Achy Breaky Heart

Discussion

On chart review, the patient was found to be 28 L positive with a 100 lb increase in her documented weight since admission. On exam, she had clear signs of volume overload with anasarca and JVD. Her hemodynamic instability with vasopressor requirement and echocardiogram findings of severe RV dilatation and flattened interventricular septum were consistent with RV pressure/volume overload.

In this case, despite the RV’s relatively high compliance, acute volume overload led to RV dilatation. The RV function is represented by the points on the descending part of the Frank-Starling curve associated with decreased RV stroke volume and cardiac output. This is due to elevated RV end-diastolic volume and reversal of the ventricular septal gradient as seen by septal flattening. Clinically, this manifests as a shock state.

Although massive pulmonary embolism can yield a similar presentation, the patient had been anticoagulated for several days prior to her decompensation and lower extremity Dopplers were negative. While negative DVT studies cannot definitively rule out the presence of a PE, the development of PEs while on therapeutic anticoagulation is a rare occurrence with a prevalence of 1.2% in a recent study published by Liu et al.,2018. Regardless, the patient was continued on argatroban therapy during the remainder of her hospitalization. Over the next 3 days, >14 L ultrafiltrate were removed and the patient was rapidly weaned off pressors and extubated to room air. Transthoracic echo did not show evidence of valvular vegetations, LV systolic failure or demonstrate LV outflow tract obstruction from a hyperdynamic LV, making these choices less likely.

References

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