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Sanjiv Shah

12 Dec, 4 tweets, 2 min read

Answer to today's case: the pt had a very stiff LA, poss. due to AF ablation. But stiff LA alone cannot cause big V waves. Sympathetic activation➡️splanchnic vasoconstriction w/redistribution of volume from gut/liver➡️lungs/heart with minimal exertion + stiff LA = big V waves.

@corviamedical

This pt also had significant coronary microvascular dysfxn. Exercise➡️myocardial ischemia➡️LV diastolic dysfunction➡️increased load on LA. I tried everything to treat him, nothing worked for 7 years. And then he got an IASD as part of the @corviamedical REDUCE LAP-HF I trial.

Huge improvement in symptoms, now NYHA class I-II.

TDI shows that he has almost no atrial contractile (booster) function despite being in normal sinus rhythm. Septal a' velocity ~ 4 cm/s, lateral a' velocity ~ 3 cm/s.

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Sanjiv Shah

@HFpEF

11 Dec

Case: 64 yo man w/HFpEF, HTN, obesity, CAD, AF s/p ablation, NYHA 3. Invasive hemodynamics shown below. PCWP 11 at rest, ⬆️ to 32 with V waves up to 75 with 20W bike exercise. Only 1+ MR at rest/exercise. What caused the severe elevation in PCWP and V waves with minimal exercise?

Read 5 tweets

Sanjiv Shah

@HFpEF

11 Dec

#HFpEF pearl of the day: There are both "slow" and "fast" mechanisms of congestion in HFpEF patients. The "fast" mechanism is mediated by splanchnic vasoconstriction, which also may have implications for cardiorenal syndrome.

See: ahajournals.org/doi/10.1161/CI…

Read 4 tweets

Sanjiv Shah

@HFpEF

9 Dec

Case: 74-year-old woman with HTN, obesity (BMI 46 kg/m2) with dyspnea, leg edema, ⬆️JVP, BNP = 28 pg/ml, LVEF 60%. What is the cause of HFpEF and abnormal septal motion?

Invasive hemodynamics: RA 18, PA 44/20 (mean 28), PCWP 20, CO 5.1 L/min.

Answer: Obesity HFpEF phenotype with severe pericardial, epicardial fat over the RV causing pericardial constraint (not constrictive pericarditis--pericardium was normal). See: ahajournals.org/doi/10.1161/CI…

Read 9 tweets

Sanjiv Shah

@HFpEF

8 Dec

#HFpEF pearl of the day: Evaluation of motion of the interventricular septum can be helpful to determine etiology/pathophys in HFpEF pts. Case: 58 yo man w/SOB, ascites, 2+ LE edema. EF 50%. Initially referred to hepatology for poss. liver failure. What did liver biopsy show?

What was the histologic finding on liver biopsy?

Read 14 tweets

Sanjiv Shah

@HFpEF

7 Dec

#HFpEF pearl of the day: For echo diagnosis of ⬆️LV filling pressures, remember the 11-13-15 rule. Septal E/e' > 11 in A-fib, > 13 with exercise, > 15 at rest (in sinus rhythm) = ⬆️LV filling pressure is likely. None of these are perfect, but good rule of thumb.

Here is an example of elevated septal E/e' (> 11) in AF:

Here is a nice review on the topic: sciencedirect.com/science/articl…

Read 4 tweets

Sanjiv Shah

@HFpEF

6 Dec

Case: 63-year-old woman with long-standing rheumatoid arthritis presents with dyspnea, LE edema, fatigue. Exam JVP 12 cm, 3/6 holosystolic murmur at LSB, 1+ LE edema. LVEF 60%. TR gradient 40 mmHg, RA pressure 15 mmHg. PASP 55 mmHg.

Mitral inflow: E velocity 62 cm/s, A 35 cm/s, E/A ratio 2.1.

Septal TDI: Septal e’ 5 cm/s

Read 19 tweets

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