A case of adriamycin cardiomyopathy with repeated worsening of heart failure (HF).
Rest TTE showed LVDd/s and LVEF were 69/58 mm and 27% with moderate functional mitral
regurgitation (MR). Exercise stress induced marked worsening of MR. Simple leg exercise
increased PCWP (29 to 44 mmHg), RAP (4 to 10 mmHg) and CI (2.12 to 2.74 L/min/m2). We considered exercise induced worsening of MR is one of the major mechanisms of
repeated worsening of HF and performed mitral annuloplasty. After surgery, exercise
stress increased RAP (4 to 13 mmHg), PCWP (15 to 30 mmHg) and CI (2.18 to 2.68 L/min/m2).
Because the intensities of the exercise were different, we standardized them by the
stressed blood volume (SBV). We estimated the SBV using the equation of venous return
curve previously reported (Uemura K et al, AJP 2004). Exercise increased SBV from
31.5 to 55.8 ml/kg before surgery and from 25.7 to 57.3 ml/kg after surgery. ΔPWCP/ΔSBV
decreased from 0.62 to 0.48 mmHg/(ml/kg) and ΔRAP/ΔSBV increased from 0.25 to 0.29 mmHg/(ml/kg).
This indicates that the presence of stress induced worsening of MR contribute to make
PCWP sensitive to the change of SBV while little change in the RAP sensitivity. Mitral
surgery improves not only static pump function but also dynamic response for stress
induced changes in hemodynamics and may prevent flush pulmonary edema.
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