https://orcid.org/0000-0001-9375-0596
An 82-year-old woman with HFpEF complicated by recurrent hospitalizations, obesity, atrial fibrillation, diabetes, and chronic kidney disease presented with worsening dyspnoea and oedema. Echocardiogram revealed ejection fraction 57%, normal left ventricular mass, mild left atrial enlargement, a dilated inferior vena cava, and pulmonary artery systolic pressure of 48 mmHg. Parenteral diuretics and antibiotics were administered, but symptoms worsened. Because this represented her eighth hospitalization in the past 12 months, the patient elected to pursue palliative care, and died 4 days later.
At autopsy, total heart weight upon removal from the chest was 758 g, with marked circumferential epicardial fat deposition. Following dissection of epicardial fat, the heart weighed 415 g (expected weight 241 g). Thus, epicardial fat accounted for 343 g (46%) of the total heart mass. Cause of death was established as sepsis complicated by congestive heart failure.
This case illustrates multiple features that are typical of the obese phenotype of HFpEF, including multi-morbidity, marked volume overload, cardiomegaly, increased epicardial fat, and severe right-sided heart failure. The combination of increased diastolic chamber stiffness and excessive external restraint on the heart from epicardial adipose tissue causes dramatic elevations in filling pressure and ventricular interaction. These changes worsen congestion and may also contribute to greater risk of worsening renal function during diuresis. Patients with this stage of obesity-related HFpEF are difficult to treat, emphasizing the importance of earlier intervention to prevent or reduce excess fat in the heart and periphery.
