A 64-Year-Old Man Comes to the Physician with a 2-Week

A 64-year-old man comes to the physician with a 2-week history of lightheadedness.  He describes episodes of feeling woozy and a sense of heaviness in his head with squatting as he worked in his garden.  He also describes occasional headaches that have recently become worse.  He has no palpitations and has not lost consciousness.  He has known nonischemic cardiomyopathy with a biventricular automatic implantable cardioverter defibrillator placed 2 years ago and a lead revision 1 month ago.  Three weeks ago, an echocardiogram showed a left ventricular ejection fraction of 30%.
His supine blood pressure is 122/75 mm Hg, standing blood pressure is 125/78 mm Hg, and pulse is 60/min.  Examination shows a plethoric face.  The neck and upper chest veins are distended.  No enlarged lymph nodes are palpated.  A 2/6 holosystolic murmur radiating to the axilla is heard at the apex.  Lungs are clear to auscultation.  The liver span is 10 cm.  There is trace bilateral edema of the lower extremities.  Symmetrical pulses are palpated on the upper and lower extremities bilaterally.
Electrocardiogram shows atrioventricular sequential pacing.
Which of the following is the most likely diagnosis?

A) Effusive-constrictive pericarditis
B) Pancoast tumor
C) Subclavian steal syndrome
D) Superior vena cava syndrome
E) Ventricular arrhythmia

Correct Answer:

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