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Heart Failure & TransplantationProfessor Rounds
Discussion Provoking CasesFebruary 1, 2011
Case 1: HPI
Ms KF is a 57 y/o AAF w/ HTN, NICM (EF < 20%) and pHTN (PAP 70) who presented with progressively worsening dyspnea on exertion and LE edema.
She has had multiple admissions for heart failure exacerbations requiring admission for IV diuretics and has been listed for transplant.
Past History
NICM, (DCM, dx 1989)EF < 20% HTN HLD pHTN (PAP 70) Protein C/S Deficiency and h/o DVT/PE
on anticoagulation PUD and prior GI bleeding
Additional History
Home Medications: ASA 81, Carvedilol 25mg po BID, BiDil 1tab po BID, Lisinopril 20mg po daily, Torsemide 40mg po daily, Coumadin 5mg po qhs.
SH: Married with one son. No h/o tobacco, EtOH or illicit drug use. Worked as a secretary.
FH: No FH of SCD, CAD or CM.
Hospital Course
The patient was brought for an elective Right Heart Catheterization
Right Heart Cath
RA 15 RV 70/20 PA 70/30 PCWP 28
PA sat 66% CO 2.9 CI 1.4 PVR 421 dynes-sec/cm5
Physical Exam post RHC
VS: Afebrile, 170/90, 90, 24, 88%RA Gen: Pleasant AAF, in moderate respiratory
distress, on BIPAP. HEENT: JVD to the angle of the jaw PULM: Wet crackles at the bases, using
accessory muscles to breathe, BIPAP mask in place.
CVS: RRR, No M/R/G, Normal S1,S2, laterally displaced PMI.
Abd: soft, overweight, NTND Extr: warm extremities, 2+ pitting edema
Labs
Na 142 K 4.2 Cl 106 CO2 33 BUN 21 Cr 1.2 7.33/50/125/26
WBC 4.2 Hb 12.1 Plt 166 INR 1.2 Trop 0.027 CKMB 1.4 BNP 1450 LFTs normal
Echo
Echo Results
LV mildly dilated, LVIDd 6.1cm LVEF 20% with severe global HK Normal RV size with moderately
decreased function No significant valvular disease
Clinical Questions/Discussion Points
Evaluation for a heart transplant, specifically in hypercoagulable patients?
Evaluation for transplant in patients with severe pulmonary hypertension and high PVR?
Pharmacologic therapy for patients with high PVR?
Contraindications for transplant?
Case 2: HPI
Ms DM is a 61 y/o female with CAD, ICM with <20% s/p LVAD (HeartWare 9mos PTA) who presented for heart transplantation.
Additional History
PMH HTN HLD DMII ICM, EF <20% CKD (baseline Cr
1.3) s/p HeartWare
LVAD placement 9 mos PTA
Home Medications: ASA 81, Carvedilol 6.25 BID, Lisinopril 20, Spironolactone 25, Coumadin 5
SH: Lives with her husband, h/o tobacco use, quit 5 years ago, No EtOH or illicit drugs.
Post-Transplant Complications
Course was complicated by vasodilatory shock and cardiogenic shock in the setting of severe LV and RV dysfunction post-operatively.
Physical Exam and Labs
Intubated and sedated 7.4/39/103/24 PA sat 53% Lactate 4.8 WBC 10.6, Hb 11.4 Na 140, K 4.6 Cl 109, CO2 21 BUN/Cr 21/1.4 Trop 72, CKMB 74 Cyclosporine level
61,LDH 365 C1 esterase inhibitor Ag
high at 46
Echo
Post-transplant Course
Course was further complicated by tachyarrhythmias.
EKG
EKG
Clinical Questions/Discussion Points
Common complications post transplant? Etiologies for acute LV dysfunction post
transplant? Presentation of acute rejection post
transplant? Management of acute rejection post
transplant? Common arrhythmias post transplant?