Severe acute reversible myocardial dysfunction without ischemic heart disease is a relatively uncommon clinical entity. In the ICU, sepsis is often implicated, related perhaps to cytokines such as tumor necrosis factor (TNF) and interleukin 2. Although not widely recognized, a number of other causes have been described that may require specific interventions. asthma inhalers
We describe a patient who developed severe transient myocardial depression resulting in pulmonary edema, in the absence of sepsis. The various mechanisms of “reversible cardiomyopathy” are reviewed. buy claritin online
A 38-year-old woman was admitted to the hospital for management of right renal cell carcinoma. She had donated her left kidney 6 years previously to her sister. Several months prior to referral, she had developed symptoms initially attributed to renal calculi. Subsequent investigation, however, demonstrated renal cell carcinoma in the lower pole of her right kidney. She underwent right partial nephrectomy with subsequent apparent good perfusion of the remaining kidney intraoperatively.
Postoperatively she was noted to be oliguric (10 to 20 ml/h) with a creatinine level rising at anephric rates. Diethylene triamine pentetic acid renal scan done on the second postoperative day showed no perfusion or function of the remaining right kidney. On the third postoperative day, the patient developed respiratory distress. Oxygen at a concentration of 80 percent was required to maintain oxygenation and her chest radiograph was compatible with pulmonary edema. Hemodialysis was performed with removal of 4 L of fluid. The following day, her respiratory function deteriorated further and she required endotracheal intubation and mechanical ventilation despite dialysis and ultrafiltration. Bronchoscopy with bronchoalveolar lavage was noncontributory and no evidence of infection was documented. Several sets of blood cultures drawn at this time were negative. A pulmonary artery catheter was inserted, demonstrating a pulmonary capillary wedge pressure of 17 mm Hg and cardiac index (Cl) of 2.8 L/min/m2 (Table 1).
Table 1—Hemodynamic Parameters and Echocardiographic Measurements Before and After Surgical Removal of the Necrotic Remnant Kidney
|Day 4||Day 5||ReceivingNitroprussidePrenephrectomy||Fost-nephrectomyt|
|PCWP, mm Hg||17||21||6||12|