Brendan Masi, Anvitha Kambham, Abraham E Libman, Himanshukumar Nayak, Roxana Lazarescu
Congestive hepatopathy is an underrecognized manifestation of elevated cardiac filling pressures and systemic venous congestion in heart failure. Although acute decompensated heart failure often presents with pulmonary edema and respiratory compromise, advanced diastolic dysfunction may also produce hepatic congestion, ascites, pleural effusions, and cardiorenal syndrome. We present the case of a 48-year-old male with hypertension, hyperlipidemia, type 2 diabetes mellitus, and recently diagnosed heart failure with preserved ejection fraction (HFpEF) who presented with progressive dyspnea, orthopnea, bilateral lower extremity edema, and declining exercise tolerance. Laboratory evaluation demonstrated hypervolemic hyponatremia, acute kidney injury, hyperbilirubinemia, and cholestatic-predominant liver injury. Echocardiography revealed preserved ejection fraction with severe concentric left ventricular hypertrophy and findings suggestive of elevated right-sided filling pressures, including a dilated inferior vena cava with reduced inspiratory collapse. Left heart catheterization demonstrated significantly elevated left ventricular end-diastolic pressure despite nonobstructive coronary artery disease. Abdominal imaging showed hepatomegaly, ascites, mesenteric congestion, pleural effusion, and gallbladder wall thickening without biliary obstruction. The patient improved with aggressive intravenous diuresis and guideline-directed therapy. The combined clinical, laboratory, imaging, hemodynamic, and treatment-response findings were most consistent with congestive hepatopathy and cardiac ascites due to severe systemic venous congestion. Preserved systolic function does not exclude severe extracardiac congestion, including hepatic congestion, ascites, and cardiorenal syndrome. Recognizing congestive hepatopathy can prevent unnecessary hepatobiliary evaluation and direct appropriate hemodynamic management and decongestion.