trying to understand what happened

[regor]

Last July my stepdaughter, age 21, died of a cardiorespiratory arrest due to undiagnosed and untreated CHF.

The autopsy revealed an enlarged left ventricle (1.2 cm in thickness vs 0.4 cm for the right ventricle) with prominent organizing thrombi, gross mitral valve prolapse, and it gave the following measurements for the cardiac valve: tricuspid 11.8 cm, pulmonic 8.1 cm, mitral 11.6 cm, aortic 8.4 cm. There was no evidence of dissection or dilatation of the aorta. An echocardiogram taken the previous October showed the enlarged left ventricle, ejection 25 - 30%, mild mitral and tricuspid valve prolapse, no aortic or pulmonic regurgitation, and at that time the aortic root was normal at 3.1 cm. A chest x-ray taken 12 days before her death showed her heart to be “stable in its enlargement” as compared with 6 days earlier.

Q1 Can the aortic valve be 8.4 cm while the aortic root is 3.1 cm?

Q2 If there was a further enlargement of her heart in the days or weeks preceding her death, could this have resulted from the CHF, or is it more likely that it was the other way around -- that her enlargement suddenly increased, throwing her into CHF?

Q3 The first time she was brought in she was diagnosed with pneumonia in one lung, admitted for 2 ½ days, and sent home with a 10-day supply of antibiotics. Is pneumonia one consequence of CHF?

Q4Could pulmonary edema have been mistaken for pneumonia? She had no fever, white blood cell count normal, microbiologic cultures of her lung tissue were negative.

[CCF-M.D.-RCJ]

Regor,

I'm terribly sorry to learn of your loss.

Q1 Can the aortic valve be 8.4 cm while the aortic root is 3.1 cm?

There is a discrepancy here that I cannot reconcile.  Was the aortic valve 8.4 cm squared?  That would make more sense.

Q2 If there was a further enlargement of her heart in the days or weeks preceding her death, could this have resulted from the CHF, or is it more likely that it was the other way around -- that her enlargement suddenly increased, throwing her into CHF?

More than likely, size had little to do with the sudden death.  Sudden death in persons with CHF is almost always from an arrhythmia.

Q3 The first time she was brought in she was diagnosed with pneumonia in one lung, admitted for 2 ½ days, and sent home with a 10-day supply of antibiotics. Is pneumonia one consequence of CHF?

No, but CHF can masquerade as pneumonia.

Q4Could pulmonary edema have been mistaken for pneumonia? She had no fever, white blood cell count normal, microbiologic cultures of her lung tissue were negative.

Yes, I have known many doctors to be fooled in this way.

I hope you can find some peace.  If you need me to clarify an answer, please place a comment.

[nikl]

I am not that familiar with CHF but after reading this it worried me that how would I be able to tell the difference between my sons asthma or that it could be CHF. I did not know that the lungs fill up with fluid and my sons goes through this period twice a year where he gets severe asthma bordering pneumonia. How would a person tell if it is CHF or just bad asthma? We always go to the Dr. and get breathing treatments when it gets this bad but now I am worried about how a person would know the difference?

[knicks30]

Im sorry to hear about your stepdaughter. Such a tragic story especially considering she was only 21 years old with Congestive Heart Failure. Did they say what was the cause of CHF?? Was she born with an abnormal heart? You say she had an enlarged left ventricle?? Did she have hypertension(high blood pressure)? Or was her enlarged left ventricle due to be congenital? Im guessing it was congenital. When she has an enlarged ventricle that is called Hypertrophic Obstructive Cardiomyopathy or HOCM. With that disease the person could be at increased risk for sudden cardiac death from a fatal arrythmia like Ventricular Fibrillation. Im guessing thats what happened to her.

I dont know if youll get your question answered today because the doctors havent been answering questions lately for some reason.

It might have been hopeful for her to wear a cardiac monitor or an event monitor to see how her heart rhytms were. Did she ever faint or complain of a fast heartbeat??

Sorry again,

Ivan

[cardiogirl]

If a doctor diagnosed your child with asthma (I would assume that the child has seen a specialist) and he has no history of heart problems or defects, it is asthma.  CHF is progressive, also, and there would be more symptoms than this alone.  CHF in a child is not common, either.  Search through the wealth of information within this forum, or check symptoms at WebMD.com and you will feel much better, I'm sure.

Best wishes with the asthma, I understand how frightening it can be when it is triggered.  Hang in there.

[cardiogirl]

My post about the asthma was to nikl.  Regor, I am sorry to hear about your stepdaughter.

PS: Does anyone know where the doctors are?

[cardiogirl]

Thanks - I missed that comment, thank you for letting me know.  I'm doing a little nail biting at the moment.

[va_tony]

Pluto,

Your guess about the whereabouts of the doctors is likely correct.  There was a meeting of the "Heart Rhythm Society" this past week in San Francisco.  I was out there on business (see my comment in reply to Phil's "Message from Med Help to all Forum Participants" below).

Tony

[regor]

Nikl, I didn’t mean to frighten anyone about the possibility of CHF being mistaken for something else as a common occurrence, although that seems to be what happened to my stepdaughter. Because of space limitations, much was left out of my posting. You should know that she had marfans and cardiomyopathy and had been placed on the transplant list the previous month. So the ER docs should have been on the lookout for CHF, especially after fluid showed up in one lung, followed 6 days later by edema in her feet and ankles. The arrest occurred 11 hours after she was brought into the ER for the 3rd time in 2 ½ weeks, and 15 min. after she received a shot of Ativan because she had started to hyperventilate. The only treatment she ever received was antibiotics for the pneumonia.

[regor]

Thanks for your comment, Ivan. She didn’t die as the result of an arrhythmia. She had an implanted pacemaker-defibrillator which had not fired and upon examination was found not to be defective. Her heart just stopped.

In addition to the fluid in her lungs, feet and ankles, she had 250 cc of fluid in her pericardial sac, the pleural (chest) cavities each contained 250 cc fluid, and the peritoneal cavity (abdomen) contained 1000 cc of clear yellow fluid. Her liver also showed centrilobular congestion of the heptic parenchyma, which I understand to be the result of blood backing up from the heart.

[nurse12hr]

I know this may not be applicable, but my dog was misdiagnosed with pneumonia just 1 month before he died of severe CHF.

Apparently, it can look just the same on xray, and I am assuming it can be the same for humans.

I am so sorry for your loss.

[fizzixgal]

My ep was also in SF this week. It's probably a good guess that they were all at the same conference.

[regor]

Thank you so much. You have confirmed what I suspected right from the beginning -- that she was in CHF all along. I do have a couple of comments and one more question:

Q1 The figures given came directly from the autopsy report. The previous month she had had a complete evaluation at another hospital prior to being put on the transplant list. I’ll try to get that record in order to see how those measurements compare both with her echo the previous October and with the pathologist’s findings.

Q2 Ivan made the same observation. However, she apparently didn’t die as the result of an arrhythmia. She had an implanted pacemaker-defibrillator which had not fired and upon examination was found not to be defective. It seems her heart just stopped. Revived after 5 -10 min. of CPR and put on life support, she was in tachycardia. Her blood pressure continued to drop, however, and several hours later she had another arrest which took her.

One last question: 15 min. before her first arrest she began to hyperventilate. The nurse told her she needed to calm her breathing and gave her a shot of Ativan. Could the Ativan have triggered the arrest, especially if the respiratory distress she was experiencing had been brought on by a sudden drop in blood pressure?

[knicks30]

See when you say "heart just stops" which means cardiac arrest. The causes of cardiac arrest happened becaues of her congestive heart failure. Its kinda rare but it happens. You also say she had a defibrillator implanted, that is because she had a problem with the rythm of her heart. A rythm called ventricular fibrillation, which is a fatal arrythmia that can result in sudden death or cardiac arrest. In ventricular fibrillation the heart doesnt beat it "quivers" and when it does that it cannot supply blood in demand and eventually the heart will stop. With a defibrillator, when the heart goes into Ventricular Fibrillation the defibrillator will shock the dangerous heart rythm and the rythm goes back to normal and the heart pumps normally. You say that the defibrillator did not work so therefore her dangerous arrythmia(ventricular fibrillation) resulted in cardiac arrest.

Hope you understand.

Ivan,

[knicks30]

Also i understand that you may think she didnt die of an arrythmia. In an autopsy, you cannot tell of an arrythmia because the heart is not working but it can still be seen the person died of an arrythmia because someone of her age dying of cardiac arrest is because of an arrythmia caused by the underlying congestive heart failure. Usually in older patients that go into cardiac arrest because of an arrythmia is because of an underlying coronary artery disease but thats not her case.

Again her heart was enlarged, which led to heart failure, the heart failure itself caused the dangerous fatal arrythima(ventricular fibrillation), then the fatal arrythmia caused cardiac arrest.

Best of luck to you an your family,

Ivan.

[CCF-M.D.-RCJ]

Glad I can help in some small way.

"Q2 Ivan made the same observation. However, she apparently didn’t die as the result of an arrhythmia. She had an implanted pacemaker-defibrillator which had not fired and upon examination was found not to be defective. It seems her heart just stopped. Revived after 5 -10 min. of CPR and put on life support, she was in tachycardia. Her blood pressure continued to drop, however, and several hours later she had another arrest which took her."

If the autopsy did not find a cause, I would still be suspicious of an arrythmia.  The ICDs are set to detect at certain heart rates and above.  We occasionally see persons die from arrythmias that are fast enough to cause an arrest, but not yet at the level to trigger the ICD.  Alternatively, some persons develop arrythmias that are of such low amplitude that they are undetectable by the ICDs -- this can happen in persons who develop fluid in the pericardial sac, as an example.

"One last question: 15 min. before her first arrest she began to hyperventilate. The nurse told her she needed to calm her breathing and gave her a shot of Ativan. Could the Ativan have triggered the arrest, especially if the respiratory distress she was experiencing had been brought on by a sudden drop in blood pressure?"

I have seen this scenario numerous times.  Usually some medically important "event" has happened (example: pulmonary embolus), and the patient's only symptom is anxiety.  A drug like ativan is given, and the patient's status significantly worsens.  Ativan can certainly precipitate low blood pressure in the right set of circumstances.

Hope that helps.

[regor]

Thank you. Even though nothing can bring her back, you have been most helpful. These are questions I needed answered for my (and my wife's) own peace of mind.

[Dr. Erik]

May God grant you peace and comfort during this difficult time. I am truly sorry for your loss. You will see your daughter again someday in God's kingdom! There will be no more sickness or sorrow there. Take care!


Erik

[pandora9048]

i'm sorry for your loss.