09 | Critical care echocardiography to guide haemodynamic management in dilated cardiomyopathy with pneumonia-associated acute respiratory distress syndrome: the role of dynamic indices beyond ejection fraction

Background. Acute pulmonary injury profoundly alters heart–lung interaction by increasing right-ventricular afterload, impairing venous return, and limiting left-ventricular filling and forward flow. In patients with Dilated Cardiomyopathy (DCM), such load-dependent fluctuations are often underestimated by static echocardiographic parameters. The integration of advanced, physiologically responsive indices - including Global Longitudinal Strain (GLS), stroke volume, TAPSE/PAPs (a surrogate of RV-PA coupling), and Venous Excess Ultrasound (VExUS) scoring - provides a dynamic evaluation of biventricular performance, supporting individualized management.

Case Presentation. A 68-year-old man with advanced DCM (baseline LVEF 28%, GLS −12%) and chronic heart failure was discharged after 40 days in the coronary care unit, where he had been treated for acute decompensated heart failure. Four days later, he was readmitted to the Emergency Department with dyspnea, fever, hypotension and dizziness. Laboratory tests revealed elevated inflammatory markers and severe hypoxemia (PaO₂/FiO₂ 120, HFNC 60 L/min, FiO₂ 0.60). Chest CT showed bilateral interstitial infiltrates.

Empiric antibiotic therapy and low-dose dobutamine were initiated. Advanced transthoracic echocardiography demonstrated stable left-ventricular systolic function (GLS −12%) and a cardiac index of 2.8 L/min/m², excluding acute-on-chronic systolic dysfunction. However, TAPSE/PAPs (0.30) was markedly reduced compared with baseline, and VExUS (3) indicated severe venous congestion, findings consistent with transient RV–PA uncoupling secondary to pulmonary vascular load rather than primitive left-ventricular failure.

Continuous diuretic therapy with furosemide and ethacrynic acid was started to maintain a negative fluid balance, titrated by serial dynamic echocardiographic indices. Dobutamine was progressively tapered as RV–PA coupling improved. During recovery, GLS improved (−12%→−14%), TAPSE/PAPs normalized (0.30→0.45), and VExUS decreased (3→1). The patient received targeted antibiotic therapy achieving complete resolution of pneumonia. He recovered fully and was discharged after 21 days.

Results. Pneumonia-associated ARDS likely increased pulmonary vascular resistance, leading to transient RV–PA uncoupling and venous congestion that clinically mimicked heart failure exacerbation. Sequential evaluation of dynamic echocardiographic parameters - integrating functional, coupling, and congestion indices - helped haemodynamic interpretation and guided a shift from heart failure-oriented therapy to infection-targeted management.

Conclusions. In advanced heart failure, dynamic echocardiographic indices reveal haemodynamic adaptations beyond LVEF and help differentiate cardiac from pneumogenic dyspnea, improving diagnostic accuracy and therapeutic precision.