CAN MOVEMENT LEAD TO DECOMPENSATED HEART FAILURE?
Dr Dolly C Yadav, Dr Himanshu Gul Mirani
Queen’s Medical Centre, Nottingham University Hospital NHS Trust
Case Presentation:
A 48-year-old patient presented with H/O worsening breathlessness and orthopnoea with cough and whitish sputum for two weeks without chest pain or syncope or fever
Background history: ischemic heart disease, recurrent VT, LVSD, percutaneously placed CRT-D 2 months earlier, and CKD3. They had improved with CRT-D therapy; diuretics were being down-titrated
A - patent and own
B - laboured breathing, RR 36/min, SPO2 94% on 10L O2, bilateral crackles and systolic murmur on auscultation
C – warm center and cool peripheries, CRT 3sec, BP 104/68 mm Hg, HR 101/min
D -GCS E4V5 M6, BL pupils 3mm and reactive
E – temperature 36.6C, peripheral oedema
Point of care testing:
ECG showed paced rhythm, unchanged from last admission
Blood gas revealedT1RF
Chest XR refer to Figure 1
Chest X ray report: florid pulmonary oedema bilaterally and small bilateral pleural effusions. Appearances are most likely to represent heart failure/fluid overload. Concurrent infective changes is challenging to exclude, and is overlying left atrium rather than left ventricle likely to be contributing to the presentation of heart failure. Suggest cardiology review and pacing check.
Management and Outcome:
Working Diagnosis: Decompensated heart failure ?CAP R/O COVID19/influenza
Plan:
Maintain SPO2 > 94%
Send swabs for respiratory infection, FBC,U&E, CRP, blood cultures, troponin
Sepsis bundles
IV diuretic
Diagnostic investigation reports:
COVID-19 & respiratory viruses’ swab – negative
No inflammatory makers
Normal range electrolytes
Unchanged U&E
Troponin negative
Soon after, respiratory failure worsened, however, examination remained unchanged. Consequent D-dimer was raised and CTPA was performed that revealed retracted lead of the CRTD (refer to the report above). Subsequent ECGs showed VT, lacked pacing spikes, and it was cardioverted chemically, following which the patient was admitted for LV lead re-implantation in acute coronary unit.
Key Learning Points:
In patients with severe refractory heart failure and intraventricular conduction disease, CRT (cardiac
resynchronisation therapy) is an effective treatment
If patients present with decompensated heart failure after an initial improvement from CRT, then failed LV sensing or pacing, as a result of a shift in the lead tip, should be considered
LV lead dislodgement as the main cause of loss of LV stimulation reportedly ranges in 2% to 12% of patients