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A Case of Advanced Heart Failure with Severe Systolic Dysfunction Deteriorated with Right Heart Failure
The 21st Annual Scientific Meeting
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JHFS
S33
O14-4
O15-2
A Case of IgG4-related Pericarditis with Heart Failure Hideki Kunichika, Shiro Ono, Koutaro Shiomi, Masashi Kanemoto, Eizo Akagawa, Ryousuke Yoshitomi; Department of Cardiovascular Medicine, Saiseikai Yamaguchi General Hospital
Acute Right Heart Failure Induced by ICD Lead Implantation in Patient with Severe Left Ventricular Dysfunction Toyoji Kaida1, Toshimi Koitabashi1, Yuichiro Iida1, Takeru Nabeta1, Shunsuke Ishii1, Emi Maekawa1, Takashi Naruke1, Yoshiyasu Minami1, Takayuki Inomata2, Junya Ako1; 1 Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan; 2Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
Background: Immunoglobulin G4 (IgG4)-related disease is increasingly recognized as a systemic autoimmune disorder characterized by increasing level of serum IgG4 and IgG4-positive lymphocyte infiltration. However, there are a few case reports of IgG4 related pericarditis, and clinical course is still unclear. Case Presentation: A 60’syear-old male presented with progressive exertional dyspnea, systemic edema, and pericardial effusion. Cardiac CT showed circumferential pericardial effusion and thickened pericardium. His serum IgG4 levels were mildly increased (174 mg/dl). Cardiac catheterization revealed that both ventricular pressure traces showed an early diastolic dip and plateau. Constrictive pericarditis was diagnosed. A surgical pericardiectomy was performed and the resultant specimen showed significant IgG4-positive plasma cell infiltration and marked fibrous thickening of his pericardium; therefore, a diagnosis of constrictive pericarditis due to IgG4-related disease was made. And also, oral administration of 0.6-mg/kg/day prednisolone resolved his heart failure. Conclusion: Our experience with this case indicates that cardiac CT was useful and supports the diagnosis of IgG4-related pericarditis, which was consistent with the findings of effusive constrictive pericarditis.
A 72-year-old woman was admitted to our hospital due to severe heart failure (HF) with reduced left ventricular ejection fraction (LVEF; 33%) and ventricular tachycardia. Since LV lead implantation for CRT-D failed, an ICD lead was implanted in the right ventricle (RV). Several days after the implantation, right HF was significantly exacerbated. Echocardiogram showed severe RV dilatation and the obstruction of tricuspid valve motion by the ICD lead causing massive TR. Since the withdrawal of the ICD lead failed to decrease TR, CRT-D implantation was performed with the relocation of ICD lead and successful LV lead implantation. Thereafter, HF was improved. Relocation of intracardiac lead should be immediately considered for acute right HF in addition to the conservative treatment for left HF in patients with severe LV dysfunction.
O14-5 Constrictive Pericarditis after Repeated Accumulation of Pericardial Effusion due to Long-term Chylopericardium Tomoki Uchikawa1, Kisho Ohtani1, Takeo Fujino2, Ko Takesue1, Masashi Sada1, Keisuke Shinohara1, Shouji Matsushima1, Tomomi Ide1, Taiki Higo1, Hiroyuki Tsutsui1; 1 Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan; 2Department of Advanced Cardiopulmonary Failure, Kyushu University Graduate School of Medical Sciences Primary chylopericardium is a rare disease characterized by the accumulation of chylous fluid containing high triglyceride in the pericardial cavity without a specific cause. We report a case of severe constrictive pericarditis due to 9-year history of primary chylopericardium and surgical ligation of the thoracic duct and pericardial window creation. A 24-year old woman diagnosed as primary chyropericardium, was admitted to our hospital for further treatment of heart failure. She had undergone ligation of the thoracic duct and the creation of a pericardial window. She complained of exertional dyspnea and physical examination revealed elevated jugular venous pressure. Chest X-ray showed a normal cardiac silhouette with extensive transudative pleural effusion. Echocardiogram showed severe mitral regurgitation which was slightly observed before surgery, a few pericardial effusion. Left and right ventricular simultaneous pressure recordings revealed equilibration of both ventricular diastolic pressures and a dip-and-plateau configuration. A CT scan demonstrated the thickened pericardium. Based on these findings, she was diagnosed as constrictive pericarditis and severe mitral regurgitation probably due to worsening mitral annular disjunction caused by the tight pericardium adhesion to the myocardium. During surgery, extensive tissue adhesions were observed from pericardium to epicardium. Histological examination revealed fibro-adipose pericardium with chronic inflammation and myxoid degeneration. She successfully underwent pericardiectomy and mitral valve plasty, and discharged home with greatly improved symptoms.
O15-1 A Case of Advanced Heart Failure with Severe Systolic Dysfunction Deteriorated with Right Heart Failure Hiromi Kayamori, Takeshi Kashimura, Tohru Watanabe, Tomoyasu Suzuki, Shinya Fujiki, Takayuki Wakasugi, Yuka Hayashi, Tohru Minamino; Department of Cardiovascular Biology and Medicine, Niigata University, Niigata, Japan Case: The patient was a 28-year-old female with dilated cardiomyopathy and EmeryDreifuss muscular dystrophy. She had admitted to our hospital 21 months prior with acute decompensated heart failure and standard therapy for heart failure including CRT-D had been introduced, however thereafter, her left ventricular ejection fraction had been around 20%. She had frequently admitted with acute renal failure caused by diarrhea and mild dehydration. This time, she appeared with increased level of creatinine and increased body weight and ascites. Dobutamine, intravenous furosemide, extracorporeal ultrafiltration method (ECUM), and cessation of ACE inhibitor were effective to increase urine volume and to decrease ascites, respectively and transiently. However, once after transaminase started to increase, body weight and ascites restarted to increase. Subsequently, central venous pressure increased and became ECUMdependent and a left ventricular assist device was introduced. Conclusion: In treatment of patients with advanced heart failure with severe systolic dysfunction, right heart failure is critical.
O15-3 Kussmaul Sign Caused by Non-physiological VVI Pacing Akihiro Hayashida, Minako Ohara, Atsushi Hirohata, Keizou Yamamoto, Kiyoshi Yoshida; The Sakakibara Heart Institute of Okayama Case: A 72-year-old woman was hospitalized with dyspnea on exertion and edema. She had a history of surgical repair of atrial septal defect and a VVI pacemaker implantation for symptomatic sick sinus syndrome. Physical examination showed a sign of right heart failure: heaved motion of the internal jugular vein (V wave) during systole, and an increased central venous pressure on inspiration (Kussmaul sign). Electrocardiography revealed no apparent P wave with regular ventricular pacing rhythm of 80 bpm. Echocardiography showed preserved left ventricular ejection fraction with moderate tricuspid regurgitation. Right-sided heart failure was suspected and furosemide was administrated intravenously. Electro-physiological study revealed preserved ventricloatrial conduction, suggesting the presence of viable atrial myocardium. Additional atrial lead was inserted and AAI pacing was started. On physical examination, the V wave and the Kussmaul sign disappeared immediately after the procedure. Her symptom improved. Conclusions: Kussmaul sign observed after VVI pacemaker implantation suggested the presence of right-sided heart failure caused by both non-physiological pacing and ventriclo-atrial conduction.
O15-4 Left Ventricular Reverse Remodeling following Pulmonary Vein Isolation in a Patient with Long Standing Persistent Atrial Fibrillation Kazuma Ino1, Shunsuke Ishii1, Toyoji Kaida1, Yuichiro Iida1, Takeru Nabeta1, Emi Maekawa1, Takashi Naruke1, Toshimi Koitabashi1, Takayuki Inomata2, Junya Ako1; 1The Department of Cardiovascular Medicine, Kitasato University, Kanagawa, Japan; 2The Department of Cardiovascular Medicine, Kitasato university Kitasato Institute Hospital, Tokyo, Japan A 58-year-old male was diagnosed with persistent atrial fibrillation complicated with dilated cardiomyopathy more than 5 years ago. He was treated with anticoagulant therapy and optimal medical therapy, including β-blockers. Despite long-term medical treatment, left ventricular reverse remodeling (LVRR) did not occur. Because heart failure management became difficult (serum brain natriuretic peptide (BNP) levels of 1831 pg/ ml), we performed pulmonary vein isolation (PVI) for long standing atrial fibrillation. A prominent LVRR occurred after one month (LV ejection fraction: 38 to 53%, LV diastolic dimension: 70 to 59 mm) and serum BNP levels improved (83 pg/ml). Heart failure management, such as β-blockers, has been shown to induce LVRR. In this case, LVRR did not occur using pharmacological therapy and it required a PVI. In this
•
JHFS
S33
O14-4
O15-2
A Case of IgG4-related Pericarditis with Heart Failure Hideki Kunichika, Shiro Ono, Koutaro Shiomi, Masashi Kanemoto, Eizo Akagawa, Ryousuke Yoshitomi; Department of Cardiovascular Medicine, Saiseikai Yamaguchi General Hospital
Acute Right Heart Failure Induced by ICD Lead Implantation in Patient with Severe Left Ventricular Dysfunction Toyoji Kaida1, Toshimi Koitabashi1, Yuichiro Iida1, Takeru Nabeta1, Shunsuke Ishii1, Emi Maekawa1, Takashi Naruke1, Yoshiyasu Minami1, Takayuki Inomata2, Junya Ako1; 1 Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan; 2Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
Background: Immunoglobulin G4 (IgG4)-related disease is increasingly recognized as a systemic autoimmune disorder characterized by increasing level of serum IgG4 and IgG4-positive lymphocyte infiltration. However, there are a few case reports of IgG4 related pericarditis, and clinical course is still unclear. Case Presentation: A 60’syear-old male presented with progressive exertional dyspnea, systemic edema, and pericardial effusion. Cardiac CT showed circumferential pericardial effusion and thickened pericardium. His serum IgG4 levels were mildly increased (174 mg/dl). Cardiac catheterization revealed that both ventricular pressure traces showed an early diastolic dip and plateau. Constrictive pericarditis was diagnosed. A surgical pericardiectomy was performed and the resultant specimen showed significant IgG4-positive plasma cell infiltration and marked fibrous thickening of his pericardium; therefore, a diagnosis of constrictive pericarditis due to IgG4-related disease was made. And also, oral administration of 0.6-mg/kg/day prednisolone resolved his heart failure. Conclusion: Our experience with this case indicates that cardiac CT was useful and supports the diagnosis of IgG4-related pericarditis, which was consistent with the findings of effusive constrictive pericarditis.
A 72-year-old woman was admitted to our hospital due to severe heart failure (HF) with reduced left ventricular ejection fraction (LVEF; 33%) and ventricular tachycardia. Since LV lead implantation for CRT-D failed, an ICD lead was implanted in the right ventricle (RV). Several days after the implantation, right HF was significantly exacerbated. Echocardiogram showed severe RV dilatation and the obstruction of tricuspid valve motion by the ICD lead causing massive TR. Since the withdrawal of the ICD lead failed to decrease TR, CRT-D implantation was performed with the relocation of ICD lead and successful LV lead implantation. Thereafter, HF was improved. Relocation of intracardiac lead should be immediately considered for acute right HF in addition to the conservative treatment for left HF in patients with severe LV dysfunction.
O14-5 Constrictive Pericarditis after Repeated Accumulation of Pericardial Effusion due to Long-term Chylopericardium Tomoki Uchikawa1, Kisho Ohtani1, Takeo Fujino2, Ko Takesue1, Masashi Sada1, Keisuke Shinohara1, Shouji Matsushima1, Tomomi Ide1, Taiki Higo1, Hiroyuki Tsutsui1; 1 Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan; 2Department of Advanced Cardiopulmonary Failure, Kyushu University Graduate School of Medical Sciences Primary chylopericardium is a rare disease characterized by the accumulation of chylous fluid containing high triglyceride in the pericardial cavity without a specific cause. We report a case of severe constrictive pericarditis due to 9-year history of primary chylopericardium and surgical ligation of the thoracic duct and pericardial window creation. A 24-year old woman diagnosed as primary chyropericardium, was admitted to our hospital for further treatment of heart failure. She had undergone ligation of the thoracic duct and the creation of a pericardial window. She complained of exertional dyspnea and physical examination revealed elevated jugular venous pressure. Chest X-ray showed a normal cardiac silhouette with extensive transudative pleural effusion. Echocardiogram showed severe mitral regurgitation which was slightly observed before surgery, a few pericardial effusion. Left and right ventricular simultaneous pressure recordings revealed equilibration of both ventricular diastolic pressures and a dip-and-plateau configuration. A CT scan demonstrated the thickened pericardium. Based on these findings, she was diagnosed as constrictive pericarditis and severe mitral regurgitation probably due to worsening mitral annular disjunction caused by the tight pericardium adhesion to the myocardium. During surgery, extensive tissue adhesions were observed from pericardium to epicardium. Histological examination revealed fibro-adipose pericardium with chronic inflammation and myxoid degeneration. She successfully underwent pericardiectomy and mitral valve plasty, and discharged home with greatly improved symptoms.
O15-1 A Case of Advanced Heart Failure with Severe Systolic Dysfunction Deteriorated with Right Heart Failure Hiromi Kayamori, Takeshi Kashimura, Tohru Watanabe, Tomoyasu Suzuki, Shinya Fujiki, Takayuki Wakasugi, Yuka Hayashi, Tohru Minamino; Department of Cardiovascular Biology and Medicine, Niigata University, Niigata, Japan Case: The patient was a 28-year-old female with dilated cardiomyopathy and EmeryDreifuss muscular dystrophy. She had admitted to our hospital 21 months prior with acute decompensated heart failure and standard therapy for heart failure including CRT-D had been introduced, however thereafter, her left ventricular ejection fraction had been around 20%. She had frequently admitted with acute renal failure caused by diarrhea and mild dehydration. This time, she appeared with increased level of creatinine and increased body weight and ascites. Dobutamine, intravenous furosemide, extracorporeal ultrafiltration method (ECUM), and cessation of ACE inhibitor were effective to increase urine volume and to decrease ascites, respectively and transiently. However, once after transaminase started to increase, body weight and ascites restarted to increase. Subsequently, central venous pressure increased and became ECUMdependent and a left ventricular assist device was introduced. Conclusion: In treatment of patients with advanced heart failure with severe systolic dysfunction, right heart failure is critical.
O15-3 Kussmaul Sign Caused by Non-physiological VVI Pacing Akihiro Hayashida, Minako Ohara, Atsushi Hirohata, Keizou Yamamoto, Kiyoshi Yoshida; The Sakakibara Heart Institute of Okayama Case: A 72-year-old woman was hospitalized with dyspnea on exertion and edema. She had a history of surgical repair of atrial septal defect and a VVI pacemaker implantation for symptomatic sick sinus syndrome. Physical examination showed a sign of right heart failure: heaved motion of the internal jugular vein (V wave) during systole, and an increased central venous pressure on inspiration (Kussmaul sign). Electrocardiography revealed no apparent P wave with regular ventricular pacing rhythm of 80 bpm. Echocardiography showed preserved left ventricular ejection fraction with moderate tricuspid regurgitation. Right-sided heart failure was suspected and furosemide was administrated intravenously. Electro-physiological study revealed preserved ventricloatrial conduction, suggesting the presence of viable atrial myocardium. Additional atrial lead was inserted and AAI pacing was started. On physical examination, the V wave and the Kussmaul sign disappeared immediately after the procedure. Her symptom improved. Conclusions: Kussmaul sign observed after VVI pacemaker implantation suggested the presence of right-sided heart failure caused by both non-physiological pacing and ventriclo-atrial conduction.
O15-4 Left Ventricular Reverse Remodeling following Pulmonary Vein Isolation in a Patient with Long Standing Persistent Atrial Fibrillation Kazuma Ino1, Shunsuke Ishii1, Toyoji Kaida1, Yuichiro Iida1, Takeru Nabeta1, Emi Maekawa1, Takashi Naruke1, Toshimi Koitabashi1, Takayuki Inomata2, Junya Ako1; 1The Department of Cardiovascular Medicine, Kitasato University, Kanagawa, Japan; 2The Department of Cardiovascular Medicine, Kitasato university Kitasato Institute Hospital, Tokyo, Japan A 58-year-old male was diagnosed with persistent atrial fibrillation complicated with dilated cardiomyopathy more than 5 years ago. He was treated with anticoagulant therapy and optimal medical therapy, including β-blockers. Despite long-term medical treatment, left ventricular reverse remodeling (LVRR) did not occur. Because heart failure management became difficult (serum brain natriuretic peptide (BNP) levels of 1831 pg/ ml), we performed pulmonary vein isolation (PVI) for long standing atrial fibrillation. A prominent LVRR occurred after one month (LV ejection fraction: 38 to 53%, LV diastolic dimension: 70 to 59 mm) and serum BNP levels improved (83 pg/ml). Heart failure management, such as β-blockers, has been shown to induce LVRR. In this case, LVRR did not occur using pharmacological therapy and it required a PVI. In this