52-Year-Old Male Patient With New Onset Shortness of Breath
A 53-year-old previously active male patient with a history of cluster headaches on verapamil and no prior personal or family cardiac history presented to the emergency department with a chief complaint of 3 months of progressive dyspnea. Over the last 3 months, the patient endorsed a 15-pound weight gain, lower extremity edema, early satiety, and abdominal bloating and was now dyspneic at rest.
On physical exam, the patient had markedly elevated jugular venous pressures to 20 cm above the right atrium and clear lungs. His heart rate was regular at 94 bpm with an accentuated second heart sound and right ventricular (RV) heave. A 3/6 systolic murmur was present at the left lower sternal border, and 1+ lower extremity edema was present. His blood pressure was 117/73 mmHg, and oxygen saturation was 92% on 3 liters oxygen. Initial laboratory tests showed the following:
- Aspartate aminotransferase = 704 IU/L
- Alanine aminotransferase = 909 IU/L
- Blood urea nirogen = 44 mg/dL
- Creatinine = 2.84 mg/dL
- Lactic acid = 9.8 mmol/L
- Troponin = 0.02 ng/mL
An electrocardiogram (ECG) and echocardiogram are shown in Figures 1-3. The ECG was notable for severe RV hypertrophy with RV strain and echocardiogram demonstrated severe RV enlargement and dysfunction. The patient underwent a ventilation perfusion scan, which showed low probability for pulmonary embolism.
What is the best next step in management of this patient's symptoms?