case_images: PMC7150732_01
case_images: Electrocardiogram on presentation. The patient was noted to be in sinus rhythm with a first-degree AV block with a prolonged PR interval of 223 msec and a stable right bundle branch block that had been present for many years.
case_images: CRIC2020-7148708.001.jpg
case_images: PMC7150732_01_CRIC2020-7148708.001.jpg
case_images: fig1
case_images: Electrocardiogram at the time of admission demonstrated sinus rhythm with a stable right bundle branch block (Figure 1).
case_images: Plot of serum creatinine and weight over the 30 days after initial presentation. Shaded areas represent time periods where the patient received treatment with intravenous vasopressor agents. Dopamine was used as the vasopressor on days 1-8 and 16-23 while intravenous phenylephrine was used on days 27-29 with the patient being transitioned to oral phenylephrine thereafter. Note that despite correction of volume status by day 10, and the relative stability of weight thereafter, the patient still developed renal failure (second shaded area) supporting a pathophysiologic role for distributive shock in the face of high-output cardiac failure.
case_images: CRIC2020-7148708.002.jpg
case_images: PMC7150732_01_CRIC2020-7148708.002.jpg
case_images: fig2
case_images: He was started on intravenous diuretics and dopamine and successfully diuresed over 12 days to a negative fluid balance of 16.5 L with an improvement in renal function (Figure 2). Repeated attempts to wean the dopamine were associated with dramatic drops in blood pressure and oliguric renal failure (Figure 2).
case_images: Simultaneous left and right ventricle hemodynamic monitoring with left ventricular pressure shown in yellow and right ventricular pressure shown in green. Red lines added to highlight the concordance between right ventricular and left ventricular pressure with respiration. Concordance between right ventricular and left ventricular pressures with respiration is suggestive of restrictive physiology.
case_images: CRIC2020-7148708.003.jpg
case_images: PMC7150732_01_CRIC2020-7148708.003.jpg
case_images: fig3
case_images: Additionally, the patient was noted to have concordance of ventricular pressures that suggested of restrictive physiology (Figure 3).