Dyspnea and Right-Sided Heart Failure in a Patient With a History of Pneumonectomy

A 67-year-old man who never smoked was evaluated in the emergency department for 3 months of progressive dyspnea, lower extremity edema, and 20lb weight gain. Eighteen months before this, he had presented with hemoptysis and was ultimately found to have squamous cell lung cancer invading the left pulmonary artery without lymph node involvement, stage pT4N0M0, for which he underwent left pneumonectomy. His medical history was additionally notable for paroxysmal atrial fibrillation and factor V Leiden mutation (anticoagulated on apixaban). Social history was notable for work as a grocer in a supermarket; the patient denied history of asbestos exposure and had no known TB exposure or prior infection. The patient was admitted to general cardiology where he was afebrile, in atrial fibrillation with rapid ventricular response to 127 beats/min with associated hypotension (80/55 mm Hg); his oxygen saturation was 95% on room air. Physical examination was most notable for jugular venous distension and bilateral edema to the thigh. Electrocardiogram did not demonstrate ischemia. Laboratory evaluation demonstrated a creatinine level of 1.10 mg/dL, elevated from his recent baseline level of 0.52 mg/dL. Lactic acid was normal. His cardiac biomarkers were abnormal with an elevated N-terminal pro-B-type natriuretic peptide value (3,682 pg/mL) and high sensitivity troponin T (43 ng/L). Both WBC count and hemoglobin values were normal as were his thyroid hormone levels. IV diuretic and antiarrhythmic therapies were initiated with furosemide and amiodarone, respectively.