SESSION TYPE: Cardiovascular Student/Resident Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Unilateral pulmonary edema (UPE) is a rare complication of acute ischemic severe mitral regurgitation (MR) that almost always appear as a right focal lung opacity. We present a case of pulmonary edema limited to the left hemithorax associated with acute myocardial infarction (MI).
CASE PRESENTATION: A 68-year-old woman, with known coronary artery disease, was admitted with worsening recurrent chest pain and mild dyspnea of 2 weeks duration. On examination, she was hypoxic with 80% oxygen saturation on room air which improved with lying on her right side. Blood pressure was 100/65, pulse 60/min, respiratory rate 20/min. Auscultation revealed crackles in the lower two thirds of the left lung and an apical soft pansystolic murmur. EKG showed new ST segment depression in leads V2-V5. Chest X-ray (CXR) showed left hemithorax opacification indicating UPE. Troponin level was elevated. The diagnosis of non-ST elevation MI was made and the patient was treated with Heparin, nitroglycerin, clopidogrel and asprin,in addition to IV furosemide and CPAP. Transthoracic echocardiography showed new severe eccentric MR with hypokinesis of the lateral and posterior walls and an ejection fraction of 45-50%. Urgent cardiac catheterization showed acute totally occluded left circumflex artery which was successfully opened and stent placed.The patient gradually improved clinically after the procedure with a good response to diuretics. A follow-up CXR showed complete resolution of the pulmonary edema.
DISCUSSION: UPE is a rare, frequently misdiagnosed radiologic and clinical condition with a variety of mechanisms, both cardiac and non-cardiac. One etiology is ischemic MR. Right-sided pulmonary edema is a rare complication in various case reports with the frequent use of transesophageal echocardiography as a tool to demonstrate eccentric MR jet targeting the ostia of one of the right pulmonary veins, with reversal of flow in the veins resulting in focal pulmonary edema. Left-sided pulmonary edema is even less frequently seen possibly due to the direction of the regurgitant stream and the superior left lung lymphatic drainage. The prevalence of right pulmonary veins sharing common ostia is only 0.5%, compared to 8-14% for the left pulmonary veins. This might be a possible explanation of the focal nature of right UPE versus the UPE involving the entire left hemithorax as seen in our case.
CONCLUSIONS: This case illustrates the possibility of acute ischemic MR being complicated by UPE involving the left hemithorax. Although it is extremely rare, it should be considered in the differential diagnosis in an appropriate clinical setting. Prompt diagnosis and aggressive treatment is necessary as both acute ischemic MR and UPE are independently associated with increased mortality.
1) Circulation. 2010 Sep 14;122(11):1109-15. Epub 2010 Aug 30. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema.
DISCLOSURE: The following authors have nothing to disclose: Manju Bengaluru Jayanna, Susan Schima, Ahmed Aboeta
No Product/Research Disclosure InformationCreighton University Medical Center, Omaha, NE