RE: Pulmonary edema complicating ovarian hyperstimulation syndrome: low-pressure edema, high-pressure edema, or mixed edema?

To the Editor: I read with interest the case report of pulmonary edema complicating ovarian hyperstimulation syndrome (OHSS): low-pressure edema, or mixed edema? by BaHammam¹ and would like to highlight some of my concerns.

First, I agree with the paradigm that OHSS causes a capillary leaky syndrome similar to that seen with major extravascular fluid transudation and third spacing occurs under low-pressure pulmonary edema (if no underlying cardiac disease is present) and elevated right-sided heart pressures. When this pulmonary edema is occurring with high left-side heart filling pressure in the absence of pulmonary veno-occlusive disease or mitral stenosis, we need to think about some sort of either systolic or diastolic myocardial depressant state caused by toxins, sepsis, hyperdynamic, hypermatabolism (high output), arrhythmia, or ischemia, besides the volume overload.

In this report the presence of low systemic vascular resistance, high WBCs, and hypotension can indicate a systemic inflammatory state, infection or sepsis that can cause transient myocardial depression and high filling pressures (CVP and PCWP), a part of the fluid overload state. Despite that the measured cardiac index was 5.6 L/m/m², it should have been much higher under such a hypermetabolic condition and hyperdynamic circulation in a young person with normal myocardial function. I think in this situation it would have been very helpful to have information regarding echocardiographic details of cardiac function at the time of ICU admission, a sepsis work up, and repeat follow up echo and full hemodynamic parameters to concur with the final conclusion.