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An 82-Year-Old Woman With Ongoing Dyspnea FREE TO VIEW

Guido Tavazzi, MD; Gabriele Via, MD; Antonio Braschi, MD; Susanna Price, MD, PhD
Author and Funding Information

aDepartment of Anesthesia, Intensive Care and Pain Therapy, University of Pavia, Pavia, Italy

bDepartment of Anesthesia and Intensive Care and Emergency Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy

cDepartment of Adult Intensive Care, Royal Brompton Hospital NHS Foundation Trust, London, England

CORRESPONDENCE TO: Guido Tavazzi, MD, Fondazione IRCCS Policlinico San Matteo, Department of Anesthesia, Intensive Care and Emergency Medicine, Viale Camillo Golgi 19, 27100, Pavia (PV), Italy


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(1):e9-e11. doi:10.1016/j.chest.2016.02.687
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Published online

An 82-year-old woman presented to the ED with severe dyspnea and hypertension (200/133/100 mm Hg). Her medical history included chronic obstructive pulmonary disease and a recent admission for heart failure that was treated with furosemide and a calcium channel blocker. Her ECG was known to show left bundle branch block. Chest auscultation revealed bilateral bibasal crackles. Her oxygen saturation was 92% using helmet CPAP (Fio2, 60%; positive end-expiratory pressure, 10 cm of water). Arterial blood gas analysis revealed a pH of 7.30, Pao2 of 66 mm Hg, Paco2 of 54 mm Hg, a hemoglobin value of 15.9 g/dL, and a lactate level of 1.8 mg/dL. The brain natriuretic peptide level was 350 ng/dL and both 3-h and 6-h troponin I (TnI) assays were negative (0.04 ng/mL). The creatinine level was 1.72 mg/dL and the BUN level was 75 mg/dL. The ECG showed sinus rhythm (85 beats/min), complete left bundle branch block, QS in V1-V2 with no new changes on the ECG suggestive of cardiac ischemia. Lung ultrasonography (LUS) revealed bilateral pleural effusions and features consistent with pulmonary interstitial syndrome. Focused cardiac ultrasonography (FoCUS) demonstrated mild left ventricular (LV) dilatation with moderate to severe LV systolic dysfunction (ejection fraction [EF], 35%) with no other abnormalities. Chest radiography confirmed the LUS findings (Video 1). Acute coronary syndrome was ruled out, and the diagnosis of acute decompensation of chronic hypertensive heart disease was made. She was treated with intravenous urapidil and furosemide, with substantial improvement allowing transfer to the general medical ward.

Twelve hours later she became acutely desaturated, with arterial gas analysis showing a pH of 7.11, Pao2 of 57 mm Hg, Paco2 of 89.4 mm Hg, oxygen saturation of 76%, bicarbonate level of 27.3 mEq/L, base excess of –1.4 mmol/L, and lactate level of 4.2 mg/dL. She became progressively hypotensive (90/60/45 mm Hg) and was transferred to the intensive care unit and intubated for severe respiratory distress. Vasodilating agents were stopped, and she was given norepinephrine (0.04 μg/kg/min) and epinephrine (0.02 μg/kg/min). Central venous saturations were 50%, the ECG was unchanged, and repeated TnI assay results were 0.05 ng/mL. Comprehensive echocardiography was performed.

Question: Based on the clinical findings and the echocardiogram, what would be the next step and the most likely diagnosis?

Answer: Comprehensive echocardiography should be performed to demonstrate the cause of the acute heart failure and the ongoing myocardial ischemia.

In this case, the clinical presentation and FoCUS findings (LV systolic impairment, bilateral pleural effusion, and homogeneous B-line distribution pattern) suggested cardiogenic pulmonary edema as the most likely diagnosis. Comprehensive transthoracic echocardiography (Video 2) showed a mildly dilated left ventricle (end-diastolic volume, 165 mL) with septal dyskinesia, basal to midlateral hypokinesia, and apical and inferior basal akinesia with an EF of 35%. No significant valvular dysfunction was seen. Transmitral pulsed-wave Doppler demonstrated an isolated diastolic A wave. Mitral annular plane systolic excursion (MAPSE) was markedly abnormal, with reduced lateral, septal, and inferior wall excursion and associated increased duration of myocardial contraction with postejection shortening (annular displacement peaking after the T wave on the ECG) (Video 2).

In this patient with clinical, radiographic, and LUS features of pulmonary edema, transmitral filling would usually be expected to demonstrate dominant early diastolic filling (E wave). Demonstration of an isolated A wave in this setting should prompt interrogation of MAPSE for its amplitude, timing, and duration. Reduction in MAPSE amplitude can occur in both acute and chronic LV dysfunction. When longitudinal contraction is prolonged (as in this case), the left ventricle continues to develop tension into diastole, with a consequent suppression of early diastolic (E wave) filling. The additional finding of postejection shortening is highly suggestive of myocardial ischemia as the underlying cause.

Based on these findings, a nitrate infusion was initiated, and the patient underwent coronary angiography that demonstrated a 95% stenosis of the circumflex coronary artery. This was treated with a drug-eluting stent. On return to the ICU (Video 3), two-dimensional transthoracic echocardiographic findings were unchanged, with persistent regional wall motion abnormalities and an EF of 34%. However, MAPSE amplitude in all regions had improved, and postejection shortening had resolved, with restoration of a normal transmitral filling pattern (for the patient’s age). The patient improved clinically and hemodynamically, with rapid weaning of pharmacologic support and resolution of radiographic abnormalities. She was extubated and discharged 2 days later to the cardiology ward. TnI peaked to a level of 1.92 ng/mL immediately after the coronary intervention and then rapidly decreased to normal levels.

The architecture of the myofibril layers of the left ventricle is complex. Most of its fibers are organized circumferentially, particularly in the midwall and the base of the ventricle. There is, however, a progressive change in fiber orientation across the wall of the left ventricle, and longitudinally directed fibers prevail in the subendocardial and subepicardial free walls. In contrast to the EF, which reflects the radial/circumferential function, MAPSE measures longitudinal LV function by quantifying the displacement of the annulus toward the apex. MAPSE should be measured using M-mode ultrasonography to interrogate the septal, lateral, anterior, and posterior walls in the apical four- and two-chamber views. Systolic excursion should be measured from the lowest point at end-diastole to the maximal point at end-systole, usually corresponding to the T wave on the ECG. Reduced MAPSE is mostly related to either subendocardial ischemia or fibrosis and correlates well with EF in normal patients and in those with dilated cardiomyopathy. There is discussion in the literature as to whether individual values should be used or the mean of the walls sampled. However, a value < 6 mm for predicting a severely depressed EF has a specificity of 100% in men and 88% in women, with a sensitivity of 73% in men and 100% in women. The positive predictive value for MAPSE ≥ 11 mm in women to predict a normal EF was 94% (sensitivity, 92%). The positive predictive value for MAPSE ≥ 13 mm in men to predict a normal EF was 94% (sensitivity 92%). In ischemia, MAPSE is more sensitive than EF in detecting early abnormalities and can be readily measured in patients with poor image quality, in which EF is known to be inaccurate.

Longitudinal wall motion abnormalities are seen in a range of cardiac diseases, including in the presence of conduction abnormalities (in which uncoordinated contraction is seen only in the interventricular septum), and coronary ischemia. The phenomenon of postejection shortening and associated transmitral filling abnormalities (suppression of early diastolic filling) has been well described in the cardiology literature. In ischemia, the development of longitudinal dyssynchrony may be directly related to coronary occlusion and invariably resolves within 48 h of successful revascularization. Further, these changes occur earlier in the ischemic cascade than do more traditional measures of regional wall motion abnormalities, as the subendocardial longitudinal fibers are more sensitive to perfusion mismatch. Further, these changes are seen prior to the development of an abnormal ECG and can be used as early indicator of myocardial ischemia.

This case portrays how the use of relatively simple echocardiographic techniques to study transmitral filling in association with longitudinal LV function can be key to a timely diagnosis of myocardial ischemia and informing patient management in the acute setting (Video 4).

  • 1.

    FoCUS and LUS are useful for the first-line investigation of the causes of dyspnea.

  • 2.

    In the setting of chronic heart disease or when the clinical setting and other accompanying bedside tests are conflicting, or both, FoCUS alone may be insufficient, and comprehensive echocardiography should always be performed by an experienced echocardiographer.

  • 3.

    Standard echocardiographic measurements of LV systolic function may be inadequate in diagnosing myocardial ischemia.

  • 4.

    The study of longitudinal LV function and associated transmitral filling patterns are sensitive and early indicators of ongoing myocardial ischemia in the acute setting.

Financial/nonfinancial disclosures: None disclosed.

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

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

Lichtenstein D.A. .Mezière G.A. . Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134:117-125 [PubMed]journal. [CrossRef] [PubMed]
 
Hu K. .Liu D. .Herrmann S. .et al Clinical implication of mitral annular plane systolic excursion for patients with cardiovascular disease. Eur Heart J Cardiovasc Imaging. 2013;14:205-212 [PubMed]journal. [CrossRef] [PubMed]
 
Henein M.Y. .O'Sullivan C. .Davies S.W. .Sigwart U. .Gibson D.G. . Effects of acute coronary occlusion and previous ischaemic injury on left ventricular wall motion in humans. Heart. 1997;77:338-345 [PubMed]journal. [CrossRef] [PubMed]
 
Sengupta P.P. .Krishnamoorthy V.K. .Korinek J. .et al Left ventricular form and function revisited: applied translational science to cardiovascular ultrasound imaging. J Am Soc Echocardiogr. 2007;20:539-551 [PubMed]journal. [CrossRef] [PubMed]
 
Matos J. .Kronzon I. .Panagopoulos G. .Perk G. . Mitral annular plane systolic excursion as a surrogate for left ventricular ejection fraction. J Am Soc Echocardiogr. 2012;25:969-974 [PubMed]journal. [CrossRef] [PubMed]
 
Aurigemma G.P. .Silver K.H. .Priest M.A. .Gaasch W.H. . Geometric changes allow normal ejection fraction despite depressed myocardial shortening in hypertensive left ventricular hypertrophy. J Am Coll Cardiol. 1995;26:195-202 [PubMed]journal. [CrossRef] [PubMed]
 
Yuda S. .Inaba Y. .Fujii S. .et al Assessment of left ventricular ejection fraction using long-axis systolic function is independent of image quality: a study of tissue Doppler imaging and m-mode echocardiography. Echocardiography. 2006;23:846-852 [PubMed]journal. [CrossRef] [PubMed]
 
Henein M.Y. .Gibson D.G. . Long axis function in disease. Heart. 1999;81:229-231 [PubMed]journal. [CrossRef] [PubMed]
 
Henein M.Y. .Priestley K. .Davarashvili T. .Buller N. .Gibson D.G. . Early changes in left ventricular subendocardial function after successful coronary angioplasty. Br Heart J. 1993;69:501-506 [PubMed]journal. [CrossRef] [PubMed]
 
Detry J.M. . The pathophysiology of myocardial ischaemia. Eur Heart J. 1996;17:48-52 [PubMed]journal
 
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]
 

Figures

Tables

References

Lichtenstein D.A. .Mezière G.A. . Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134:117-125 [PubMed]journal. [CrossRef] [PubMed]
 
Hu K. .Liu D. .Herrmann S. .et al Clinical implication of mitral annular plane systolic excursion for patients with cardiovascular disease. Eur Heart J Cardiovasc Imaging. 2013;14:205-212 [PubMed]journal. [CrossRef] [PubMed]
 
Henein M.Y. .O'Sullivan C. .Davies S.W. .Sigwart U. .Gibson D.G. . Effects of acute coronary occlusion and previous ischaemic injury on left ventricular wall motion in humans. Heart. 1997;77:338-345 [PubMed]journal. [CrossRef] [PubMed]
 
Sengupta P.P. .Krishnamoorthy V.K. .Korinek J. .et al Left ventricular form and function revisited: applied translational science to cardiovascular ultrasound imaging. J Am Soc Echocardiogr. 2007;20:539-551 [PubMed]journal. [CrossRef] [PubMed]
 
Matos J. .Kronzon I. .Panagopoulos G. .Perk G. . Mitral annular plane systolic excursion as a surrogate for left ventricular ejection fraction. J Am Soc Echocardiogr. 2012;25:969-974 [PubMed]journal. [CrossRef] [PubMed]
 
Aurigemma G.P. .Silver K.H. .Priest M.A. .Gaasch W.H. . Geometric changes allow normal ejection fraction despite depressed myocardial shortening in hypertensive left ventricular hypertrophy. J Am Coll Cardiol. 1995;26:195-202 [PubMed]journal. [CrossRef] [PubMed]
 
Yuda S. .Inaba Y. .Fujii S. .et al Assessment of left ventricular ejection fraction using long-axis systolic function is independent of image quality: a study of tissue Doppler imaging and m-mode echocardiography. Echocardiography. 2006;23:846-852 [PubMed]journal. [CrossRef] [PubMed]
 
Henein M.Y. .Gibson D.G. . Long axis function in disease. Heart. 1999;81:229-231 [PubMed]journal. [CrossRef] [PubMed]
 
Henein M.Y. .Priestley K. .Davarashvili T. .Buller N. .Gibson D.G. . Early changes in left ventricular subendocardial function after successful coronary angioplasty. Br Heart J. 1993;69:501-506 [PubMed]journal. [CrossRef] [PubMed]
 
Detry J.M. . The pathophysiology of myocardial ischaemia. Eur Heart J. 1996;17:48-52 [PubMed]journal
 
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]
 
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