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Case Presentation
History of Present Illness: A 75-year-old Hispanic elderly man with multiple comorbidities presented to the emergency department (ED) with complaints of shortness of breath and decreased exercise tolerance that had been progressively worsened over the past 4 months. Prior to this presentation, he had recurrent admission due to similar complaints. He was being evaluated at an ambulatory cardiology clinic for an elective valvular intervention after being recently diagnosed with severe aortic stenosis and heart failure with reduced ejection fraction (HFrEF).
Past Medical History: Past medical history includes severe chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, pulmonary embolism and recently diagnosed nonischemic cardiomyopathy, heart failure with severely reduced left ventricular (LV) systolic function (HFrEF), New York Heart Association (NYHA)/American College of Cardiology (ACC) class III/stage C and valvular heart disease (VHD)/severe aortic valve stenosis, and moderate mitral valve regurgitation.
Investigations: Initial laboratory findings revealed respiratory acidosis and leukocytosis with a white blood cell (WBC) count of 26,000/mm3 with a left-sided shift; however, infective workup was negative. He had a hemoglobin of 12.8 g/dL and platelets of 342 mmol/liter. At presentation, laboratory results were as follows: lactate 3.9 mmol/liter, potassium 5.3 mEq/dL, sodium 140 mEq/dL, glucose 187 mg/dL, creatinine 1.3 mg/dL, glomerular filtration rate (GFR) 42.5 mL/min, blood urea nitrogen (BUN) 34 mg/dL, and pro–B-type natriuretic peptide (BNP) 12,333 pg/min. A 12-lead electrocardiogram showed a normal sinus rhythm with marked LV hypertrophy and nonspecific ST-segment changes. A chest X-ray revealed emphysematous changes with significant vascular congestion and increasing consolidation of the lung fields. Earlier investigations including a transthoracic echocardiogram (TTE) showed severely decreased LV ejection fraction (EF) of 25% with restrictive pattern of diastolic dysfunction and increased filling pressure. There was mild aortic regurgitation and severe calcific aortic valve stenosis with an average peak velocity of 4.4 cm/s, mean gradient of 42 mmHg, dimensionless valve index (DVI) of 0.22, and aortic valve area (AVA) by continuity 0.44 cm2. On mitral valve, moderate mitral annular calcification (MAC) was noted with moderate mitral valve regurgitation. Right-sided structures and function were normal except for moderately elevated pulmonary artery pressure. These findings were similar in a subsequently performed transesophageal echocardiogram (TEE). The patient had previously undergone coronary evaluation with a left heart catheterization, which showed nonobstructive disease with moderate disease involving the left anterior descending and circumflex arteries.
Management: Given hypoxemia and hemodynamic instability, the patient was admitted to the cardiac intensive care unit and was treated for acute-on-chronic hypercapnic and hypoxic respiratory failure secondary to pulmonary edema with superimposed pneumonia and COPD. Broad-spectrum antibiotics were initiated, as well as diuretics and phenylephrine for hemodynamic support in view of developing cardiogenic shock. Later, he required intubation with mechanical ventilation and experienced acute kidney injury and atrial fibrillation with rapid ventricular response. After heart team discussion, given multiple baseline comorbidities, recurrent admissions for heart failure (HF), and worsening clinical status despite medical therapy, he was deemed intermediate to high risk ...