2019 Research Forum

Applicant & Principal Investigator: Nosheen Hasan MD R2 Faculty Sponsor: David Aguirre MD A Case of Acute Onset Heart Failure in a Previously Healthy 26-Year-Old Female

David Aguirre MD, Nosheen Hasan MD R2, Fowrooz Joolhar MD, Amie Cocoros MS III, Sarah El-Halees MS IV

INTRODUCTION Heart failure is a relatively uncommon diagnosis in previously healthy young adults, particularly that of new and rapid onset. PURPOSE We present a unique case of a young female with multiple possible etiologies of worsening heart failure, with one likely exacerbating another.

DISCUSSION A 27-year-old multiparous Caucasian female with an extensive history of intravenous drugs presented to an outside hospital at 35 weeks gestation with pelvic pain. This patient delivered emergently via a C-section but was found to be bacteremic with Methicillin-sensitive Staphylococcus aureus. TTE showed mobile vegetation on the tricuspid valve suggestive of endocarditis, severe tricuspid regurgitation, and global hypokinesis of left ventricle with LVEF of 35%. Patient was subsequently treated with IV Nafcillin. Through the course of next two weeks in the hospital, this patient experienced worsening shortness of breath with a repeat TTE indicating severe tricuspid regurgitation with an echo-density suggestive of ruptured chordae tendinae, and severe left global hypokinesis with a LVEF of 20%. This patient was started on Lisinopril, Carvedilol, and Digoxin for optimal heart failure management. Follow up left heart catheterization indicated no coronary artery occlusion, therefore ruling out ischemic causes leading to the primary diagnosis of postpartum cardiomyopathy. She left the hospital against medical advice, but presented to Kern Medical Center two days later. On arrival, she was dyspneic at rest and was found to be volume overloaded with diffuse anasarca. On physical exam, this patient had a holosystolic murmur at the lower left sternal border that increased on inspiration, bibasilar lung crackles, and 3+ pitting edema of the lower extremities. Labs were significant for BNP of 1793, and positive urine toxicology screen for amphetamines and opiates. Due to the inadequate and interrupted treatment, the patient was restarted on IV Nafcillin, Lisinopril, Carvedilol, and aggressive diuresis. Repeat TTE indicated dilated cardiomyopathy with severe LV hypokinesis and EF of 10-15% and subsequent TEE confirmed a 0.6x1.1cm vegetation with ruptured chordae tendinae and moderate pulmonary hypertension. Due to the severe left ventricular dysfunction, the patient was not an ideal candidate for valve replacement surgery thus medical management was continued. Upon significant clinical improvement in symptoms and completed endocarditis treatment, the patient was discharged home. Plans of close outpatient follow-up and treatment for the heart failure were made, but the patient was lost to follow up as she has been unreachable. CONCLUSION Postpartum cardiomyopathy is often a diagnosis of exclusion, and often known to develop rapidly in the last trimester of pregnancy or within 6 months of delivery. Our patient likely had an underlying non-ischemic methamphetamine induced cardiomyopathy with a component of postpartum cardiomyopathy. Patient’s acute tricuspid valve endocarditis and subsequent rupture of chordae tendinae further exacerbated her symptoms and put her into acute decompensated heart failure. Optimal management included IV antibiotics, Beta blockers, Ace-inhibitors and aggressive diuresis which resulted in significant clinical improvement.

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