Dyspnea in a 63-Year-Old Who Had Heart Surgery as a Child

Sarah Blissett, MD, MHPE; Punag Divanji, MD; Harsh Agrawal, MD; Vaikom S. Mahadevan, MD; Elyse Foster, MD


December 09, 2019

Physical Examination and Workup

Upon physical examination, the patient's blood pressure is 90/57 mm Hg. His heart rate is 66 beats/min and regular. His jugular venous pressure is minimally elevated to 6 cm above the sternoclavicular angle. His chest is clear to auscultation. S1 is normal; a crisp, mechanical S2 is observed. A grade 2/6 systolic ejection murmur and a long, grade 2/4 diastolic murmur are auscultated over the left upper sternal border. Trace pedal edema is noted.

Laboratory investigations reveal no hematologic, electrolyte, or renal abnormalities. Thyroid-stimulating hormone, creatinine kinase, and ferritin levels are within the reference ranges. His N-terminal prohormone of brain natriuretic peptide level is elevated, at 1480 pg/mL.

An ECG reveals a ventricularly paced rhythm (QRS duration, 182 msec) at 70 beats/min with underlying atrial fibrillation. No high-rate episodes are detected on interrogation of the device. Echocardiography reveals an interval decrease in the left ventricular (LV) ejection fraction (EF) to 25%-30%. This is accompanied by global hypokinesis and septal motion consistent with a paced rhythm, normal right ventricular (RV) size and function, mild pulmonic stenosis, mild pulmonic regurgitation, a normally functioning mechanical aortic valve, and an intact ventral septal defect patch. See the video below.

The patient undergoes right- and left-heart catheterization, revealing a right atrial pressure of 8 mm Hg, RV systolic pressure of 55 mm Hg, RV end-diastolic pressure of 9 mm Hg, pulmonary pressure of 44/12 mm Hg (mean, 24 mm Hg), pulmonary capillary wedge pressure of 15 mm Hg, and aortic pressure of 100/51 mm Hg (mean, 70 mm Hg). No step-up is noted on saturations obtained in the right-sided heart chambers. Cardiac output is normal (Fick cardiac output, 4.4 L/min). Salient coronary angiography findings are shown in Figure 1.

Figure 1.


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