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?