Dilated Inferior Vena Cava

A 47-8. Year-Old Man with Systemic Lupus Erythematosus and Heart ...

(Medicine): A 47-year-old man with systemic lupus erythematosus (SLE) and progressive cardiac failure was transferred to this hospital after a cardiac arrest.

One year before admission, dyspnea, leg edema, and abdominal distention gradually developed, and the patient was told that his liver was abnormal. He became progressively incapacitated and eventually bedridden, with dyspnea on exertion and paroxysmal nocturnal dyspnea. Two months before admission, cardiac catheterization reportedly showed 60% occlusion of the right coronary artery, 30% occlusion of the left anterior descending artery, and mitral-valve regurgitation. Mitral-valve replacement was planned.

Two days before admission, fever, myalgia, nausea, vomiting, abdominal pain, and diarrhea developed. The next day, pain in the left arm, severe dyspnea, and orthopnea developed; the patient went to the emergency department at another hospital. On examination, he was pale and retching. The temperature was 36.6°C, the blood pressure 133/107 mm Hg, the pulse 133 beats per minute, the respiratory rate 28 breaths per minute, and the oxygen saturation 75% while he was breathing ambient air. The oral mucous membranes were dry. There were basilar rales in the right lung field and decreased breath sounds throughout both lung fields. A cardiac monitor showed intermittent runs of ventricular tachycardia, and an electrocardiogram (ECG) revealed couplets, intermittent ventricular tachycardia with polymorphic waveforms, a prolonged QT interval corrected for heart rate (QTc) of approximately 520 msec, and ST-segment elevations in leads V (see the figure in the Supplementary Appendix , available with the full text of this article at NEJM.org). Calcium, magnesium, and amiodarone were administered. Laboratory-test results are shown in Table 1 Table 1Laboratory Data.. Transthoracic echocardiography showed a left ventricular ejection fraction of 55%, left ventricular hypertrophy, severe mitral-valve regurgitation, moderate tricuspid-valve regurgitation, biatrial enlargement, mild right ventricular dilatation, a pulmonary-artery systolic pressure of 40 to 50 mm Hg, and a dilated inferior vena cava with impaired inspiratory collapse; there was no pericardial effusion. Cardiac catheterization reportedly showed coronary artery disease that was unchanged from 2 months earlier and normal left ventricular function.

The patient was admitted to the intensive care unit. During the night, a bradycardic arrest with unknown rhythm occurred. Cardiopulmonary resuscitation was performed, atropine and bicarbonate were administered intravenously, and amiodarone was discontinued. The urine output decreased; vitamin K, furosemide, and albumin were administered. Laboratory-test results are shown in Table 1 . In the morning, an ECG showed normal sinus rhythm with intraventricular conduction delay and was otherwise unchanged. That evening, he was transferred to this hospital.

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