Pathology · Year 2 · from Pathology
Case 2: Congestive Heart Failure - Chronic Passive Congestion
Patient Demographics
- Age: 71 years old
- Sex: Male
- Occupation: Retired teacher
Chief Complaint
"My legs are swelling and I can't breathe lying flat"
History of Present Illness
A 71-year-old man with a history of coronary artery disease, prior myocardial infarction (5 years ago), hypertension, and type 2 diabetes presents with progressive bilateral lower extremity swelling and dyspnea over the past 3 weeks. He now sleeps propped up on 3 pillows (orthopnea) and wakes at night gasping for air (paroxysmal nocturnal dyspnea). He has gained 12 pounds over the past month despite poor appetite. He reports his abdomen feels distended and he feels full after eating small amounts. He has been less compliant with his medications and dietary sodium restriction recently due to financial difficulties.
Physical Examination
- Vital Signs: BP 152/88 mmHg, HR 92 bpm irregular, RR 22/min, SpO2 91% on room air
- General: Elderly male in mild respiratory distress, sitting upright
- HEENT: JVP elevated to angle of jaw (>15 cm H2O)
- Cardiovascular: Irregularly irregular rhythm (atrial fibrillation), S3 gallop, laterally displaced PMI, 2/6 holosystolic murmur at apex
- Lungs: Bibasilar crackles to mid-lung fields
- Abdomen: Distended, positive fluid wave, tender hepatomegaly (liver edge 4 cm below costal margin), positive hepatojugular reflux
- Extremities: 3+ pitting edema to mid-thigh bilaterally
Diagnostic Workup
Laboratory Studies:
| Test | Result | Reference Range |
|---|---|---|
| BNP | 1,850 pg/mL | <100 pg/mL |
| Creatinine | 1.8 mg/dL | 0.7-1.3 mg/dL |
| Sodium | 132 mEq/L | 136-145 mEq/L |
| AST | 68 U/L | 10-40 U/L |
| ALT | 52 U/L | 7-56 U/L |
| Total bilirubin | 2.4 mg/dL | 0.1-1.2 mg/dL |
| Albumin | 3.0 g/dL | 3.5-5.5 g/dL |
Imaging:
- Chest X-ray: Cardiomegaly, bilateral pleural effusions (larger on right), pulmonary vascular congestion, Kerley B lines
- Echocardiogram: Severely reduced LV ejection fraction (25%), dilated LV and LA, severe mitral regurgitation, elevated PA pressures (55 mmHg)
Liver Biopsy (performed for elevated LFTs):
- Centrilobular congestion with sinusoidal dilation
- Centrilobular hepatocyte atrophy
- Minimal fibrosis (early cardiac cirrhosis)
- Pattern consistent with chronic passive congestion
Pathology Correlation
This case demonstrates chronic passive congestion from heart failure:
- Pathophysiology of Congestion:
- Left heart failure → elevated pulmonary venous pressure → pulmonary congestion
- Right heart failure → elevated central venous pressure → hepatic and peripheral congestion
- Congestion is passive (impaired venous outflow) vs hyperemia (active arterial dilation)
- Pulmonary Congestion (Left Heart Failure):
- Elevated left atrial pressure transmitted to pulmonary veins
- Fluid transudation into alveoli (pulmonary edema)
- Crackles on auscultation
- "Heart failure cells" - hemosiderin-laden macrophages (chronic congestion)
- Hepatic Congestion (Right Heart Failure):
- "Nutmeg liver" - alternating red (congested centrilobular) and pale (periportal) zones
- Centrilobular hepatocyte necrosis from hypoxia
- Elevated AST/ALT and bilirubin
- Progressive fibrosis can lead to cardiac cirrhosis
- Peripheral Edema:
- Elevated hydrostatic pressure from venous congestion
- Decreased oncotic pressure from hypoalbuminemia
- Sodium and water retention from neurohormonal activation
- Dependent distribution (gravity-dependent)
Clinical Image
Cross-section of liver demonstrating the "nutmeg liver" pattern of chronic passive congestion. The alternating dark red areas (congested centrilobular zones) and lighter tan areas (relatively spared periportal zones) create a mottled appearance resembling a cut nutmeg. The centrilobular regions are most affected because they are farthest from the arterial blood supply and most susceptible to hypoxia.
Image Source: Wikimedia Commons - "Chronic Passive Congestion of Liver" License: CC BY-SA 3.0 URL: https://commons.wikimedia.org/wiki/File:Chronic_passive_congestion_of_liver_(2).jpg
Diagnosis
Acute on Chronic Systolic Heart Failure (HFrEF) with biventricular failure
- New York Heart Association Class IV
- Stage D (advanced refractory)
Treatment
- IV furosemide for aggressive diuresis (goal net negative 2-3 L/day)
- Sodium and fluid restriction
- Daily weights and intake/output monitoring
- Optimize guideline-directed medical therapy:
- ACE inhibitor or ARB
- Beta-blocker (when euvolemic)
- Mineralocorticoid receptor antagonist
- Consider SGLT2 inhibitor
- Rate control for atrial fibrillation
- Anticoagulation for atrial fibrillation
- Consider cardiac resynchronization therapy (CRT) or ICD
- Evaluate for advanced therapies (LVAD, transplant)
Teaching Points
- Congestion is passive blood accumulation from impaired venous outflow (vs. hyperemia which is active)
- "Nutmeg liver" results from centrilobular congestion in right heart failure
- Centrilobular hepatocytes are most vulnerable because they are farthest from arterial supply
- Transudative edema results from increased hydrostatic pressure and/or decreased oncotic pressure
- BNP is released from stretched ventricular myocytes and correlates with filling pressures
- Heart failure cells (hemosiderin-laden alveolar macrophages) indicate chronic pulmonary congestion
- The difference between left and right heart failure explains the different clinical presentations