Paroxysmal Atrial Fibrillation with RVR, hypotension, volume depletion, good EF, AND pulmonary edema. Strange. Why? What to do?

A 30-something woman presented with a few days of feeling ill.  She had a history of paroxysmal atrial fibrillation, bio-prosthetic mitral valve, and tricuspid valvuloplasty, and was on Coumadin.Records showed she is usually in sinus rhythm and has normal LV function.She presented hypotensive (systolic pressure 80), with diffuse B lines, flat IVC, good LV function, and an irregular, fast heart beat.Here is here ECG:Atrial fib with RVR and some probable ischemic ST depression in V3-V6Here is her POCUS:What do you think?  There is asmall LV with good function and alarge left atrium, andmoderately large RV.There is another finding on the ultrasound which I ' ll explain below.  Do you see it?Herinferior vena cava was very flat, with respiratory variation, and she haddiffuse bilateral B linesHere is her chest X-ray:This shows pretty severe pulmonary edema.Questions:1. Why does she have severe pulmonary edema, excellent LV function, a small LV, and a flat IVC?2. What precipitated this acute emergency and why?3. What do you want to dofirst?Clinical CourseThe paradoxes of this case were not immediately identified.  At first they had thought, due to the flat IVC and good LV function, that she was septic with pneumonia (thus relatively volume depleted, interpreting the B-lines and X-ray as pneumonia rather than as pulmonary edema). Thus, they had given fluids and antibiotics.  This management did not improve the pulmonary edema.Comment:Whether this is...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs