Breathless after bypass

A 65-year-old normotensive, non-athletic man presented to the cardiology clinic with exertional dyspnoea and chest discomfort. Echocardiography revealed mild left ventricular hypertrophy with good systolic function but with regional wall motion abnormalities suggesting ischaemia. Coronary angiography showed significant three-vessel disease. He underwent coronary artery bypass surgery, which was complicated by recurrent pericardial and pleural effusions, requiring a pericardial window procedure. Over the following year he became increasingly oedematous and breathless. On ECG the complexes were low voltage with impaired R wave progression and atrial fibrillation. Echocardiography revealed progression of the left ventricular hypertrophy (LVH) with a bright myocardium and restrictive filling pattern. MRI scanning confirmed the diagnosis of cardiac amyloidosis. He was referred for transplant but was considered unsuitable due to extensive mediastinal scarring. This case demonstrates the importance of a high index of suspicion for amyloidosis, especially in patients with unexplained LVH. Cardiac MRI or biopsy may expedite the diagnosis.