Date post: | 16-Jul-2015 |
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ACD: An interesting case
of dyspnea4/9/2015
Rahul Ravilla
PGY3
Simulated Case presentation
55 year old woman presents with shortness of breath.
Past medical history
VSD repair at age of 4
Liver cirrhosis
DM type 2
Chronic back pain
Neuropathy
Past surgical history
Bilateral Knee surgery
Bilateral shoulder surgery
Hysterectomy
Bilateral oophorectomy
Review of systems
Abdominal pain- Right upper quadrant
Lower extremity pain
Orthopnea
Lower extremity swelling
Shortness of breath/ Dyspnea on exertion- NYHA Stage 4.
Physical examination
BP 110/64 | Pulse 80 | Temp(Src) 98.4 °F (36.8 °C) (Oral) | Resp 22 | Ht 5' 4" (1.6 m) | Wt 190 lb
(86 kg) | BMI 33 kg/m2 | SpO2 95% on RA
Gen: overweight white female appears stated age, slightly jaundice, AAOx3, NAD
HEENT: normocephalic, atraumatic, dry mucus membranes, no scleral icterus, PERRLA, EOMI
Neck: no LAD, huge venous pulsations in the right neck
Lungs: CTAB
Heart: RRR, S1, S2, Harsh systolic ejection murmur at RUSB, radiating to carotids, notable
carotid pulsations (pulsating 1-2 inches from sides of neck)
Abd: obese, non-tender, mildly distended, non-tense, NBS
Ext: Presacral edema and 4+ peripheral edema to thighs
Neuro: intact
Skin: no rashes or lesions
Laboratory work up
CBC- 5.0/8.0/90
BMP- 128/3.6/92/ 28/42/0.9 Ca- 9.1 Po4- 4.4, Mg- 1.6, Gluc-157
BNP- 200
Albumin- 3.3
T bil- 2.3, D bil- 0.6, AST-90, ALT- 20, Alk phos- 110, GGT- 80, LD- 150
INR- 1.28
Abg- 7.46/38/80 on room air
What would you do at this point?
PT gets worked up at OSH then sent to you.
Work up at OSH
Transthoracic echocardiogram
CT CHEST
Treated for CAP
Medications- Furosemide 40mg PO, Spironolactone, HCTZ, Propranolol,
Sertraline, Oxycodone.
Work up at UAMS
Transthoracic echo- Normal EF of 60%, No AS, No MR, Ventricular septum
flattening, Dilated RA and RV, normal tricuspid valve with leaflet separation,
Moderate to Severe TR.
Bubble study- There was a mild right-to-left shunt, in the baseline state( few
bubbles appear in the left heart at the 10th cardiac cycle). This is consistent
with an extracardiac shunt such as a pulmonary AVM.
ECG- next slide
CT Chest/Abdomen
What is the diagnosis?
What test will confirm?
Right heart catheterization
LEFT HEART HEMODYNAMICS (mmHg):
AO : 108/46/54
LV Systolic : 104
LVEDP : 24 (5-12mm)
RIGHT HEART HEMODYNAMICS (mmHg):
Right atrium - 38/14, Mean 21; O2 sat 58% (0-8mm)
Right ventricle - 46/15; Mean 19; O2 sat 55.1% (15-30mm/3-12mm)
Pulmonary artery - 44/26; Mean 36; O2 sat 52.6%
PCWP - 25/33; Mean 27; O2 sat 92.3% ( 3-15mm)
Fick Cardiac output - 4.18 L/min (4-6.5 L/min)
Cardiac index - 2.22 L/min/m2 (2.6-4.6)
How would you interpret that right heart
cath? What is causing the right sided
increased pressure?
Probably the best place to start when there are elevated pressures is the left
ventricle end diastolic pressure. LVEDP normal ranges are 5-12mmHg, and the
value of 24 in this case is markedly abnormal. Abnormally high LVEDP indicates
presence of left heart failure which is the cause of right heart and wedge increased
pressures. In this case, the severe tricuspic regurgitation is worsening the right
heart failure symptoms and causing the huge neck vein pulsations.
So what is the treatment?
How do you treat this patient with left heart
failure and tricuspid regurgitation?
Lots of loop diuretics. Patients like these may get 10-20 liters of diuresis
prior to significant improvement.
If left heart failure is stretching apart the RV and causing tricuspid regurg,
sometimes adequate diuresis can shrink the heart down and significantly
improve the regurgitation.
Tricuspid regurgitation Causes Functional TR- Valve anatomy is normal. Caused by dilation of RA and RV dilating the TR annulus ~ 70%
from causes of elevated pulmonary HTN.
Left-sided heart failure.
Mitral stenosis or regurgitation.
Primary pulmonary disease – cor pulmonale, pulmonary embolism, pulmonary hypertension of any cause.
Left to right shunt – atrial septal defect, ventricular septal defect, anomalous pulmonary venous return.
Eisenmenger syndrome.
Stenosis of the pulmonic valve or pulmonary artery.
Hyperthyroidism.
26% have normal pulmonary artery pressure
<2% have Atrial fibrillation
TR Causes: Intrinsic Valve defects
Direct valve injury
Chest trauma
Infective endocarditis
Ebstein's anomaly
Rheumatic fever
Carcinoid syndrome
IHD of RV damaging papillary musculature
Marantic endocarditis in SLE, RA
Drug induced like Fenfluramine, Phentermine
Indications for surgery For patients undergoing left-sided valve surgery:
For patients with severe tricuspid regurgitation (TR) who are undergoing left-sided valve surgery, tricuspid valve surgery is recommended,
For patients with mild, moderate, or greater functional TR who are undergoing left-sided valve surgery, concomitant tricuspid valve repair is suggested if there is either 1) tricuspid annular dilation (diameter on transthoracic echocardiogram of >40 mm or 21 mm/m2 indexed for body surface area or intraoperative diameter>70 mm) or 2) prior evidence of right heart failure.
Isolated tricuspid surgery –
Tricuspid valve surgery is suggested (weak recommendation) for patients with severe primary TR with symptoms unresponsive to medical therapy, preferably before the onset of significant right ventricular dysfunction, Patients with severe congestive hepatopathy may benefit from surgery to prevent cirrhosis.
The 2012 ESC valvular guidelines include a strong recommendation for tricuspid valve surgery in patients with symptomatic severe isolated primary TR without severe right ventricular dysfunction.
The role of tricuspid valve surgery in patients with severe TR with no or minimal symptoms is uncertain. Surgical treatment of moderate to severe TR may be helpful in patients undergoing pericardiectomy for constrictive pericarditis, although supporting data are limited.
References
Long-term prognosis of isolated significant tricuspid regurgitation. Lee JW,
Song JM, Park JP, Lee JW, Kang DH, Song JK. Circ J. 2010;74(2):375.
2014 AHA/ACC guideline for the management of patients with valvular heart
disease: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. Nishimura RA et al J Am Coll
Cardiol. 2014;63(22):e57