0
ONLINE EXCLUSIVES
Ultrasound Corner |

A 39-Year-Old Woman With Palpitations and DyspneaWoman With Palpitations and Dyspnea FREE TO VIEW

Gisela I. Banauch, MD, FCCP; Adam Katz, PA-C, MPAS, FCCP; Eric Cucchi, PA-C, MPAS
Author and Funding Information

From the Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Massachusetts Medical School - Medicine, Worcester, MA.

CORRESPONDENCE TO: Gisela I. Banauch, MD, FCCP, University of Massachusetts Medical School - Medicine, 55 Lake Ave N, Room S6-842, Worcester, MA, 01655; e-mail: banauchg@ummhc.org


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(4):e137-e139. doi:10.1378/chest.14-1101
Text Size: A A A
Published online

A 39-year-old woman presented to the ED with sudden onset of dyspnea after developing palpitations. On further questioning, she had noted swollen legs and had been on a flight from Utah to Massachusetts 10 days prior to admission. Her past medical history included obesity, and she had started taking oral contraceptive agents 2 months prior to her presentation.

On presentation, the patient had a temperature of 36.3°C. Her BP was 129/80 mm Hg, heart rate was regular and tachycardic at 131 beats/min, respiratory rate was 32 breaths/min, and oxygen saturation on room air was 98%. The physical examination revealed an obese woman in no acute distress, with bilateral vesicular breath sounds without wheezes, crackles, or rhonchi. Cardiac auscultation revealed normal first and second heart sounds without murmurs, rubs, or gallops. Examination of the extremities revealed bilateral symmetric nonpitting edema to the mid-thigh.

Pertinent laboratory values included a troponin level of 1.78 ng/mL and brain natriuretic peptide level of 1,150 pg/mL. Her ECG showed sinus tachycardia with right-axis deviation, normal conduction intervals, and no horizontal ST depressions suggesting cardiac ischemia. A chest radiograph showed clear lungs. A goal-directed ultrasound examination (lung ultrasound and echocardiogram) was then performed (Video 1).

Based on the echocardiogram, what is the most likely diagnosis?

Video 1.

Case Presentation

Diagnosis: Acute pulmonary embolism

The chest ultrasound shows A lines with sliding lung in both anterior, upper hemithoraces (Video 1). A lines are the two-dimensional (2-D) ultrasound image that is generated when an air-filled hemithorax is subjected to ultrasound. The appearance of A lines is compatible with either normally aerated lung or pneumothorax.1 The presence of sliding lung determines whether pneumothorax is likely present or not. When sliding lung is seen on the 2-D image, pneumothorax cannot be present at the particular site of the chest that is being imaged. Sliding lung is the shimmering quality that the 2-D ultrasonographic image of the pleural line assumes when the parietal and the visceral pleural move against each other during normal respiration (Video 1). The presence of sliding lung indicates that the ultrasound beam penetrates to the level of the visceral pleura, thus assuring the examiner that there is no air interposed between the parietal and the visceral pleura, as would be the case in a pneumothorax.

Thus, this patient experienced dyspnea with normally aerated lung on both ultrasound and chest radiograph, and in the absence of wheezing on physical examination. A goal-directed echocardiogram was then performed to further search for cardiac causes of dyspnea (Video 1).

The goal-directed echocardiogram shows signs of right-sided heart dysfunction, with a systolic and diastolic deformation of the short axis of the left ventricle from its normal circular shape at the midventricular level to a shape resembling the letter D2 (“D sign”) (Video 1).

Furthermore, the right ventricle appeared dilated in the apical four-chamber view and in the subcostal four-chamber view (Video 1). Normal, right ventricular, end-diastolic area in both of these views should not exceed 66% of left ventricular end-diastolic area. End diastole is defined as the time point at which the atrioventricular valves have just closed. Dilation of the right ventricular end-diastolic area to 67% to 100% of the left ventricular end-diastolic area represents a moderate degree of right ventricular dilation. Dilation of the right ventricle to such an extent that its end-diastolic area exceeds the end-diastolic area of the left ventricle is considered severe right ventricular dilation; this was the case in this patient.

A further sign of right-sided heart dysfunction depicted in Video 1 is the presence of vigorous contractility at the right ventricular apex, with poor contractility of the adjacent lateral wall of the right ventricle, often referred to as McConnell sign. This echocardiographic sign is thought to arise from muscle fibers that are shared between the right and the left ventricles at the apex, with normal left ventricular apical contraction thus inferring the appearance of vigorous motion to the right ventricular apex.3

In addition, Video 1 shows a septal “bounce,” which represents another sign of right-sided heart dysfunction. The septal bounce consists of a rapid back-and-forth motion of the interventricular septum toward and away from the center of the left ventricular cavity during systole, and is thought to be due to the different systolic rates of rise of intracavitary pressure in the more-muscular left ventricle as opposed to the less-muscular right ventricle.4 This septal bounce is best appreciated in the parasternal short axis view in Video 1, but is also identifiable in the other views of video 1 when they are carefully reviewed.

The subcostal view of the inferior vena cava in Video 1 further strengthens the diagnosis of right-sided heart dysfunction by depicting a dilated inferior vena cava with poor respiratory variation, consistent with right ventricular failure and congestion of the central venous system.

The sudden onset of dyspnea with a normal lung and signs of significant right-sided heart dysfunction on goal-directed ultrasound makes a diagnosis of pulmonary embolism very likely. To further expedite this patient’s ultimate diagnosis and provide more rapid treatment, an ultrasonographic assessment of both lower extremities for DVT should then have completed the goal-directed ultrasound assessment. Presence of DVT would further support this patient’s diagnosis of acute dyspnea due to a submassive pulmonary embolism, though the absence of a DVT on lower extremity ultrasound would not exclude this diagnosis. Multiorgan ultrasound of the target organs involved in thromboembolic disease (ie, lung, heart, and lower extremity veins) has been shown to accurately reflect the diagnosis of pulmonary embolism, to have superior sensitivity and specificity compared with ultrasound examination of only a single organ, and to substantially reduce the need for CT angiographic examination.5,6

Instead of a lower extremity ultrasound, an emergent spiral CT scan of the chest was performed, which showed a saddle embolus at the main pulmonary artery bifurcation with extension into pulmonary arteries of both lower lobes, the right middle lobe, and the left upper lobe. Based on this constellation of clinical, echocardiographic, laboratory, and radiographic findings, the patient agreed to systemic thrombolysis, which was administered within 24 h of admission.

On the day following her presentation and following the thrombolysis, the patient’s dyspnea and sinus tachycardia had both resolved, and a repeated goal-directed echocardiogram was performed to assess whether echocardiographic signs of right-sided heart dysfunction also had resolved (Video 2). This follow-up study clearly demonstrates the resolution of right ventricular dilation in the apical and subcostal four-chamber views. For greater clarity, the corresponding views before thrombolysis precede the same views obtained from the same patient within 12-18 h of completion of thrombolysis, and within 24 h of admission (Video 2). This video also shows that the geometry of the left ventricle has normalized to a circular cross section in the midventricular parasternal short-axis view. The inferior vena cava has returned to normal size and normal respiratory variation, and provides further echocardiographic evidence of normal right ventricular systolic function. Other signs of right ventricular dysfunction, such as the septal bounce and the McConnell sign, have also resolved.

Video 2.

Discussion

Detection of right-sided heart dysfunction can be further enhanced through two different quantitative measurements of right ventricular systolic function: (1) tricuspid annular motion (TAM), and (2) velocity of tricuspid annular myocardium during the ejection phase of right ventricular systole. Normal values for TAM equal or exceed 17 mm in adults,7 and normal values for lateral tricuspid annular myocardial systolic velocity exceed 8.7 cm/s in adults.8 For the patient presented here, TAM was measured and changed from a borderline decreased value of 1.78 cm on diagnosis to a more normal value of 2.22 cm after thrombolysis (Video 3).

Video 3.

Discussion

  • 1. Point-of-care echocardiography is invaluable for timely diagnosis and follow-up in patients with submassive pulmonary embolism.

  • 2. In the appropriate clinical scenario, echocardiographic signs that suggest a pulmonary embolism include:

    • • right ventricular dilation, best appreciated in the apical four-chamber view, but also often seen in the subcostal four-chamber view

    • • deformation of the left ventricular geometry, best appreciated in the parasternal short-axis view

    • • right ventricular hypokinesis, best appreciated in the apical four-chamber view and the subcostal four-chamber view. The advanced echocardiographer can further verify hypokinesis with quantitative measurements.

  • 3. For patients with submassive pulmonary embolism, resolution of abnormal echocardiographic findings is an effective and time-efficient way to assess response to therapy.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. This submission is dedicated to Kimberly Roberts. In her easy, cheerful way, she showed us all how one can accept great personal adversity with amazing grace.

Additional information: To analyze this case with the videos, see the online version of this article.

Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. [CrossRef] [PubMed]
 
Vieillard-Baron A. Assessment of right ventricular function. Curr Opin Crit Care. 2009;15(3):254-260. [CrossRef] [PubMed]
 
López-Candales A, Edelman K, Candales MD. Right ventricular apical contractility in acute pulmonary embolism: the McConnell sign revisited. Echocardiography. 2010;27(6):614-620. [CrossRef] [PubMed]
 
Jessup M, Sutton MS, Weber KT, Janicki JS. The effect of chronic pulmonary hypertension on left ventricular size, function, and interventricular septal motion. Am Heart J. 1987;113(5):1114-1122. [CrossRef] [PubMed]
 
Koenig S, Chandra S, Alaverdian A, Dibello C, Mayo PH, Narasimhan M. Ultrasound assessment of pulmonary embolism in patients receiving CT pulmonary angiography. Chest. 2014;145(4):818-823. [CrossRef] [PubMed]
 
Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145(5):950-957. [CrossRef] [PubMed]
 
Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-713. [CrossRef] [PubMed]
 
Dalen H, Thorstensen A, Vatten LJ, Aase SA, Stoylen A. Reference values and distribution of conventional echocardiographic Doppler measures and longitudinal tissue Doppler velocities in a population free from cardiovascular disease. Circ Cardiovasc Imaging. 2010;3(5):614-622. [CrossRef] [PubMed]
 

Figures

Tables

Video 1.

Case Presentation

Video 2.

Discussion

Video 3.

Discussion

References

Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. [CrossRef] [PubMed]
 
Vieillard-Baron A. Assessment of right ventricular function. Curr Opin Crit Care. 2009;15(3):254-260. [CrossRef] [PubMed]
 
López-Candales A, Edelman K, Candales MD. Right ventricular apical contractility in acute pulmonary embolism: the McConnell sign revisited. Echocardiography. 2010;27(6):614-620. [CrossRef] [PubMed]
 
Jessup M, Sutton MS, Weber KT, Janicki JS. The effect of chronic pulmonary hypertension on left ventricular size, function, and interventricular septal motion. Am Heart J. 1987;113(5):1114-1122. [CrossRef] [PubMed]
 
Koenig S, Chandra S, Alaverdian A, Dibello C, Mayo PH, Narasimhan M. Ultrasound assessment of pulmonary embolism in patients receiving CT pulmonary angiography. Chest. 2014;145(4):818-823. [CrossRef] [PubMed]
 
Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145(5):950-957. [CrossRef] [PubMed]
 
Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-713. [CrossRef] [PubMed]
 
Dalen H, Thorstensen A, Vatten LJ, Aase SA, Stoylen A. Reference values and distribution of conventional echocardiographic Doppler measures and longitudinal tissue Doppler velocities in a population free from cardiovascular disease. Circ Cardiovasc Imaging. 2010;3(5):614-622. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543