Hepatojugular Reflux Research Articles

A Rare Case of Late Onset-Pompe’s Disease: Presented as Heart Failure

Pompe disease is a hereditary lysosomal storage disorder characterized by a deficiency in the acid alpha-glucosidase (GAA) enzyme, leading to glycogen accumulation in muscle and neurons. Clinical manifestations vary from severe infantile-onset with hypertrophic cardiomyopathy and early mortality due to respiratory insufficiency to late-onset with proximal muscle weakness, gross motor delay, and progressive respiratory insufficiency. A case of an 11-year-old boy who reported to the pediatric emergency department with a nine-year history of progressive muscle weakness and a one-month history of anemia symptoms (easy fatigue, shortness of breath, pale appearance) and heart failure (orthopnea, dyspnea). His family history included consanguineous marriages and similar conditions in his brother and maternal uncle. On examination, he appeared pale, malnourished, and exhibited signs of respiratory distress and tachypnea. His cardiovascular examination revealed apex beat displacement, elevated JVP, bilateral pedal edema, mild ascites, positive hepatojugular reflux, and systolic murmurs. Respiratory examination indicated bilateral crepitation and wheezes. Musculoskeletal examination showed decreased muscle mass and power, especially in proximal muscles. Abdominal examination revealed hepatosplenomegaly and mild ascites. Radiological findings included an enlarged cardiac shadow with pleural effusion and bilateral radio-opaque shadows on chest x-ray, while echocardiography showed impaired left ventricular systolic function with mild to moderate mitral and tricuspid regurgitation. Laboratory tests indicated elevated aspartate aminotransferase, LDH, and creatine kinase levels, along with normocytic, normochromic anemia. Muscle biopsy from the hamstring revealed PAS stain positive granules. These clinical, radiological, and laboratory findings strongly suggest late-onset Pompe disease, marking this as potentially the second reported case in Pakistan.

The Ultrasound Hepato-Jugular Reflux: Measuring the Hepato-Jugular Reflux with Ultrasound with Comparison to Invasive Right Heart Catheterization

BackgroundUltrasound can overcome barriers to visualizing the internal jugular vein, allowing hepato-jugular reflux and jugular venous pressure measurement. We aimed to determine operating characteristics of the ultrasound hepato-jugular reflux and ultrasound jugular venous pressure predicting right atrial and pulmonary capillary occlusion pressures. MethodsIn a prospective observational cohort at three US academic hospitals the hepato-jugular reflux and jugular venous pressure were measured with ultrasound before right heart catheterization. Receiver operating curves, likelihood ratios, and regression models were utilized to compare the ultrasound hepato-jugular reflux and ultrasound jugular venous pressure to the right atrial and pulmonary capillary occlusion pressures. ResultsIn 99 adults undergoing right heart catheterization, an ultrasound hepato-jugular reflux had a negative likelihood ratio of 0.4 if 0 cm and a positive likelihood ratio of 4.3 if ≥ 1.5 cm for predicting a pulmonary capillary occlusion pressure ≥ 15 mmHg. Regression modeling predicting pulmonary capillary occlusion pressure was not only improved by including the ultrasound hepato-jugular reflux (P < .001), it was the more impactful predictor compared with the ultrasound jugular venous pressure (adjusted odds ratio 2.6 vs 1.2). The ultrasound hepato-jugular reflux showed substantial agreement (kappa 0.76; 95% confidence interval, 0.30-1.21), with poor agreement for the ultrasound jugular venous pressure (kappa 0.11; 95% confidence interval, -0.37-0.58). ConclusionIn patients undergoing right heart catheterization, the ultrasound hepato-jugular reflux is reproducible, has modest impact on the probability of a normal pulmonary capillary occlusion pressure when 0 cm, and more substantial impact on the probability of an elevated pulmonary capillary occlusion pressure when ≥ 1.5 cm.

Titrated segmental epidural anesthesia for bilateral total knee replacement in a patient with severe aortic stenosis and severe bilateral carotid artery stenosis: a case report

BackgroundTotal knee replacement is a major orthopedic procedure for severe, painful, and mobility-limiting knee arthritis. Aortic valve stenosis is the most frequent valvular heart disease and the most commonly performed valvular procedure. Stenosis of the valve may lead to left ventricular hypertrophy, ventricular dysfunction, myocardial ischemia, and a state of fixed cardiac output. Changes in hemodynamic parameters such as hypotension and bradycardia in patients with carotid artery stenosis may lead to cerebrovascular accidents, especially during anesthesia.Case presentationA 76-year-old woman with a 6-year history of bilateral knee pain. The pain was dull, aching, and severe in intensity, and it prevented her from sleeping despite optimal analgesics. A general physical examination revealed an elderly, frail woman in mild respiratory distress. She had bilateral small-volume radial pulses, positive hepatojugular reflux, and heart sounds of S1, S2, and S4 with an ejection systolic murmur, and carotid bruits were heard bilaterally. Epidural anesthesia was done by injection of 2.5 mL of 0.5% plain bupivacaine in aliquots every 5 min until the level of the block reached the suprapubic region (titrated segmental epidural anesthesia). The patient was not preloaded with intravenous fluid prior to the establishment of epidural anesthesia, and the epidural anesthesia-induced hypotension that may ensue was managed with intraoperative dopamine infusion at 5 µg/kg/min.ConclusionsTitrated segmental epidural anesthesia with intraoperative infusion of low-dose dopamine reduces the perioperative risk of myocardial infarction, cerebrovascular accident, and neurocognitive deficit in a patient with severe aortic stenosis and severe bilateral carotid stenosis.

#5203 THE INCESSANT QUEST FOR DRY WEIGHT: SHOULD WE ADOPT NEW STRATEGIES?

Abstract Background and Aims The estimate of the hydration state in the chronic hemodialysis patient is a key point of his care. Currently, there is no Gold Standard feasable in daily routine despite the increasingly numerous tools such as impedancemetry and pulmonary cardiac ultrasound. The objective of our study is to compare the results of the clinical estimation of dry weight with the results of impedancemetry and cardiac ultrasound results. Method This is a transverse study in the dialysis unit of Taher Sfar Mahdia hospital. The estimation of the hydration state was assessed before and after the hemodialysis session by the three above methods. The volume evaluation was carried out by a clinical score (NYHA&amp;gt; III dyspnea, orthopnee; jugular turgor (TJ), hepato-jugular reflux (HRJ), crackling in auscultation, peripheral edema and pre-dialysis hypertension); as well as by cardiac ultrasound (diameter of the lower vein, E/E ratio and systolic pulmonary arterial pressures). Results The values ​​measured by the different techniques decreased significantly after the hemodialysis session (p &amp;lt;0.001). At the two -stroke studied, we have objectified a significant correlation between the results of the impedancemetry, the index of the lower vein and its compliance. A significant difference between the results provided by the techniques studied and the results of the clinical evaluation was found in 64 % of patients. Only the orthopnee (p = 0.03) and the hepato-jugular reflux (p = 0.04) were significantly associated with the ultrasound overload diagnosis. Conclusion The existence of a difference between the subjective and objective target weight suggests the incessant need for a mixture between the different techniques evaluated. Our strategy requires to be adapted to the particularities of each patient.

Changes in the liver in organic and functional tricuspid insufficiency (Fredex's sign, hepato-jugular reflux, central venous pressure, etc.)

Changes in the liver in organic and functional tricuspid insufficiency (Fredex's sign, hepato-jugular reflux, central venous pressure, etc.)

Hepatojugular 'reflex' or 'reflux'? A tale of two vowels.

Hepatojugular reflux is an important, prognostic clinical sign in the field of medicine. The majority of medical students or clinicians may attempt to elicit this sign during abdominal or cardiovascular examinations. However, some individuals may incorrectly call it the hepatojugular 'reflex' rather than a 'reflux'. In the first instance, that may not pose a problem to either patient or clinician-however, it may reflect a lack of basic understanding of how the human body works.

1116 DOUBLE-CHAMBERED RIGHT VENTRICLE AND VENTRICULAR SEPTAL DEFECT IN AN ELDERLY WOMAN: A RARE CASE.

Abstract Introduction Double-chambered right ventricle (DCRV) is a rare congenital heart defect with right ventricular outflow tract (RVOT) obstruction. The right ventricle (RV) is divided into anatomically proximal high-pressure and distal low-pressure chambers by abnormal muscle bundle. DCRV is frequently associated with others congenital heart defects, particularly ventricular septal defects (VSDs). Although its typically presents during childhood and adolescence, it can also present in adulthood. Case Presentation An 84-years-old woman was admitted to our hospital, in emergency department, with a 30-days history of worsening dyspnea and exercise intolerance. She was Ukrainian and did not speak Italian or English. The patient past medical history was unknow except for untreated bilateral glaucoma complicated by blindness. Vital signs were notable for tachycardia, tachypnea (respiratory rate, 28/minute), blood pressure of 118/76 mm Hg, SpO2 of 91%. Physical exam revealed left-sided parasternal systolic murmurs, abolished vesicular murmur at lung bases and jugular vein distension with hepatojugular reflux. The ECG showed atrial fibrillation. Chest X-ray showed moderate cardiomegaly, bilateral pleural effusions, and pulmonary congestion. Transthoracic echocardiography (TTE) was performed and revealed a normal-sized left ventricle with mildly reduced left ventricle ejection fraction (EF 48%), left atrial enlargement, biventricular hypertrophy with asymmetrical interventricular septal hypertrophy. Also, we found massive right atrium and enlarged right ventricle with reduced longitudinal contractility (TAPSE of 13 mm and tricuspid annular tissue Doppler S’ velocity = 7.0 cm/sec). Color flow Doppler in parasternal short-axis view revealed a turbulent systolic flow into the right ventricle. Continuous-wave spectral Doppler analysis showed a peak velocity of 5.6 m/ sec corresponding to a peak gradient of 120 mmHg. Real time 3D-TTE confirmed the of mid-ventricular obstruction due to abnormal trabecular tissue. Therapy including diuretics, beta-blockers and anticoagulants was started. Subsequently, a transesophageal echocardiography (TOE) confirmed the presence of an anomalous mid-ventricular muscle bundle and revealed an associated small sub-aortic ventricular septal defect (VSD) leading to the diagnosis of acute RV failure due to double-chambered RV with VSD and atrial fibrillation. Due to the high risk of complications, patient was considered not amenable for surgery. She was discharged on medical therapy. Conclusions We report a rare case of DCRV and VSD diagnosed in an elderly patient. Due to its rarity, DCRV continues to be misdiagnosed, especially in adulthood. Three-dimensional echocardiography and TOE were most useful tool to define diagnosis and pathophysiology in such an elderly and non-compliant patient.

Congestive hepatopathy secondary to graves’ disease: a case report

Graves’ disease is a common cause of hyperthyroidism in iodine-sufficient parts of the world. Excessive thyroid hormone is known to have multiple effects on various organs, including the liver. We reported a case of 49-year old male patient with worsening jaundice, ascites, tremor, and palpitation, with previous history of uncontrolled Graves’ disease. Findings from examination reveals signs of congestive hepatopathy, such as positive hepatojugular reflux and dilated hepatic vein. Treatment options for hyperthyroidism in patients with liver dysfunction includes methimazole and radioactive iodine-131. Liver dysfunction in patients with thyrotoxicosis is commonly found in daily practice, but establishing the cause of liver dysfunction can be a challenge because of the multiple cause of liver injury in hyperthyroidism.

The clinical value of hepatojugular reflux on congestive heart failure: A meta-analysis.

Hepatojugular reflux is a cardiac physical examination with a long history of use in heart failure diagnosis across many clinical settings. However, the development of new diagnostic methods has thrown the clinical role of hepatojugular reflux into question. Our meta-analysis aimed to determine the diagnostic accuracy of hepatojugular reflux and assess its usefulness in diagnosing congestive heart failure among at-risk patients. This meta-analysis of studies reporting diagnostic hepatojugular reflux values of patients at risk for congestive heart failure followed PRISMA guidelines. We searched MEDLINE, EMBASE, Web of Science, CENTRAL, and Google Scholar for eligible studies from inception through February 1, 2021. After QUADAS-2 quality assessment, we conducted data synthesis using the random effects model and a hierarchical summary receiver operating characteristic model. As an additional analysis, we sorted the studies by clinical setting and performed synthesis again. We submitted our protocol to PROSPERO (International Prospective Register of Systematic Reviews; ID No. CRD42020215004). The literature search provided 4121 studies for evaluation. Seven studies and their 5195 participants were deemed eligible for synthesis. Clinical diagnosis was the most frequent reference standard. Bivariate random-effects analysis found hepatojugular reflux sensitivity of 0.12, 95% confidence interval (CI) [0.07-0.19], and specificity of 0.96, 95% CI [0.95-0.97]. The DOR was 29.7, 95% CI [18.4-45.3]. The additional analysis of the emergency settings provided a sensitivity of 0.14, 95% CI [0.12-0.17] and specificity of 0.95, 95% CI [0.93-0.96]. Our meta-analysis suggests that hepatojugular reflux has practical value for diagnosis of congestive heart failure with high specificity.

Ischemic Stroke Revealing Infective Endocarditis in a Young Subject: About a Clinical Case

Introduction: Neurological complications are possible during infective endocarditis. They are often life-threatening and can be a source of sequelae. Case Presentation: We report the case of an 11-year-old patient admitted to the cardiology department of the CHU-ME “LUXEMBOURG” in Bamako for functional impotence of the left hemibody, accompanied by fever and NYHA stage II dyspnea. The clinical examination on admission shows the poor general condition, normal consciousness, and sensory-motor deficit of the pyramidal type of the left hemibody. The cardiovascular examination notes a systolic murmur at the mitral focus, hepato-jugular reflux, hepatomegaly, and slight edema in the lower limbs. Brain CT showed localized hypodensity in favor of an ischemic stroke. The electrocardiogram shows a sinus rhythm. Transthoracic Doppler echocardiography revealed mitral insufficiency with vegetation of 17 × 14 mm on the anterior mitral valve, with left ventricular ejection fraction estimated at 75%. Dual antibiotic therapy associated with conventional treatment for heart failure was initiated. The clinical evolution was marked by the persistence of the deficit of the left upper limb, the cardiac Doppler echography of control after 6 weeks of treatment found the same vegetation. A discussion with the heart team with a view to a surgical cure has been initiated for the rest of the treatment. Conclusion: A motor deficit associated with fever related to an ischemic vascular accident should lead to a search for infective endocarditis on cardiac Doppler ultrasound.

Identifying Discordance of Right- and Left-Ventricular Filling Pressures in Patients With Heart Failure by the Clinical Examination

In ≈25% of patients with heart failure and reduced left-ventricular ejection fraction, right-ventricular (RV), and left-ventricular (LV) filling pressures are discordant (ie, one is elevated while the other is not). Whether clinical assessment allows detection of this discordance is unknown. We sought to determine the agreement of clinically versus invasively determined patterns of ventricular congestion. In 156 heart failure and reduced LV ejection fraction subjects undergoing invasive hemodynamic assessment, we categorized patterns of ventricular congestion (no congestion, RV only, LV only, or both) based on clinical findings of RV (jugular venous distention) or LV (hepatojugular reflux, orthopnea, or bendopnea) congestion. Agreement between clinically and invasively determined (RV congestion if right atrial pressure [RAP] ≥10 mm Hg and LV congestion if pulmonary capillary wedge pressure [PCWP] ≥22 mm Hg) categorizations was the primary end point. The frequency of clinical patterns of congestion was: 51% no congestion, 24% both RV and LV, 21% LV only, and 4% RV only. Jugular venous distention had excellent discrimination for elevated RAP (C=0.88). However, agreement between clinical and invasive congestion patterns was poor, к=0.44 (95% CI, 0.34-0.55). While those with no clinical congestion usually had low RAP and PCWP (67/79, 85%), over one-half (24/38, 64%) with isolated LV clinical congestion had PCWP <22 mm Hg, most (5/7, 71%) with isolated RV clinical congestion had PCWP ≥22 mm Hg, and ≈one-third (10/32, 31%) with both RV and LV clinical congestion had elevated RAP but PCWP <22 mm Hg. While clinical examination allows accurate detection of elevated RAP, it does not allow accurate detection of discordant RV and LV filling pressures.

Right‐sided congestive heart failure secondary to supraventricular tachycardia in a dog with a right atrial mass

AbstractA dog was referred to the authors’ hospital for further investigations of pelvic limb collapsing episodes. Physical examination revealed a positive hepatojugular reflux, positive fluid thrill on abdominal palpation and an irregular heart rhythm (144 bpm) with pulse deficits. A six‐lead ECG showed focal atrial tachycardia. Doppler echocardiography revealed systolic dysfunction, dilated cardiomyopathy phenotype and the presence of a heterogeneous mass in the right atrium; this was confirmed by a CT study. Free abdominal fluid was detected, sampled and analysed: this was consistent with modified transudate secondary to right‐sided congestive heart failure. The dog responded well to heart failure and anti‐arrhythmic medications. He was presented eight weeks after development of respiratory signs (cough). Investigations revealed stable cardiac disease but several radiopaque nodules within the lung parenchyma compatible with metastatic disease. Ten weeks after presentation, the dog was euthanised due to worsening of the respiratory signs.

Prevalence of Severe Anemia (Hb ≤ 5 g/dl) in Non-Dialyzed Chronic Renal Failure Patients in the Nephrology and Hemodialysis Department of Point G University Hospital

Introduction: Chronic renal failure (CRF) is defined as glomerular filtration rate (GFR) less than 60 ml/min/1.73m2 for at least three (3) months. Anemia is one of its most common complications. Anemia increases the risk factor for cardiovascular mortality by 18% per gram of hemoglobin loss. Objectives: To determine the prevalence and characteristics of this severe anemia, to determine the indications for transfusion, the complications related to this anemia, the evolution and the prognosis of these patients. Materials and Methods: This was a descriptive study with retrospective data collection over 18 months (January 1, 2017 to June 30, 2018) that included hospitalized CRF patients. Were included, non-dialyzed chronic renal failure patients with Hb ≤ 5 g/dl hospitalized during the said period. Not included were chronic renal failure patients with an Hb level ≥ 5 g/dl, those followed up and/or hospitalized outside the study period. Results: Among 1176 patients, 26 had severe anemia (Hb level ≤ 5 g/dl) on CRF, a prevalence of 2.21%. The mean age was 40 years ± 32.62 with extremes of 15 and 67 years. Seventeen women and 9 men. The etiology of chronic renal failure (CRF) was hypertensive vascular nephropathy in 50% of cases. CRF was end-stage in 18 patients (69.2%). The mean hemoglobin level was 4.10 g/dl ± 0.64 with extremes of 2 and 5 g/dl. The anemia was microcytic hypochromic in 50% and aregenerative (96.2%). The main symptoms were asthenia in 20 cases (76.9%), dizziness in 20 cases (76.9%), exertional dyspnea in 19 cases (73.1%). Signs of cardiac decompensation (n = 12) were jugular turgor 10 cases (38.5%), hepato-jugular reflux 06 cases (23.1%), mitral insufficiency murmur 06 cases (23.1%). The main complication was left ventricular hypertrophy 17 cases (77.3%). There was no correlation between anemia and sex (p = 0.291), age (p = 0.778), malaria (p = 0.158), etiology of CRF (p = 0.26). The evolution after treatment of anemia was favorable in 19 patients (73.1%), unfavorable in 02 patients (7.7%) and 05 deaths (19.2%). The deaths were of cardiovascular cause: left ventricular insufficiency 04 cases, stroke 01 case. Conclusion: Anemia is frequent in patients with chronic renal failure and remains an important risk factor for cardiovascular disease and poor general condition.

Thrombus in giant right atrial appendage aneurysm.

A 57-year-old female with no abnormal disease history presented to our clinic for persistence shortness of breath over 1 year. On admission, the physical examination revealed a heart rate 89 beats/min with sinus rhythm, hepatojugular reflux syndrome, hepatomegaly, and peripheral oedema. No cardiac murmur can be noticed. Chest X-ray revealed a pronounced bulge of the right heart margin (Panel A, arrow), with normal pulmonary vascular markings. Transoesophageal echocardiography detected a giant echolucent mass with intra-cavity thrombus (Panel B, arrowhead, 6.02 cm × 3.70 cm; Supplementary material online, Video S1). Computerized tomography angiography (CTA) confirmed a giant aneurysm with intra-cavity thrombus arising from the right atrial appendage, compressing the right ventricle (Panels C and D, 8.30 cm × 6.53 cm in short-axis, arrowhead, and asterisk). The patient received surgical intervention under cardiopulmonary bypass. After median sternotomy, the intra-cavity thrombus, which was then removed, could...

P1684 Cardiac amyloidosis hits the valve first

Abstract Case report. 60-year-old man without previous history of coronary artery disease was admitted to our hospital. He complained of weakness, low extremities edema. Physical examination revealed also enlargement of the liver, positive hepatojugular reflux, multiple ecchymoses on patient’s face, especially in periorbital area. The arterial blood pressure was 100/60 mm Hg. ECG showed sinus rhythm 83/min, low R waves in V2, V3 with biphasic T waves in V4-V6. The last coronary angiography revealed normal coronary arteries, it was performed 6 months ago because of atypical chest pain and inconclusive stress test. Echocardiography revealed severe tricuspid regurgitation (TR) due to leaflets restriction and malcoaptation. TR gradient was about 10 mm Hg. Interventricular septum 12 mm, left ventricle posterior wall 9 mm, mass index 87 g/m2, relative wall thickness 0.38; no LV regional wall motion abnormalities was noted, left ventricular ejection fraction (LV EF) was about 50%, mitral valve E/A ratio was 1,4, but average E/E" = 17. Left atrium volume 33 ml/m2. Insignificant amount of pericardial effusion also was found. 3D evaluation of tricuspid valve (TV) showed no leaflets defects and chordal ruptures. LV global longitudinal strain (LV GLS) was – 11,1 % with the apex/(mid + base) ratio 1,3 - apical sparing pattern. Cardiac MRI with gadolinium also showed severe TR and diffuse late subendocardial gadolinium enhancement in both ventricles. We suspected cardiac amyloidosis with significant tricuspid valve involvement, torrential TR, and right ventricle volume overload. The rectum biopsy was negative. The cardiac muscle biopsy with congo red straining was positive for amyloidosis. The patient was transferred to hematology clinic where the diagnosis of AL-amyloidosis was confirmed. The treatment with lenalidomide and prednisone was started. Unfortunately, one month later the patient died. The autopsy was not performed due to religious reasons. Discussion AL-amyloidosis is a systemic disease characterized by multiple organ and tissue changes and associated with poor prognosis. Cardiac involvement is a major prognostic factor as it accounts for approximately 75% of death due to heart failure or arrhythmias. Infiltration of myocardium with amyloid leads to diastolic than systolic dysfunction of the heart and to developing of the heart failure. The most common presentation of heart involvement in AL-amyloidosis is fatigue and dyspnea. In this case the main complaint of the patient was peripheral edema, echocardiography showed damaged TV and preserved LV systolic function. In literature, we found only one case report describing cardiac amyloidosis presented as severe TR. Conclusion In patients presenting with significant isolated valvular dysfunction and heart failure the cardiac amyloidosis can be suspected. The comprehensive echocardiography is the most useful tool to detect this problem. Abstract P1684 Figure. 3D picture of tricuspid valve

HEMODYNAMICS IN HEART FAILURE – IS CLINICAL EXAMINATION RELEVANT?

Elucidating hemodynamic parameters remains the hallmark of management inpatients with acute or chronic heart failure. Demystification of assessment offilling pressures is a continual and vital pursuit for cardiologists. In the era ofhand-held imaging devices, extensive diastolic guidelines and readily availableemerging biomarkers ala, brain natriuretic peptide (BNP); is the role of clinicalexamination (CE) becoming obsolete? CE consists of carefully taken targetedhistory and meticulously conducted physical examination. The determination of 'wet' is based on the presence of any sign or symptom that is associated with elevated ventricular fillingpressures. Assessing volume status is critical in the management of HF, helpful in titrating the dosage of diuretic and agentsused to modulate preload and afterload. Clinical findings that help to assess volume status are distention of jugular veins (JVD),hepatojugular reflux (HJR). Orthopnea, bendopnea and square-wave response of blood pressure during Valsalva maneuver.7Volume depletion can be detected by the presence of signs of dehydration, changes in blood pressure and heart rate withchanges in posture.7 A new term has been introduced in the world of cardiology called 'bendopnea' observed in patients with advanced HF. Patientsdevelop dyspnea on bending forward at the waist and it is assessed in patients while sitting in a chair and bending forwardtouching their feet with hands. It is deemed to be present if a patient develops dyspnea within 30 seconds of bending forward. 25 25Bendopnea was seen in a minority of patients with elevated filling pressure with low cardiac output. Recent studies have 26documented the presence of bendopnea in one fifth to half the number of patients presenting for evaluation for heart failure andits presence has been seen to increase worse outcomes in six months.26-29. To conclude, meticulously conducted clinical examination is of immense importance in the management of patients with HF. Itoffers both diagnostic and prognostic information and is helpful in guiding the therapy. Clinical examination is more accurate inassessing elevated ventricular filling pressure inferred from signs of elevated right atrial pressure. Detection of low cardiacoutput remains challenging. In patients of HF with deteriorating renal function, low cardiac output and right-left equalizer of fillingpressure should be considered

Is hepatojugular reflux a good predictor of heart failure with preserved ejection fraction?

Hypertension may occur with left ventricular (LV) diastolic dysfunction, and the consequence may be symptoms and signs of heart failure (HF). Hepatojugular reflux (HJR), described as a sign of regurgitation of the tricuspid valve, may reflect structural and functional changes of the LV in the hypertensive patient. The signal may be present in the presence of HF. Case: male, 49 years old with uncontrolled blood pressure. Physical examination showed jugular turgescence, HJR, and elevated blood pressure. Complementary exams showed signs of atrial and left ventricular overload in the electrocardiogram and, the echocardiogram showed left atrium volume increase, concentric LV hypertrophy and signs of grade I diastolic dysfunction. DISCUSSIO: The HJR present correlates with pulmonary artery pressure and probably reflect the increase in central blood volume.

The predictive value of brain natriuretic peptide for acute decompensated heart failure in rehospitalized elderly patients

Objective To evaluate changes in brain natriuretic peptide(BNP)levels in predicting the risk of acute decompensated heart failure(ADHF)in rehospitalized elderly patients. Methods A cohort study was performed in 48 elderly(≥65 years)patients hospitalized for ADHF from June 2015 to June 2016.All patients underwent standard treatment in internal medicine and were followed up for one month after discharge.The study endpoint was rehospitalization for ADHF.According to whether there was an increase in BNP levels in one-month follow-up, participants were divided into two groups: a group with increased BNP(n=20)and a group without increased BNP(n=28). General clinical information, disease history, signs of circulatory congestion, cardiac ultrasound, and BNP levels were collected and compared between the two groups. Results Compared with the group without increased BNP, the group with increased BNP had higher rates of type 2 diabetes, positive hepatojugular reflux, and jugular vein engorgement(χ2=5.749, 7.243, 4.286, respectively, P<0.05 or P<0.01)and lower left ventricular ejection fraction(t=-3.558, P<0.01). BNP increase in the BNP group was higher than in the non-BNP group(394.2±171.3 ng/L vs.94.2±56.3 ng/L, P<0.01). The rehospitalizationrate in the BNP group was significantly higher than in the non-BNP group(55% or 11 patients vs.17.8% or 5 patients, P<0.01). Multivariate Cox regression analysis found that the increase in BNP in the one-month follow-up was correlated with the increase in rehospitalization(HR=4.118, 95%CI: 1.427-11.884, P<0.01). When the absolute value of BNP rose to over 310ng/L, the risk of rehospitalization in ADHF patients increased. Conclusions Increase in BNP one month after discharges is an effective predictor for rehospitalization in elderly patients with ADHF. Key words: Heart Failure; Natriuretic Peptide, Brain; Hospitalization

A case report of pediatric calciphylaxis–a rare and potentially fatal under diagnosed condition

Rationale:Though to be rare, calcific uremic arteriolophathy (CUA) is an ectopic calcification entity causing pain and disabilities in patients with chronic renal insufficiency, thus increasing the morbidity and mortality.Patient concern:We report a case of four years old boy admitted with acute respiratory failure. Physical examination revealed: irritability, purple subcutaneous hard nodules, tachypnea, dry spasmodic cough, respiratory rate 45/min, heart rate 110/min, blood pressure 100/60 mmHg, with normal heart sounds, no murmurs, hepatomegaly with hepato-jugular reflux. He was diagnosed at 2 years old with stage 5 chronic kidney disease due to untreated posterior urethral valve, and subsequently started peritoneal dialysis. He developed severe renal osteodystrophy, refractory to standard phosphate binders.Diagnoses:Pathology examination revealed the presence of diffuse calcifications involving the skin, brain, heart, lung, kidney, stomach and pancreas, consistent with the underlying diagnosis of CUA.Intervention:Apart from standard treatment for end stage renal disease and associated co-morbidities, intensive care procedures have been initiated: oxygen therapy, continuous positive airway pressure, inotropic medication (Dopamine, Dobutamine), anticonvulsants (Diazepam), and antiedematous therapy (Dexamethasone).Outcome:His pulmonary function rapidly deteriorated up to the severe hypoxemia, seizures and cardio-respiratory arrest, despite the initiation of intensive care measures.Lessons:A careful follow up of small children might detect in time an abnormal urinary pattern. The diagnosis of growth failure should also trigger urgent further investigation.

Elevated levels of vitamin B12 in chronic stable heart failure: a marker for subclinical liver damage and impaired prognosis.

BackgroundElevated vitamin B12 is a sign for liver damage, but its significance in chronic stable heart failure (HF) is less known. The present study investigated the clinical correlates and prognostic significance of vitamin B12 levels in stable systolic HF.MethodsA total of 129 consecutive patients with HF and 50 control subjects were enrolled. Data regarding demographics, clinical signs, therapeutic and conventional echocardiographic measurements were recorded for all patients. Right-sided HF was defined as the presence of at least one of the typical symptoms (ankle swelling) or specific signs (jugular venous distention or abdominojugular reflux) of right HF. Cox proportional hazards regression analyses were performed to determine the independent prognostic determinants of mortality.ResultsBaseline B12 levels in HF patients (n=129) with and without right sided HF were significantly higher compared to healthy controls (n=50): Median 311 pg/mL and 235 pg/mL vs 198 pg/mL, respectively (P=0.005). Folic acid levels were similar between the study groups. Age, ejection fraction, left atrial size, estimated glomerular filtration rate, and direct and indirect bilirubin levels were significantly correlated to serum B12 level in univariate analysis. In multivariate analysis, independent correlates of B12 were direct bilirubin (R=0.51, P<0.001) and age (R=0.19, P=0.028). Patients with HF were followed-up for a median period of 32 months. Median B12 levels were significantly higher in patients who subsequently died (n=35) compared to survivors, but folic acid was not different between the two groups. ROC analysis showed that B12 values ≥270 pg/mL had 80% sensitivity and 58% specificity for predicting all-cause mortality (area under the curve=0.672, 95% CI=0.562−0.781; P=0.003). However, in Cox regression analysis, only left atrial diameter, level of direct bilirubin, and the presence of abdominojugular reflux were independent predictors of death.ConclusionIncreased B12 in stable HF patients is associated with increased direct bilirubin due to right HF, indicating a cardiohepatic syndrome, but neither B12 nor folic acid are independently associated with mortality.