No Room to Breathe: A Case of Massive Cardiomegaly Secondary to Rheumatic Heart Disease
Document Type
Article
Abstract
Background
A 79-year old male with a past medical history of atrial fibrillation, CAD s/p CABG, severe pulmonary hypertension, and rheumatic fever with subsequent rheumatic heart disease s/p mitral valve repair, subsequent mechanical replacement, and ASD closure, who presented to the hospital with progressively worsening shortness of breath and weight gain over a period of 6 months.
Case
On arrival, the patient was found to be tachycardic and hypoxemic, requiring supplemental oxygen by high flow nasal cannula. Initial labs were remarkable for Cr. 1.6, negative troponins, and a blood gas consistent with chronic respiratory acidosis. A CT chest demonstrated no pulmonary embolism, but did reveal massive cardiomegaly with marked bi-atrial enlargement resulting in compression of both lungs. A transthoracic echocardiogram revealed an enlarged right ventricle with reduced function, a massively dilated left atrium (13×13cm), a massively dilated right atrium, severe pulmonary hypertension, and preserved left ventricular systolic function. The patient remained profoundly hypoxic despite adequate diuresis with correlating weight loss, and a right heart catheterization was pursued but unsuccessful despite placement under fluoroscopy due the extent of his bi-atrial enlargement.
Decision-making
A diagnosis of massive cardiomegaly with predominant bi-atrial enlargement secondary to rheumatic heart disease was made. Despite multiple surgical interventions prior to this hospitalization including ASD closure and mitral valve replacement, the patient developed significant enlargement of his cardiac silhouette resulting in irreversible hypoxia. He ultimately made the decision to transition to a more comfort oriented approach.
Conclusion
Cardiomegaly in patients with or without heart failure may be a predominant and irreversible structural cause of cardiac dyspnea. This may be due to a reduction in lung ventilatory capacity from compression. This case highlights the importance of early detection and treatment of acquired cardiomegaly syndromes including infectious and infiltrative etiologies to avoid potential hypoxia due to overcrowding of the chest cavity.
First Page
33750
Last Page
33755
DOI
10.1016/S0735-1097(20)33750-5
Publication Date
3-16-2020
Recommended Citation
Sheikh, T, Holahan, B, Joshi, A. et al. NO ROOM TO BREATHE: A CASE OF MASSIVE CARDIOMEGALY SECONDARY TO RHEUMATIC HEART DISEASE. JACC. 2020 Mar, 75 (11_Supplement_1) 3123.