The surprise behind acute heart failure decompensation

Objective: A 48 years old male, rural provenience, smoker presented for orthopnea and fever (39.1 de-grees C) 7 hours prior presentation. Medical history: aortic disease (without medical documents). Family medical history: mother- type 2 DM, brother-heart fa-ilure (at 40 years). At admission: febrile (38.7 degrees C), BMI 18 kg/m2, ortopnea, spontaneous SpO2 86%, BPA=130/40mmHg, symmetrically bilateral, HR=125/ min, irregular, grade II/VI aortic murmur, irradiated on carotid arteries, grade IV/VI apical holosystolic murmur, subcrepitant rales in 2/3 inferior bilateral lung fields, major leg swelling, symmetric pulse in the periferic arteries, turgid jugular veins, hepatojugular reflux, hepatomegaly (17/9 cm).

Methods: Biologic at admission: NT pro BNP >30.000 pg / ml, slightly increased troponin I, negative presep-sin, respiratory acidosis, hepatic cytolysis, nitrate reten-tion (RGG 33 ml / min), spontaneously increased INR (6), positive nonspecific inflammatory syndrome. X-ray: interstitial and bilateral alveolar opacities, impor-tant cardiomegaly. ECG: atrial fibrillation, QRS + 60 gr axis, slow wave R progression in V1-V6. Intermediary diagnosis: Acute pulmonary edema, Atrial fibrillation with uncertain onset, Multiple organ disfunction, Fe-brile syndrome with unexplained etiology. Hypothesis for the etiology of febrile syndrome: infectious endo-carditis or respiratory infection.

Results: Echocardiography: Severe dilated LV with se-vere systolic dysfunction (LVEF=16%). Particular as-pect of the myocardium (suggestive for noncompacti-on). Severe dilatation of LA. Bicuspid aortic valve with moderate stenosis and regurgitation. Moderate functi-onal mitral regurgitation. Dilated right cavities. Severe functional tricuspid regurgitation. Moderate secondary pulmonary hypertension. No pericardial effusion. No images suggestive of vegetation/thrombosis. Extended biological investigations: 3 negative hemocultures, po-sitive test for influenza B virus, normalization of coagu-lation, liver and kidney function. Using initially iv loop diuretic therapy, then oral, MRA, ACEi, digital, anti-coagulant and antiviral (tamiflu) the evolution was fa-vorable with clinical and biological improvment. Final diagnosis: NYHA class III heart failure with severe LV systolic dysfunction. LV non-compaction cardiomyo-pathy. Persistent atrial fibrillation. Bicuspid aortic valve with moderate stenosis and regurgitation. Moderate secondary mitral regurgitation. Moderate secondary pulmonary hypertension. Type B influenza. The coro-nary angiography showed normal epicardial coronary arteries.

Conclusions: Concomitant diagnosis of two pathologies with genetic determinism at an advanced stage of heart failure precipitated by an epidemic influenza vi-ral infection. A possible precipitating factor of cardiac decompensation remains viral myocarditis that needs to be excluded by cardiac MRI. Primary prevention of sudden death by ICD implant and enrollment of the patient on the cardiac transplant list. The two patho-logies in conjunction with the familial medical histroy (mother, brother) require family screening for the cor-rect management of survival and their quality of life.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
ESC search engine
CODE: 379
CME Credits: 10 (Romanian College of Physicians)