A 36-year-old male patient with a 10-year history of chronic dilated cardiomyopathy, chronic renal insufficiency, type 2 diabetes mellitus (T2DM), and gout was admitted to our hospital for further management of his heart failure. The patient had been experiencing worsening heart failure symptoms despite optimal medical therapy, requiring repeated hospitalizations at a local hospital. Three years prior to the current admission, he had undergone a preoperative echocardiographic assessment for heart transplantation at our hospital's cardiac surgery department, which revealed an enlarged heart, severe mitral regurgitation, moderate tricuspid regurgitation, moderate pulmonary hypertension, severely reduced left ventricular systolic function with a left ventricular ejection fraction (LVEF) of 27%, reduced right ventricular systolic function with a tricuspid annular plane systolic excursion (TAPSE) of 17 mm, and fractional area change (FAC) of 19%. While awaiting heart transplantation, he continued his previous heart failure treatment.
One month before the current admission, the patient experienced sudden syncope without obvious triggers. A cardiac ultrasound at the local hospital showed an LVEF of 25% and low blood pressure (details unknown). A chest CT scan revealed a pulmonary infection. After receiving appropriate treatment, the patient's symptoms slightly improved, with a daily urine output of approximately 2000 ml. For further treatment, he was transferred to our hospital's emergency department and admitted to the cardiac intensive care unit. On admission, the physical examination revealed clear consciousness, chronic illness appearance, no abnormalities in the thorax, symmetrical respiratory movements on both sides, moist rales audible in both lower lungs, enlarged heart borders, regular heart rhythm, systolic murmurs audible at the mitral and tricuspid valves, and edema in all four limbs. A cardiac ultrasound showed massive mitral regurgitation; massive tricuspid regurgitation with a maximum velocity (Vmax) of 4.1 m/s and a pressure gradient (PG) of 68 mmHg, indicating severe pulmonary hypertension; left ventricular (LV) dimension of 80 mm; LVEF of 26%; and FAC of 20%.
The patient received relevant treatments and underwent intra-aortic balloon pump (IABP) support on the second day of admission. Although the patient had indications for heart transplantation, his current heart failure was severe, and he could not continue to wait for transplantation. Due to severe heart failure, on the fourth day after admission, he underwent "ventricular assist device implantation, tricuspid valve repair, and temporary pacemaker placement on the heart surface" under general anesthesia with cardiopulmonary bypass in the emergency department. The surgery was successful, and the patient was transferred back to the ICU. Postoperatively, the patient received invasive mechanical ventilation, circulatory support, inotropic agents, diuretics, nitric oxide inhalation, anti-infection, anticoagulation, organ function support, and nutritional support. The patient had poor right heart function, pulmonary hypertension, severe pulmonary infection, and respiratory failure, leading to failure in weaning from the ventilator. He underwent tracheostomy, anti-infection treatment, postural drainage, and bronchoscopy, and was gradually weaned from the ventilator. During the course of the disease, the patient had poor right heart function, liver and kidney dysfunction, and complications such as bloodstream bacterial and fungal infections, intestinal flora imbalance, and acute gout attacks, which were treated accordingly. The patient's organ functions gradually improved, and the infections were gradually controlled, with stable circulation. However, due to abdominal distension and poor intestinal peristalsis, it was difficult to establish enteral nutrition, and full enteral nutrition could not be achieved. On the 23rd day after surgery, the patient suddenly developed bloody fluid and melena in the gastrointestinal decompression, with a volume of about 200 ml. Anticoagulant drugs were immediately discontinued, and treatments such as proton pump inhibitors (PPIs), somatostatin, and other hemostatic medications were administered. Subsequently, the patient passed about 300 ml of melena. Bedside gastrointestinal endoscopy revealed a suspected blood clot measuring approximately 4.5 cm × 1.5 cm in the ascending colon near the hepatic flexure, with a vaguely visible ulcerated base. No obvious active bleeding was observed at the base. The endoscopic diagnosis was multiple colonic ulcers with bleeding. The larger ulcer was closed with metal titanium clips, and relevant drug treatments were continued. However, the patient still experienced repeated episodes of melena, with hemoglobin levels fluctuating between 62–85 g/L. Hemostatic treatments and repeated blood transfusions were administered, with a total of 8.5 units of blood transfused during this period. Ten days later, the patient's bleeding suddenly increased, with melena volumes of 300–500 ml per episode and increased frequency. At the same time, the patient had tachycardia, hypotension, and a progressive decrease in hemoglobin to a minimum of 52 g/L. Hemostatic drugs, 4.5 units of red blood cell suspension, 600 ml of plasma, and anti-shock treatments were administered. An emergency endoscopy was performed, revealing colonic ulcers with bleeding. Circular or longitudinal ulcers measuring 2–4 cm were observed from the beginning of the ascending colon to the transverse colon. Titanium clips were again applied to the larger ulcers and areas of active oozing. An abdominal angiography was performed, showing no abnormalities in the intestinal blood vessels.
In the following week, the patient still had intermittent melena, and the hemoglobin level progressively decreased, requiring daily blood transfusions to maintain circulation. During the bleeding period, the patient was kept nil by mouth, and total parenteral nutrition (TPN) was provided for nutritional support. Two additional endoscopic explorations and hemostatic treatments were performed, but the patient continued to have melena, with gradually increasing volumes. A total of 18.5 units of red blood cell suspension and 600 ml of fresh frozen plasma were transfused. A multidisciplinary consultation was conducted, and after repeated assessments by the gastrointestinal surgery department, surgical intervention was considered indicated. Twenty days after the patient's first gastrointestinal bleeding episode, a "right hemicolectomy + intraoperative endoscopic exploration" was performed. Intraoperative findings: No bleeding was observed in the small intestine. An irregular ulcer with a yellow-white base and surrounding mucosal congestion and edema was found 20 cm proximal to the ileocecal valve. It was marked with a silk suture for localization. The colon, rectum, and ileocecal valve: The ileocecal valve appeared lip-shaped, with good opening and closing. Irregular ulcers with rough bases and 4 residual titanium clips were observed from the beginning of the ascending colon to the transverse colon near the hepatic flexure. The distal end of the resected intestine was located in the middle of the transverse colon, and the proximal end was 25 cm from the ileocecal valve. An end-to-side anastomosis was performed using a 25 mm stapler.
After the surgery, the resected intestinal segment, measuring approximately 55 cm in length, was examined, revealing multiple ulcers with surrounding mucosal congestion and edema. The surgery was successful, and the patient was transferred back to the ICU for continued monitoring and treatment. The patient no longer experienced melena but developed abdominal distension and high tension. A bedside abdominal radiograph indicated significant intestinal gas distension (insert image). Adjuvant medications for gas evacuation were administered, and a rectal tube was placed for decompression. The patient's intestinal gas distension gradually improved, and enteral nutrition was resumed on the 5th day after surgery. Subsequently, the patient's general condition was fair, with stable vital signs. He was transferred to a general ward for continued treatment and was eventually discharged successfully. During the bleeding process, low-dose warfarin anticoagulation was administered, and coagulation, thromboelastography (TEG), and thrombosis parameters were monitored. The patient was in a hypercoagulable state, and the international normalized ratio (INR) was maintained within the range of 1-1.5 until the day of the surgical operation. Anticoagulation was restarted on the first postoperative day, with warfarin bridged with low-molecular-weight heparin to maintain the INR within the range of 1.2–1.8. The patient's INR was gradually extended to the range of 1.8–2.2 when the condition stabilized and at the time of discharge.