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4yr

81-year-old female with a history of atrial fibrillation and mild left ventricular dysfunction presents at ED with functional class IV dyspnea (NY Heart Association) which began several weeks ago as mild dyspnea on exertion but has progressed rapidly. She was worked up by a cardiologist a year ago after a brief hospitalization for chest pain and dyspnea but did not follow up in the outpatient setting.

Physical exam, diagnostic, and laboratory findings:

  • BP: 100/63
  • pulse: 108 beats/minute
  • patient appeared sleepy
  • ECG: aFib with intermittent PVC
  • X-ray: cardiomegaly with bilateral pulmonary edema.
  • Creatinine: 3.8 mg/dL
  • eGFR: 16 mL/min/1.73 m2
  • elevated N-type pro-brain natriuretic peptide level

Transthoracic echocardiography revealed an ejection fraction of 33%

How would you manage this patient? What are the next steps to take in the diagnostic workup? How do you and the Heart Team decide whether TAVR is appropriate? What measurements do you look for when making that determination?

  • 4yr
    We do not know the etiology of her LV dysfunction, if potentially reversible diagnostic workup should initially revolve around that: (1) Potentially tachycardia mediated CM from longstanding AF with RVR (hopefully not permanent) -- would proceed to cardio version either after a month of OAC or with TEE. She should be anti coagulated permenently regardless; (2) Possible ischemia: reasonable to do a non invasive test (eg DSE) and cautiously consider cath if signficant ischemia is found, but not otherwise; (3) Valvular: It doesn't say if the echo showed AS (or severe MR), but TAVR would be an appropriate consideration if there is severe AS; (4) Amyloid/infiltrative: reasonable to workup with MRI but best to do in NSR. If none of the above reveal a treatable etiology, she will mostly be managed with neurohormonal Rx.
  • 4yr
    Need to know about the duration of atrial fibrillation. Will stabilize patient with IV diuretics, TEE followed by cardioversion to restore sinus rhythm, when renal parameters are stable RHC/LHC with cautious use of contrast agent
  • 4yr
    I would diurese the patient with IV lasix with close monitoring of renal function along with nephrology consultation. I would evaluate the aortic valve area and the dimensionless index along with valve gradients realizing that gradients may be low due to low flow from cardiomyopathy. I would consider left heart catheterization as well.
  • 4yr
    What if you knew that the atrial fibrillation was permanent? Would that change the planning of the workup?
  • 4yr
    Agree with TEE, then DC cardioversion to NSR. Then LHC/RHC with cautious and judicious dye administration. Reassess renal function in NSR. Formal renal consult. Cardiac MRI.
  • 4yr
    TEE/CV followed BY RHC and possible inotrope therapy based on results to augment diuresis.
  • 4yr
    TEE cardioversion, left and right heart cath
  • 4yr
    Tee cardio version
    Left and tight heart cardiac Cath
  • 4yr
    TEE Cardioversion followed by re eval of GFR prior to Cath.
  • 4yr
    After the cardioversion, dobutami e echo for LFLG AS evaluation
  • 4yr
    TEE, Left and Right heart. Cath
  • 4yr
    TEE and Cardioversion

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