A Heavy Heart

A CLINICAL PROBLEM-SOLVING article by Amy Miller from Brigham and Women's Hospital, Boston.
A 73-year-old man presented with a 6-month history of progressive, symmetric edema that began in the lower extremities and extended to involve his thighs, scrotum, and arms. He had dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea, as well as chest pressure on mild exertion. Despite anorexia and early satiety, he gained 16 kg (35 lb) and noted new abdominal distention.
The medical history included rheumatic heart disease, requiring mitral-valve replacement with a St. Jude mechanical valve 19 years earlier, as well as hypertension, atrial fibrillation, and benign prostatic hypertrophy.
On physical examination The jugular venous pressure was markedly elevated. There was dullness on percussion over the right lung base, with no breath sounds. The apex beat was not palpable, and there was no right ventricular heave. Auscultation revealed an irregular rhythm with a crisp, mechanical S1 and a 2/6 holosystolic murmur at the apex and lower left sternal border, with no radiation. The liver was enlarged and was pulsatile. Pitting edema involved the legs, scrotum, sacrum, and abdominal wall, and there was mild arm edema.
An electrocardiogram revealed atrial fibrillation with a slow ventricular response, low voltage in the limb leads, rightward axis, poor R-wave progression with clockwise rotation, and diffuse nonspecific T-wave changes.
The physical examination indicates elevated right-sided cardiac filling pressures. The degree of low voltage in this case is striking and suggests extensive infiltrative or fibrotic replacement of the myocardium.