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Diuretic-resistant pretricuspid shunt: what is the missing link?

CLINICAL INTRODUCTION A man in his 70s presented with dyspnoea and oedema. He had a background of chronic kidney disease stage III and atrial fibrillation (AF). The working diagnosis was heart failure (HF). On admission to the local hospital, 12 lead ECG demonstrated rate controlled AF and transthoracic echocardiography (TTE) demonstrated preserved left ventricular (LV) function with a dilated right ventricle (RV). Cardiac MRI (cMR) demonstrated a sinus venosus atrial septal defect (ASD). Despite receiving intravenous furosemide and oral metolazone, his symptoms and weight remained unchanged. Due to a suspicion the pretricuspid shunt was the cause of his right HF, he was transferred to the regional Adult Congenital Heart Disease centre for closure of his ASD. On admission to the regional centre, he remained in clinical right HF, blood tests were stable with haemoglobin 124 g/L, mean corpuscular volume 111 fl, creatinine 151 umol/L, total protein 61 g/L, albumin 20 g/L, estimated glomerular filtration rate 39 mL/min/1.73 m and a repeat 12 lead ECG (figure 1A) and TTE (figure 1B) with additional strain imaging (figure 1C) were performed.