Objective: To report the importance of hypertrophic obstructive cardiomyopathy as a potential substrate for difficult weaning from mechanical ventilation.
Design and setting: Case report in an adult intensive care unit of a tertiary care hospital.
Patients: Two patients who developed intractable pulmonary edema with subsequent difficult weaning from mechanical ventilation in the early postoperative period despite medical treatment for heart failure based on pulmonary artery catheter data.
Interventions: Mechanical ventilation, medical treatment.
Measurements and results: Pulmonary artery catheter data in these two elderly patients under mechanical ventilation were compatible with congestive heart failure, and the initial therapy was diuretics, vasodilators, and inotropes. Despite this reasonable medical treatment no hemodynamic improvement and thereby failure of weaning from mechanical ventilation was observed. Transesophageal echocardiography demonstrated hypertrophic obstructive cardiomyopathy in both cases, and therapy based on negative inotropes was instituted. This treatment change induced hemodynamic improvement and successful weaning from mechanical ventilation.
Conclusions: In mechanically ventilated patients because of congestive heart failure who have difficult weaning, despite appropriate therapy, intensivists should always suspect causes other than the obvious systolic heart failure. In this clinical setting echocardiography is warranted and produces excellent diagnostic yield for clarifying complex cardiac disturbances.