA 19-9 120 (normal 0-35, whatever that means??)
No liver bx that I can find
CT scan: "   The liver is nodular with hypertrophy of the caudate and
widening of
    the fissure consistent with cirrhosis. The spleen is enlarged and
    there are multiple splenic varices and perigastric varices. " (from nov
07)

MRI: "Cirrhosis, splenomegaly and extensive varices, consistent with
    development of portal hypertension"


my thoughts are very high risk for a toe nail clipping......let alone a
re-op TVR
(I could put in a mechanical valve to help out our friendly liver transplant
surgeons)


-michael