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‘Refeeding a heart’: an echocardiographic follow-up

A 51-year old woman with anorexia nervosa (AN) presented at the emergency department (ED) because of severe malnutrition with therapy refractory hypoglycaemia. She had extreme malnourishment (BMI 12 kg/ m), hypothermia (35.2 C), hypotension (85/52mmHg) and bradycardia (54bpm). Blood work revealed low potassium (2.70mmol/l), vitamin deficiencies and liver function abnormalities. Shortly after arriving in the ED, she required brief resuscitation and electrical cardioversion due Torsades de Pointes causing cardiac arrest. ECG showed a prolonged QTc (512ms). Her left ventricle (LV) was hypokinetic with an ejection fraction of 10–15%, LV global longitudinal strain (GLS) of 6.0% and significant LV wall atrophy, probably due to muscular wasting (Figures 1(A,B) and 2(A)). After slowly initiating nutritional support on the Cardiac Intensive Care Unit (CICU), electrolyte derangements, characteristic for refeeding syndrome, manifested on hospital day three. Caloric reduction and aggressive electrolyte repletion were initiated, followed by progressive fluid accumulation in the lower extremities consistent with refeeding edoema. A repeat echocardiography (day 10) showed amelioration of LV systolic function with an ejection fraction of 50%, LV GLS of 12.7%. There now was a remarkable hypertrophic appearance of the LV walls, most likely due to myocardial edoema (Figures 1(C,D) and 2(B)). The patients’ overall clinical status improved gradually during her hospital stay. An echocardiographic re-evaluation 1.5months after initial presentation showed complete recovery of LV systolic function with an ejection fraction of 60%, LV GLS of 20.5% and normalisation of LV wall thickness (Figure 1(E,F) and 2(C)). AN can cause life threatening medical complications. Similarly, it’s initial treatment, which can lead to refeeding syndrome, can cause severe cardiac arrhythmias, acute heart failure or sudden death. This case illustrates the sequential stages with initial severe cardiac dysfunction, due to myocardial wasting and prolonged starvation, followed by myocardial edoema due to refeeding syndrome and eventual complete recovery of LV systolic function (despite still being cachectic (BMI 14.5 kg/m)). To our knowledge, this is the first time that myocardial edoema is documented during refeeding syndrome.