35 year old male, PMH including HTN, DM, OSA and obesity who presents to the ED with leg edema. Patient has noted some SOB and  for about a month and leg edema

• tachy at 106,
• BNP elevated to 398 but
• trop negative.
• CXR with some congestion in the hila.

• 

• Pt was given 20mg IV Lasix
• active smoker.
• formerly a heavy drinker
• CXR: 1. Moderate cardiomegaly with congested hila.
• TTE: EF 25% with severe global hypokinesis and grade 3 diastolic dysfunction
• Right heart cath
  • RHC
    • elevated filling pressures with
      • wedge of 30 mmHg and
      • RA 10 mmHg
• Coronary Cath
• INDICATIONS:
  Congestive Heart Failure

  CORONARY CIRCULATION:
  Left Dominant
  Left Main: Normal
  LAD:
  Left Anterior Descending: Normal
  LCX:
  Left Circ: Normal
  RCA:
  RCA: Anomalous origin from proximal LAD, normal, non-dominant

• Coronary CT today to evaluate course of anomalous RCA showed
  • anomalous right coronary artery with prepulmonic course,
  • severe globally depressed biventricular function, and
  • no significant coronary artery plaque or stenosis.