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A Man in His 60s With Shortness of Breath, Shock, and Cardiac Arrest FREE TO VIEW

Pedro D. Salinas, MD; Alex Gifford, MD
Author and Funding Information

aDepartment of Inpatient Medicine, Intensive Care Unit, Kadlec Regional Medical Center, Richland, WA

bDepartment of Medicine, Section of Pulmonary and Critical Care Medicine, Lebanon, NH

CORRESPONDENCE TO: Pedro D. Salinas, MD, Kadlec Regional Medical Center, 888 Swift Blvd, Richland, WA 99352


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(5):e103-e105. doi:10.1016/j.chest.2016.11.062
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Published online

A man in his 60s presented to an outside hospital with worsening shortness of breath over the preceding 6 months. He was hospitalized with atrial fibrillation with rapid ventricular response, and he experienced cardiac arrest requiring defibrillation and multiple doses of epinephrine. His vital signs on transfer to our ICU were temperature, 36.3°C; heart rate, 50 beats per minute; and BP, 90/50 mm Hg on 20 μg/min on norepinephrine. His ventilator settings were volume control rate of 16; tidal volume of 360 mL, positive end-expiratory pressure of 5, and Fio2 of 1.0. On physical examination he was sedated, with a 2/6 systolic murmur and decreased S1/S2 heart sounds. Pitting edema was present in all extremities, and his skin was cool to the touch. His laboratory examinations were remarkable for a WBC count of 14.7 × 103/μL, creatine level of 2.8 mg/dL, aspartate aminotransferase level of 7,000 units/L, international normalized ratio of 5.7, and lactate level of 8 mmol/L. His chest radiograph demonstrated multifocal opacities and bilateral pleural effusions. CT of the chest and abdomen showed abdominal ascites. Multiorgan failure quickly developed, including anuric renal failure, severe hypoxemia with Pao2/Fio2 ratio of 125, coagulopathy, worsening hyperlactatemia, and refractory hypotension despite maximal doses of norepinephrine and vasopressin. Broad-spectrum antibiotics and steroids were given empirically.

The ICU team obtained a focused critical care echocardiogram (CCE) to determine the cause of shock (Video 1A-1E).

Question: Based on the current echocardiographic findings, what is the likely cause of cardiac arrest and shock?

Answer: Severe left ventricular dysfunction and probable severe aortic stenosis (Video 2, discussion)

Focused CCE assessment includes evaluation of pericardial effusion, left ventricular (LV) and right ventricular (RV) function, RV/LV ratio, and assessment of the inferior vena cava (diameter and respirophasic changes).,, The assessment of gross valvular abnormalities by color Doppler as part of the focused CCE evaluation is recommended by some but not all expert groups.,Video 1A-1E is part of the focused CCE. A deep parasternal long-axis view in Video 1A shows the presence of a left pleural effusion and reduced LV function. Video 1B is a parasternal long-axis view that demonstrates severely reduced LV function and dyskinesia, possible enlargement of the right ventricle, and a decreased aortic valve opening. A short-axis view in Video 1C confirms reduced LV function and septal flattening in diastole suggestive of RV volume overload. Video 1D is an apical four-chamber view that demonstrates an RV/LV ratio < 1, which excludes moderate to severe RV dilatation. A subcostal view in Video 1E shows a plethoric inferior vena cava with minimal respirophasic changes consistent with increased central venous pressure and an unlikely fluid-responsive shock state.

The goal of focused CCE is to help establish the cause in a patient presenting with shock.,, In this case, we were able to identify global systolic ventricular dysfunction; however, the identification of a heavily calcified aortic valve and a significant reduction of the atrioventricular valve (AV) opening was key in determining the next step in diagnosis. Further assessment of valve anatomy and measurement of transvalvular velocities and pressure gradients were required to establish the cause of cardiogenic shock in this case. The understanding of Doppler principle and correct use and interpretation is a required skill in advanced CCE.,,,

In the videos and images 1F-1K, we demonstrate some advanced CCE skills needed to diagnose the cause of cardiogenic shock in this patient. A parasternal long-axis zoom view of the aortic valve in Video 1F demonstrates a heavily calcified aortic valve with minimal leaflet movement. A parasternal short-axis view in Video 1G confirms lack of leaflet opening and an inability to distinguish the trileaflet anatomy of the aortic valve. Color Doppler in Video 1H reveals moderate aortic valve regurgitation, which contraindicates the use of an intra-aortic balloon pump in this patient with cardiogenic shock. Moderate mitral valve regurgitation is also seen.

A heavily calcified aortic valve and reduced leaflet excursion is suggestive of aortic stenosis. However, to confirm and correctly quantify the severity of aortic stenosis, the use of spectral Doppler modalities, such as continuous-wave Doppler and pulsed-wave Doppler, is necessary.

The American Society of Echocardiography recommends using three modalities to quantify aortic stenosis: peak aortic jet velocity, mean AV gradient, and calculation of aortic valve area (AVA). Even though advanced echocardiography in the intensive care setting focuses primarily on hemodynamic assessments such as cardiac output, filling pressures, pulmonary artery pressure, and RV function assessment, among other hemodynamic measurements recommended,,,, when aortic stenosis is suspected, a simple and quick screening method can be performed by obtaining a peak aortic jet velocity. This measurement is based on the characteristics of fluid dynamics in a stenotic valve, in which flow accelerates as blood enters a narrow orifice. An apical five-chamber view with continuous-wave Doppler in Video 1 image 1I shows a peak aortic valve jet velocity that measures 4.4 m/s. A peak aortic jet velocity > 4 m/s correlates with severe aortic stenosis and poor outcome. One operator-dependent limitation in obtaining accurate transvalvular velocities is the parallel alignment of the Doppler signal, since increasing the interrogation angle will underestimate true peak velocities. Also, in patients with reduced LV function, aortic jet peak velocities may be lower (ie, low-flow/low-gradient aortic stenosis), despite a high degree of stenosis, and can only be recognized when there is a discrepancy with the AVA calculation or with recalculation of velocities and gradients after an inotropic challenge with dobutamine. In our case, the high aortic jet velocity measurement was consistent with severe aortic stenosis, and a standard comprehensive echocardiogram was ordered to confirm the diagnosis (Video 1 images 1J, 1K). Video 1 image 1J demonstrates a peak aortic jet velocity of 4.5 m/s. The maximum aortic pressure gradient (ΔPmax) is calculated from the peak aortic jet velocity (Vmax) using the simplified Bernoulli equation: ΔPmax = 4 Vmax2, and the mean gradient is obtained by tracing the velocity curve and averaging instantaneous gradients as shown in Video 1 image 1J (mean gradient of 61 mm Hg). The AVA calculation is based on the continuity principle of flow. The elements needed for this calculation are the stroke volume proximal to the aortic valve and the stroke volume in the stenotic orifice. To make the calculation, the LV outflow tract diameter, the LV outflow tract velocity-time integral (VTI), and the aortic stenosis VTI need to be determined. Video 1 image 1K displays in the screen a critical AVA of 0.44 cm2. The formula for AVA calculation is: AVA = (CSALVOT × VTILVOT)/VTIAS. The simplified continuity equation uses maximum velocities instead of VTIs: AVA = (CSALVOT × VLVOT)/Vmax.

The cardiology and cardiothoracic surgery departments were consulted. Emergent balloon valvuloplasty was contraindicated due to the presence of moderate aortic regurgitation. A very high-risk surgical aortic valve replacement was planned for the next day, but unfortunately the patient died of pulseless electrical activity arrest before surgical intervention.

  • 1.

    Focused critical care echocardiography is the first diagnostic step in undifferentiated shock.

  • 2.

    Identification of a heavily calcified aortic valve, poor leaflet excursion, or lack of trileaflet anatomy requires further examination and interrogation of the aortic valve to estimate transvalvular velocities and gradients.

  • 3.

    The detection of an elevated aortic jet peak velocity can be obtained by a trained intensivist in advanced critical care echocardiography, as illustrated in this case with prompt involvement of the cardiology and cardiothoracic surgery consultants.

Financial/nonfinancial disclosures: None declared.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: The Videos can be found in the Supplemental Materials section of the online article.

Mayo P.H. .Beaulieu Y. .Doelken P. .et al American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography. Chest. 2009;135:1050-1060 [PubMed]journal. [CrossRef] [PubMed]
 
Oren-Griberg A. .Talmor D. .Brown S.M. . Focused critical care echocardiography. Crit Care Med. 2013;41:2618-2626 [PubMed]journal. [CrossRef] [PubMed]
 
Via G. .Hussain A. .Wells M. .et al International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014;27:683.e1-683.e33 [PubMed]journal. [CrossRef]
 
Expert Round Table on Echocardiography in ICU International consensus statement on training standards for advanced critical care echocardiography. Intensive Care Med. 2014;40:654-666 [PubMed]journal. [CrossRef] [PubMed]
 
Narasimhan M. .Koenig S.J. .Mayo P.H. . Advanced echocardiography for the critical care physician: part 2. Chest. 2014;145:135-142 [PubMed]journal. [CrossRef] [PubMed]
 
Narasimhan M. .Koenig S.J. .Mayo P.H. . Advanced echocardiography for the critical care physician: part 1. Chest. 2014;145:129-134 [PubMed]journal. [CrossRef] [PubMed]
 
Porter T.R. .Shillcutt S.K. .Adams M.S. .et al Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2015;28:40-56 [PubMed]journal. [CrossRef] [PubMed]
 
Baumgartner H. .Hung J. .Bermejo J. .et al Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr. 2009;10:1-25 [PubMed]journal. [CrossRef] [PubMed]
 
Otto C.M. . Textbook of Clinical Echocardiography.  2013;:- [PubMed] Saunders Philadelphiajournal
 

Figures

Tables

References

Mayo P.H. .Beaulieu Y. .Doelken P. .et al American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography. Chest. 2009;135:1050-1060 [PubMed]journal. [CrossRef] [PubMed]
 
Oren-Griberg A. .Talmor D. .Brown S.M. . Focused critical care echocardiography. Crit Care Med. 2013;41:2618-2626 [PubMed]journal. [CrossRef] [PubMed]
 
Via G. .Hussain A. .Wells M. .et al International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014;27:683.e1-683.e33 [PubMed]journal. [CrossRef]
 
Expert Round Table on Echocardiography in ICU International consensus statement on training standards for advanced critical care echocardiography. Intensive Care Med. 2014;40:654-666 [PubMed]journal. [CrossRef] [PubMed]
 
Narasimhan M. .Koenig S.J. .Mayo P.H. . Advanced echocardiography for the critical care physician: part 2. Chest. 2014;145:135-142 [PubMed]journal. [CrossRef] [PubMed]
 
Narasimhan M. .Koenig S.J. .Mayo P.H. . Advanced echocardiography for the critical care physician: part 1. Chest. 2014;145:129-134 [PubMed]journal. [CrossRef] [PubMed]
 
Porter T.R. .Shillcutt S.K. .Adams M.S. .et al Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2015;28:40-56 [PubMed]journal. [CrossRef] [PubMed]
 
Baumgartner H. .Hung J. .Bermejo J. .et al Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr. 2009;10:1-25 [PubMed]journal. [CrossRef] [PubMed]
 
Otto C.M. . Textbook of Clinical Echocardiography.  2013;:- [PubMed] Saunders Philadelphiajournal
 
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