Virtual Case Area

Review the cases presented at Heart Failure 2018 and test your knowledge!

The Virtual Case Area is a digital patient simulator with presentations of cases of patients with heart failure

Meet the virtual patients of Heart Failure 2018!

Heart failure caused by giant cell myocarditis

Context

One month ago Kelly had been hospitalized for chest pain. She was diagnosed acute myocarditis by chest pain, elevated troponins and ST-depressions in V3-V5. Echocardiography and coronary angiography were normal. Ibuprofein 600mg 3xday and bisoprolol 2.5mg 1xday were prescribed.

Briefing

39-year old woman presented to the ER because of 2 weeks’ history of discomfort at right costal margin, abdominal distension, lower limb edema, dizziness and blurring of vision.

General learning objectives

Diagnostic workup and acute stabilization of myocarditis.

Specific learning objectives

Starting of heart failure and immunomodulic chronic medication.
Indications for Implantable Cardioverter Defibrillator (ICD).

Patient characterisation

Parameters at case start

Blood pressure (mmHg): 187 / 71
Heart rate (bpm): 90
Respiratory rate (/min): 20
O₂ saturation (%): 99.9
Blood glucose (mg/dL): 118
Temperature (ºC): 36.7
Hemoglobin (g/dL): 14.5
Urinary output (mL/kg/h): 0.67 

Heart transplantation in a HIV-positive patient

Context

Mr Blanchard has an HIV infection lasting 32 years. Anterior myocardial infarction 8 years ago treated by thrombolysis, an Inferior myocardial infarction 6 years ago treated by right coronary stenting. Severe ischemic mitral regurgitation despite a percutaneous mitral clip. Defibrillator for primary prevention. Cardiac resynchronization therapy

Briefing

The patient has a LVEF of 30% with severe mitral regurgitation despite a mitral clip. For the past month, the patient has complained of a NYHA 4 grade dyspnea with increasing orthopnea, a 2 kg weight gain and a cough. His treatments include: furosemide 500 mg once daily, bisoprolol 10 mg once daily, ramipril 2.5 mg once daily, kardegic 75 mg once daily, rosuvastatin 10 mg once daily and he is also treated for his HIV infection.

Additional clinical information

Hospitalized twice in the past 12 months. During last hospitalization it was impossible to increase medication doses.
Peak oxygen consumption (VO2) of 11.5 ml/kg/min.
CD4 count 570 cells/µL and undetectable HIV viral load for 1 year

General learning objectives

Specificities of heart transplantation in HIV recipients.

Specific learning objectives

Perform pre-transplant evaluation on a patient with end-stage heart failure and HIV
Recognize HIV infection as not being a contraindication for heart transplantation
Enumerate requirements for heart transplantation on an HIV patient

Patient characterisation

Parameters at case start

Blood pressure (mmHg): 95/75
Heart rate (bpm): 74
Respiratory rate (/min): 32
O₂ saturation (%): 98
Blood glucose (mg/dL): 102
Temperature (ºC): 36.7
Hemoglobin (g/dL): 14.1
Urinary output (mL/kg/h): 0.67

Young decompensated patient with constrictive pericarditis

Context

Mr Hayden's health has deteriorated progressively during the past 5 years, significantly impacting his quality of life. During this period, Mr Hayden was hospitalized several times, and ended up hospitalized much more frequently in the past year.

Briefing

43-year old male with 1-year history of recurrent heart failure hospitalizations was admitted to the ICU due to decompensated heart failure. He has complained of fatigue and dyspnoea on exertion (NYHA III) for a few weeks. Physical examination showed hypotension, abdominal distension and peripheral oedema.

Additional clinical information

5-years ago the patient, without any previous chronic conditions, was admitted to the internal medicine ward due to fatigue and dyspnoea on exertion which started after mild upper respiratory tract infection. The suspicion of myocarditis was raised at that time. Troponin and inflammation markers were normal and echo did not reveal any abnormalities.

3 years later the patient started to suffer from ankles oedema, which was asymmetric and more visible around the right ankle. The ultrasound showed thrombophlebitis of the right lower limb. After initial treatment with enoxaparine thrombophlebitis recurred and treatment with warfarin was implemented.

Last year patient was hospitalized twice in the internal medicine ward due to signs and symptoms of decompensated heart failure: fatigue, dyspnoea on exertion, recurrent ankle oedema. ECHO study at that time revealed the enlarged left atrium (49 mm in PLAX view) without any other abnormalities described in the report. The diagnosis of chronic heart failure with preserved ejection fraction was proposed. The patient received chronic treatment: ramipril 2.5 mg, furosemide 120 mg, spironolactone 25 mg, warfarin 5 mg (according to INR level) - doses per day.

General learning objectives

Constrictive pericarditis – rare but potentially curable cause of heart failure in young patient.

Specific learning objectives

Constrictive pericarditis – rare but potentially curable cause of heart failure in young patient.
Focus on specific clinical manifestation of pericardial diseases.
Role of early echocardiography in patients admitted to ICU due to decompensated heart failure.
Evaluation of diastolic function in patients with pericardial diseases.
Searching for indirect signs of constriction in echo imaging.
Important role of multi-modality imaging of pericardial disease.
Surgical treatment of constrictive pericarditis crucial for patient’s recovery.

Patient characterisation

Parameters at case start:

Blood pressure (mmHg): 88 / 64
Heart rate (bpm): 75
Respiratory rate (/min): 16
O₂ saturation (%): 98
Blood glucose (mg/dL): 110
Temperature (ºC): 36.8
Hemoglobin (g/dL): 14.1
Urinary output (mL/kg/h): 0.67

Infective endocarditis & acute aortic regurgitation

Context

Patient presenting to the emergency department (ED) for worsening dyspnea since 3 weeks; dyspnea at rest (NYHA IV) and orthopnea at presentation. Given the evidence of lung congestion at chest X-ray the patient is admitted to the ICU.

Briefing

The patient complains of remittent fever exacerbating in the evening hours since a couple of months, temperature rarely exceeds 38°C, anorexia and weight loss, about 5 Kg in the previous 4 to 5 weeks. Transient global amnesia about two months before, neuroimaging not performed. Current medical therapy is Amlodipine 5 mg once daily, Ramipril 5 mg once daily, Aspirin 100 mg once daily.

General learning objectives

• Echocardiography represents a fundamental diagnostic tool for patients presenting to the ICU for dyspnea. Early transthoracic echocardiography (TTE) in the ICU can be of fundamental value for diagnosis of acute heart failure syndromes and to identify life-threatening conditions, such as complicated infective endocarditis (IE), requiring immediate treatment.
• Echocardiography has a crucial role in the clinical management of patients with IE and may dictate timing for surgical treatment. Identification of large, mobile vegetations, left ventricular systolic dysfunction and severe aortic regurgitation, together with the evidence of systemic embolization, led in this case to urgent surgery.

Specific learning objectives

• Echocardiography needs to be performed (and eventually repeated) by an experienced operator, especially when the clinical suspicion of IE is elevated. When performed by a non-experienced operator, echocardiography may fail to detect endocarditic vegetations. When clinical suspicion is high, the patient should be sent for transoesophageal echocardiography (TEE), even with negative TTE.
• Clinical management of patients with IE needs to be performed by the Endocarditis Team. Evaluation and decision making in patients with IE require competences from different professionals, including clinical cardiologists, imaging specialists, infectivologists, cardiac surgeons.
• In selected circumstances, TEE may not be performed in patients with suspected IE. Although TEE is highly recommended in patients with suspected IE, in some cases it may not be performed. In such circumstances, a TTE of good quality may be sufficient for diagnosis and to plan treatment and follow-up.

Patient characterisation

Parameters at case start

BP (mmHg): 145/70
HR (bpm): 70
RR (/min): 16
O2 saturation (%): 99
Glycemia (mg/dL): 120
Glycemia (mmol/L): 6.7
Temperature (ºC): 36.0
Temperature (ºF): 97 

A patient with cardiogenic shock

Context

Patient initially collapsed on the street and was resuscitated. Presented Coronary artery disease (acute occlusion of the prox. LAD and RCX) with severely depressed ejection fraction, EF=30% in echocardiography. The patient presented with severe and persistent cardiogenic shock.

Briefing

Patient was referred to hospital due to persistent cardiogenic shock. With positive inotropic treatment, Levosimendan, and negative balance, patient was stabilized. HF treatment was started and patient was referred to intermediate care. Despite treatment, patient did not improve and evaluation for VADs implantation and TPL was started. However, patient deteriorated and was referred to the ICU again.

General learning objectives

Echocardiography in the context of cardiogenic shock.

Specific learning objectives

• Echo helps to exclude mechanical complications (acute MR, ventricle septum or free wall rupture) after acute MI;
• Echo reveals systolic and diastolic function of the LV and gives important information on filling pressures;
• Echo gives information in the right ventricular function which is particularly important considering assist device implantation;
• Echo can exclude pericardial effusion as a cause of cardiogenic shock;
• Echo visualizes Thrombi. 

Patient characterisation

Parameters at case start

BP (mmHg): 139/80
HR (bpm): 70
RR (/min): 16
O2 saturation (%): 99
Glycemia (mg/dL): 120
Glycemia (mmol/L): 6.7
Temperature (ºC): 36.0
Temperature (ºF): 97 

Failing or not failing right myocardium ?

Context

Mickey suffered an aortic aneurysm rupture and was transferred immediately to a specialist heart and lung centre, for an emergency surgical repair of his ruptured aneurysm. Although Mickey was hemodynamically stable after surgery, 8 hours post repair his clinical condition severely deteriorated.

Briefing

Patient is male, 69 years old. Recently operated to correct a ruptured aortic aneurism. Shortly after surgery, the patient was hemodynamically stable. Currently, 8 hours post repair, the patient is suffering profound peripheral vasoconstriction, higher oxygen demands, higher inotropic demands and his blood pressure is dropping acutely.

General learning objectives

Identify hemodynamic deterioration, make a critical judgement, decide how to treat a critically ill patient.

Specific learning objectives

To understand the right heart failure physiology and the optimised way of treatment.

Patient characterisation

Parameters at case start

BP (mmHg): 140/85
HR (bpm): 81
RR (/min): 16
O2 saturation (%): 98
Glycemia (mg/dL): 98
Glycemia (mmol/L): 5.44
Temperature (ºC): 36.6
Temperature (ºF): 98