Role of Left Atrial Pressure Monitoring in the Management of Heart Failure

History

This 60-year-old man had coronary atherosclerosis, left bundle branch block (LBBB) with a QRS duration of 154 ms, peripheral vascular disease, and cardiomyopathy. He sought an opinion regarding management of his cardiomyopathy, which was diagnosed 10 years previously after he went to a local emergency department with chest tightness and shortness of breath. A coronary angiogram was performed that showed total occlusion of his right coronary artery, with no other significant coronary disease. His left ventricular ejection fraction (LVEF) at that time was 40%. He was managed medically, his symptoms improved markedly, and he returned to his baseline functional capacity. He was riding his bicycle regularly, working full time as a high school teacher, and doing heavy housework without difficulty. Approximately 2 years earlier, he noticed a decline in his exercise tolerance and developed intermittent dyspnea on exertion. His medical regimen was optimized, but he had no improvement in his symptoms. His LVEF was noted to have declined to 32%. A workup for ischemia was negative, and given his underlying LBBB and New York Heart Association (NYHA) class III symptoms, he was then referred for a biventricular pacemaker and treated with cardiac resynchronization therapy (CRT). Despite an optimal medical regimen and CRT, he had progressive dyspnea on exertion and worsening functional capacity. He reported development of lower extremity edema over the past 6 months and had frequent episodes of congestion. He required hospitalization five times in the previous 6 months for treatment of acute decompensated heart failure. His most recent two-dimensional echocardiogram revealed an LVEF of 29%, mild right ventricular dysfunction, and a moderately dilated left ventricle with mild mitral regurgitation. He has orthopnea that requires four pillows and frequently sleeps in a recliner. After his most recent hospitalization, he was enrolled in a home telemonitoring program, but did not experience improvement in his symptoms. He is obese and was recently diagnosed with sleep apnea, for which he uses continuous positive airway pressure at night.

Current Medications

The patient was taking carvedilol 25 mg twice daily, lisinopril 40 mg daily, torsemide 80 mg twice daily, metolazone 2.5 mg as needed for weight gain of more than 5 lb in 48 hours, spironolactone 25 mg daily, digoxin 0.125 mg daily, atorvastatin 20 mg daily, and aspirin 81 mg daily.

Current Symptoms

The patient reported orthopnea for the previous 2 weeks and noted chronic lower extremity edema over the past 6 to 7 months. He was unable to walk more than 20 feet without significant dyspnea.

Physical Examination

• BP/HR: 98/54 mm Hg/60 bpm

• Height/weight: 177.8 cm / 131 kg

• Neck veins: Difficult to assess secondary to body habitus, short neck

• Lungs/chest: Clear to auscultation and percussion

• Heart: Point of maximal impulse is lateral to the left midclavicular line, no right ventricular or left ventricular heave, distant heart sounds, normal first heart sound (S ₁ ) and second heart sound (S ₂ ) and a faint (S ₃ ) gallop, 1 to 2/6 holosystolic murmur at the left sternal border that increases in intensity with inspiration

• Abdomen: Soft, obese, nontender, and nondistended, no ascites; liver palpable 1 cm below the costal margin; no abdominal bruits

• Extremities: Warm and well perfused with 2+ pulses bilaterally, 2+ pitting edema to the midcalf, and skin changes consistent with chronic venous stasis