Shortness of breath in a 52-year-old man with HIV and severe mitral regurgitation

Shortness of breath in a 52-year-old man with HIV and severe mitral regurgitationA 52-year-old man presented to the emergency department with 3 weeks of acute on chronic dyspnea on exertion with progression to dyspnea at rest and associated orthopnea.He reported having experienced dyspnea with exertion for years, which he had attributed to work-related fatigue and which had not caused signifi cant exercise limitations.However, starting 2 years earlier, his dyspnea progressively worsened without any acute triggers.At that time, he began using more pillows for orthopnea.He denied recent travels, fevers, chills, diarrhea, chest pain, weight gain or loss, and sick contacts.His medical history included a history of well-controlled human immunodefi ciency virus (HIV) infection, heart failure with preserved ejection fraction, and mitral valve prolapse with severe mitral regurgitation.He denied using tobacco or alcohol, currently using illicit drugs, or making any dietary changes.He reported briefl y using methamphetamine 2 years ago, and he has since stopped.He endorsed taking his prescribed medications, which included emtricitabine-tenofovir alafenamide, dolutegravir, and furosemide 40 mg twice daily.Three weeks before his current presentation, the patient was admitted to an outside hospital for an acute heart failure exacerbation.At that time, he had dyspnea on exertion after walking 1 fl ight of stairs and after walking to his car from his door.While hospitalized, he underwent aggressive diuresis, which resulted in only mild improvement in his symptoms.Therefore, he was referred for consideration for percutaneous mitral valve repair. ■ EVALUATION ON ADMISSIONOn admission, the patient was afebrile, and his blood pressure was 109/73 mm Hg, heart rate 103 beats per minute, and respiratory rate 22 breaths per minute with an oxygen saturation of 99% on room air.He was alert and oriented to person, place, and time.His lungs were clear to auscultation bilaterally.Heart rate and rhythm were regular, with a III/VI holosystolic murmur at the apex.No jugular venous distention or peripheral edema was noted. Laboratory testingNotable results of blood testing were as follows: • B-type natriuretic peptide 2,122 pg/mL (reference range < 100) • Troponin I 0.02 ng/mL (< 0.04) • HIV RNA copies undetectable (undetectable) • HIV antigen-antibody test reactive (negative) • Sodium 140 mmol/L (136-145) • Bicarbonate 23 mmol/L (22-31) • Creatinine 0.9 mg/dL (0.72-1.25) • Hemoglobin 15.8 g/dL (13.0-17.0)• Hematocrit 46.7% (37.5-49.9)• Platelet count 225 × 10 9 /L (150-450) • Aspartate aminotransferase 85 U/L (5-34) • Alanine aminotransferase 84 U/L (0-55) • Direct bilirubin 0.3 mg/dL (0-0.5)• Total bilirubin 1.2 mg/dL (0.2-1.2) • Albumin 4.3 g/dL (3.5-5.2). Chest radiography and electrocardiographyA chest radiograph showed an enlarged cardiac silhouette without signs of pulmonary edema (Figure 1).An electrocardiogram (ECG) showed sinus tachycardia