Abstract 4365239: Cardiac Cachexia: A Case of Esophageal Compression

Abstract

Clinical Course: A 72-year-old male with a history of hypertrophic obstructive cardiomyopathy (HOCM), chronic atrial fibrillation, septal myomectomy, and mitral regurgitation presented with dyspnea on exertion, unintentional 80-pound weight loss for one year and two weeks of progressive dysphagia with difficulty tolerating liquids. On presentation, he was hemodynamically stable. Physical examination revealed temporal wasting, III/VI holosystolic cardiac murmur, and bilateral pitting edema. Right heart catheterization revealed an elevated pulmonary capillary wedge pressure (36 mmHg) and low cardiac index (Fick 1.1 L/min/m2). The patient was started on a milrinone infusion and treated with intravenous bumetanide. A nasogastric feeding tube was inserted for tube feeds. The patient was a former smoker, former alcohol consumer, and had no prior colonoscopies. Barium esophagram revealed concave deformities consistent with left atrial (LA) enlargement. CT chest, abdomen and pelvis with contrast revealed severe cardiomegaly, significant LA enlargement and no visible malignancy. Trans-thoracic echocardiogram (TTE) revealed left ventricular ejection fraction 55-60%, abnormal diastolic function, massively dilated LA with a volume index of 298 ml/m2 and severe mitral regurgitation with a diminutive posterior leaflet. Later gastrointestinal endoscopy and colonoscopy showed no evidence of malignancy. Due to the absence of malignancy, the patient’s failure to thrive was thought to be secondary to end stage heart failure and dysphagia due to severely dilated LA causing esophageal compression. The patient underwent percutaneous endoscopic gastrotomy tube placement for nutritional supplementation and was discharged to a rehabilitation facility. Discussion: Cardiac cachexia is often discussed in the context of advanced heart failure due to multi-organ interactions. However, in HOCM, external compression must be considered in patients with dysphagia to reduce morbidity and maintain nutritional status. In addition to TTE, barium esophagram and CT imaging are crucial for excluding malignancy. The patient’s history of HOCM, chronic atrial fibrillation and chronic mitral regurgitation likely contributed to his severe LA dilation. As the patient also suffers chronic heart failure, cardiac cachexia was likely a significant contributor to the patient’s weight loss. Early recognition and intervention are crucial to improving quality of life and survival.