15th Annual Scientific Meeting - Heart Failure Society of America

Sept. 20
Tuesday
AM
CASE DISCUSSION
Tuesday, September 20
10:30 AM-NOON
Ballroom A
CASE DISCUSSION
Sept. 20
Tuesday
AM
TuesdAY
Case Presenters: Akshay M. Desai, Boston, MA
James C. Fang, Cleveland, OH
Panelists:
Roy M. John, Boston, MA
Alan T. Kono, Lebanon, NH
Rohinton J. Morris, Abington, PA
J. Herbert Patterson, Chapel Hill, NC
Kismet D. Rasmusson, Murray, UT
10:30 Case 1: A 61 yo diabetic man with a longstanding history of
atrial fib presents with a 6 mo history of progressive lower
extremity edema and exertional dyspnea. His exam is notable
for blood pressure of 144/80 mm Hg, irregular pulse of 75
beats/min, and prominent temporalis muscle wasting. The
jugular veins are distended to the angle of the jaw seated upright
and the lungs are clear to auscultation. The cardiac exam is
notable for a prominent P2 but no gallop, and grade 2/6 systolic
murmurs at both the lower left sternal border and the apex. The
liver edge is firm and palpable four fingerbreadths below the
right costal margin. There is pitting edema to the thighs with
normal muscular strength and bulk in the extremities. ECG is
notable for atrial fib with low limb lead voltage. Echo reveals
concentric LV hypertrophy (posterior wall thickness 18 mm),
marked biatrial enlargement, and moderate tricuspid and mitral
valve regurg. The lateral mitral annular relaxation velocity is 8
cm/s. How would you approach the management of this patient
with ‘diastolic’ heart failure?
10:52 Case 2: A 75 yo woman with recurrent episodes of ADHF is
referred for management of PH. She underwent aortic valve
replacement and coronary artery bypass grafting several yrs ago
for symptomatic aortic stenosis and coronary artery disease.
Her additional history is notable for type 2 diabetes mellitus,
hypertension, and atrial fib. On exam, she weighs 275 lbs and is 55
tall with BP 150/80 and pulse 50 beats/min. She has jugular venous
distention to the jaw, dullness to percussion at both lung bases,
and a stable sternum. There is a prominent RV heave and S3; P2 is
increased and there is a systolic murmur typical of tricuspid regurg,
but no diastolic murmur is audible. The abdomen is distended and
obese with 3+ pitting edema of the lower extremities with skin
changes of venous stasis. Echo reveals mild mitral stenosis, severe
tricuspid regurgitation, and moderate RV enlargement/dysfunction.
The LV EF is normal. Labs reveal creatinine 2.5 mg/dL with BUN
55 mg/dL. Right heart cath reveals right atrial pressure 24 mm Hg,
pulmonary artery pressure of 68/24 mm Hg (mean 38 mm Hg) and
pulmonary capillary wedge pressure of 20 mm Hg with V-waves
to 26 mm Hg; aortic pressure is 156/72 mm Hg. The pulmonary
artery 02 saturation is 49% and systemic arterial saturation is 90%
generating cardiac index 2.3 L/min/m2, cardiac output of 4.7 L/min
by the Fick method; the calculated pulmonary vascular resistance
is 339 dynes/sec/cm5 and systemic vascular resistance is 1256
dynes/sec/cm5. How would you manage this patient with heart
failure, pulmonary hypertension, tricuspid regurgitation, and renal
insufficiency?
11:14 Case 3: A 74 yo man is self referred for consideration of ‘stem
cell’ therapy. He suffered an inferior MI over 20 yrs ago and
for the last 5 yrs has been noted to have severe LVdysfunction.
His functional capacity is currently NYHA III and for the
last yr he has noted a left arm ache with exertion. He denies
resting symptoms of HF. One year ago, he received a CRT-D
system without clinical improvement. He is currently treated
with losartan 50 mg daily, carvedilol CR 40 mg daily, and
aspirin 325 mg daily. On exam, he is a pleasant elderly man
in no acute distress. He is 5’10” and 197 lbs with body mass
index of 28 kg/m2. His BP is 116/61 mm Hg in the right arm
and 110/64 mm Hg in the left, with pulse 50 beats/min. The
head and neck exam are unremarkable and filling pressures
are low. The carotid upstrokes are brisk without bruits. The
lungs are clear to auscultation and percussion bilaterally.
Cardiac auscultation is notable for an S4 gallop, increased P2,
and LV heave, but no murmur. There is no hepatomegaly or
ascites. The distal extremities are warm with good pulses and
no edema. ECG reveals an A-sensed V-paced rhythm with
unclear resynchronization (leftward axis rather than rightward
axis). Labs are notable for creatinine 1.3 mg/dL, NA of 136
meq/L, BUN of 21 mg/dL, HDL 23 mg/dL, LDL 74 mg/dL,
triglycerides 375 mg/dL, BNP 887 pg/mL, hemoglobin 13 g/dL,
and hemoglobin A1c 6.6%. Echo reveals LV EF 10-15% with
end diastolic dimension 7.7 cm, mild mitral regurg, and normal
RV function w/o minimal tricuspid valve regurg. RV systolic
pressure is estimated at 59 mm Hg based on the tricuspid jet
velocity. MIBI perfusion images reveal an enlarged LV with
inferior scar, but apparent ‘viability’ in the other territories.
What therapies would you offer?
11:36 Case 4: A 60 yr old man with stage III chronic kidney
disease, nonobstructive CAD, and dilated cardiomyopathy with
implanted dual chamber defibrillator presents for evaluation of
progressive exertional dyspnea (NYHA III). His exam is notable
for BP of 100/82 mm Hg, a pulse of 75 beats/min, normal
jugular venous pressure, clear lungs, and a paradoxically split
second heart sound with a laterally displaced apical impulse in
the anterior axillary line. There is no hepatomegaly or ascites
and the extremities are well perfused without peripheral edema.
ECG reveals sinus rhythm with left bundle branch block and
QRS duration 192 ms. Echo reveals a markedly dilated LVIDD
10 cm with severely reduced function and estimated EF of
15-20% with moderate mitral regurg. Adenosine-PET perfusion
study reveals a small region of scar in the mid-basal inferior
wall with minimal reversibility. Cardiopulmonary exercise
testing reveals peak VO2 11 cc/kg/min at a RER of 1.1. What
would you do next?
Learning Objective: Using practice guidelines, research
findings and clinical experience, make decisions about the
management of difficult cases in heart failure.
TuesdAY
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