Pulmonary oedema, think beyond the heart even in the presence of severe left ventricular systolic dysfunction

We submit a case of a young patient with known severe left ventricular (LV) systolic impairment who presented with recurrent flash pulmonary oedema (FPO) requiring multiple high-dependency care admissions. Despite extensive optimisation of his underlying heart failure, the presentations remained frequent. Investigations for alternative diagnosis were not approached due to the presence of LV impairment and compliance being questioned. However, deteriorating renal function prompted further investigation with multiple imaging modalities, and an effective diagnosis of bilateral renal artery stenosis secondary to an aortoiliac thrombus was made. At the point of diagnosis, it was felt that rescue of renal function was unfeasible and thus the patient was started on anticoagulation, with initiation of peritoneal dialysis planned. This case highlights the importance of considering alternative diagnoses for the presentation of FPO even in the presence of LV impairment. If this patient had received a prompter diagnosis it is possible that the outcome would have been different.