(244) To Be Forgotten Is to Be Underestimated: The Perils of the Right Ventricle

Introduction: In heart failure, the left ventricle is often emphasized over the right, with the latter largely considered consequent to the former. However, the complex physiology of the right ventricle (RV), and its maladaptation to high pressures, underlies the commonly cryptic course of isolated RV failure and the risk of rapid decompensation. We discuss a patient with rapid progression of RV failure in newly diagnosed pulmonary hypertension (PH).

Description: 42-year-old woman, with obesity, presented with a 3-week history of progressive dyspnea on exertion and palpitations. She had completed two courses of antibiotics and steroids, for suspected bronchitis without improvement. She sought urgent medical attention due to worsening dyspnea and was found to have sinus tachycardia in the 130s, relative hypotension, and hypoxemia. Troponin and BNP were elevated. She had a leukocytosis, a normal metabolic panel and lactate. EKG showed sinus tachycardia, nonspecific T wave changes. CT and V/Q scans were negative for pulmonary embolism, but showed extensive mediastinal and hilar adenopathy, RV strain with enlarged pulmonary artery. Hypotension improved with fluids, and she was anticoagulated for NSTEMI. She had a negative cardiac stress test and TTE revealed a small hyperdynamic LV and RV pressure overload. She was then treated with diuretics and referred for a cardiac catheterization, which revealed severely elevated right heart and mean pulmonary artery pressures (48mmHg), and a low cardiac Index 1.2L. Her Metabolic panel and lactate remained normal. Patient was started on inotrope therapy, but her clinical condition continued to deteriorate, and she suffered a PEA cardiac arrest with no response after 45 mins of resuscitation. Preliminary autopsy findings suggest a metastatic carcinoma of unknown primary origin.

Discussion: This patient’s PH is suspected to be secondary to Tumor Emboli Syndrome, a rare etiology, confirmed on histopathology. Early recognition of RV failure, although essential to improve patient outcomes, can be elusive. This patient’s presentation reminds us that a patient can be in early cardiogenic shock with normal lactate and metabolic panel. The clinician must have a high degree of suspicion for right heart failure, as it can rapidly progress to cardiogenic shock or even death.