Correct!
1. Cardiovascular surgery consultation
Patients with HCM often have arrthymias. These include tachyarrthymias which can be associated with sudden death and bradyarrthymias which might require pacemaker implantation. She had not history of arrthymias, and therefore, a pacemaker is not indicated. Disopyramide (Norpace) is often added to decrease ventricular and supraventricular arrhythmias by raising the threshold for atrial and ventricular ectopy (1). In addition, disopyramide decreases the inotropic state of the left ventricle, decreases diastolic dysfunction and increases LV compliance, and thereby reducing the pressure gradient across the LV outflow tract. Our patient was receiving disopyramide. Amiodarone is often used in HCM and is the only agent proven to reduce the incidence and risk of cardiac sudden death (1). It is very effective at converting atrial fibrillation and flutter to sinus rhythm.
Although patients with severe HCM often have pulmonary artery hypertension, the hypertension is due to the mitral valve disease accompanies HCM. Pulmonary vasodilators have little or no role at present.
Cardiovascular surgery is consulted and recommends a septal myectomy since the patient is on maximal medical therapy and has severe and progressive symptoms. She underwent septal myectomy and had an estimated blood loss of 1270 ml and intraoperatively received crystalloid: 4300 mL; packed red blood cells: 2 units; fresh frozen plasma (FFP): 4 units; cell saver: 634 mL; platelets: 1 unit; and ultrafiltrate: 650 mL.
She was transferred to the ICU for vasopressor weaning and diuresis and anticoagulated post-operative. She was diuressed and was only 1 liter positive and her weight had increased only 1.2 kgs by her third post-operative day. However, on post-op day 4 she developed increasing shortness of breath with mild chest and an increase in her pulse from the 60’s to the 90’s. Her serum creatinine had also gradually risen to 2.7 mg/dL.
Which of the following are likely causes of her shortness of breath? (Click on the correct answer to proceed to the fifth of seven pages)