A 56 year-year-old
male was referred to you with progressive easy fatigueability,
moderate exertional dyspnea and two pillow orthopnea
of a 1 year duration.
Relevant physical findings include
BP 104/64 mm Hg, pulse 104/min and unlabored repirations
at 20/min. Neck veins are engorged 3 cm above the
clavicle at 30 degrees and the abdomino-jugular (also
referred to as hepato-jugular) reflux is positive.
The apical impulse is located two cm lateral to the
left mid-clavicular line in the 6th interspace. Soft
S3 and S4 gallops together with a grade 2/6 holosytolic
murmur are heard at the apex. There are bibasilar
inspiratory rales and 2+ pitting edema of the legs.
Chest x-ray reveals moderate cardiomegaly
with pulmonary congestion. EKG shows a sinus mechanism
with a CLBBB and frequent unifocal premature ventricular
contractions. Echocardiography reveals a left ventricular
end-diastolic dimension of 62 mm with global hypokinesia,
EF of 38% and moderate MR. The inferior vena cava
is moderately distended and demonstrates poor inspiratory
ONE of the following is initially indicated in the
management of this patient?