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Ultrasound Corner |

A Woman in Her 90s With Respiratory Distress After Transcatheter Aortic Valve Replacement and Pacemaker Implantation FREE TO VIEW

Colin T. Phillips, MD; Warren J. Manning, MD
Author and Funding Information

aCardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA

bDepartment of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA

CORRESPONDENCE TO: Colin T. Phillips, MD, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Baker 4, Boston, MA 02215


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


Chest. 2017;151(4):e77-e79. doi:10.1016/j.chest.2016.07.050
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Published online

A woman in her 90s with a history of New York Heart Association functional class III heart failure secondary to low-flow, low-gradient aortic stenosis, paroxysmal atrial fibrillation, and bladder cancer underwent transcatheter aortic valve replacement (TAVR). The procedure involved femoral artery access and implantation of a 29-mm Evolut R aortic valve prosthesis (Medtronic) for extreme-risk aortic stenosis (Society of Thoracic Surgeons score, 8.1%). During the procedure, she developed complete heart block and underwent placement of a temporary active fixation ventricular pacemaker.

A permanent dual-chamber pacemaker was placed on hospital day 3 for persistent complete atrioventricular nodal block. The patient developed dyspnea that evening and a new oxygen requirement to maintain saturations in the mid-90s in the setting of blood pressure of 100/40 mm Hg and a heart rate of 60 beats/min. The examination was remarkable for a woman with tachypnea (respiratory rate, 22 breaths/min) with increased work of breathing. Her jugular venous pressure was 10 cm H2O, and lung auscultation demonstrated bibasilar crackles. Cardiac auscultation revealed a 2/6 systolic crescendo-decrescendo murmur. A goal-directed handheld ultrasound examination (VScan; GE Healthcare) was performed to evaluate the dyspnea and to guide further management (Videos 1 and 2).

Question: Based on the patient's clinical history, physical examination, and the ultrasound videos, what is the most likely diagnosis? Which potential procedure-related complications warrant further assessment?

Answer: The most likely diagnosis is cardiogenic pulmonary edema. Pneumothorax, pericardial effusion due to pacemaker lead perforation, paravalvular aortic regurgitation, and right-sided ventricular dysfunction are quickly assessed with the handheld ultrasound examination.

The adage “common diagnoses are common” is challenged in patients with multiple potential complications underlying their symptoms. In the present case, we were confronted with a patient who developed new-onset dyspnea following a series of invasive procedures and 3 days of bed rest. While the initial physical examination suggested pulmonary edema as the cause of dyspnea, other malignant causes deserve consideration.

The strategy used here involved confirming the findings on physical examination (volume overload and elevated filling pressures causing pulmonary edema) followed by investigating potential complications. We chose ultrasound views to focus on the anatomical areas where complications would occur: the lung apex for pneumothorax and the subcostal and apical views of the heart for an apical pericardial effusion, aortic regurgitation, and assessment of right ventricular contractility. Importantly, each of these potential diagnoses can present concurrently with pulmonary edema. Handheld ultrasonography augments the physical examination to assess for these complications and direct further treatment beyond diuresis.

In Video 1 obtained at the anteroapex of the lungs, apical B-lines support volume overload and the presence of extravascular lung water. The B-lines occur from ultrasound beam reverberation artifacts in thickened interlobular septa due to fluid accumulation, with three or more lines being consistent with pulmonary edema., Noncardiogenic pulmonary edema, including transfusion-related acute lung injury, could also cause this finding, with the clinical scenario helping discriminate.

The subcostal view of the inferior vena cava reveals that it is subjectively dilated (measured > 2.1 cm postacquisition), although with over a 50% respiratory change consistent with a right atrial filling pressure of < 10 mm Hg., Although not shown, assessing for pleural effusions with the ultrasound at the lung bases would point to acute or chronic volume overload as the culprit.

Returning to the lung apex in Video 2, the first potential complication to address is a pneumothorax following access of the left subclavian vein for permanent pacemaker placement. With the probe on the left chest apex, the pleural-parenchymal interface is directly visualized, confirming lung sliding and excluding pneumothorax.

In addition to a pneumothorax, pericardial effusion and tamponade are other potential complications following pacemaker lead placement. Both the subcostal and apical views of the heart afford views of the pericardial space. Because the pacing wires are placed in the right ventricular septum near the apex, choosing the apical view of the heart helps assess for a small pericardial effusion near where the wire was placed. The pericardium is visualized as a bright echodense band encasing the heart. The presence of a pericardial effusion would be noted as echolucency around the echodense pericardium., Although not shown, a posterior pericardial effusion in the parasternal long-axis view is distinguished from a pleural effusion because it is located anterior to the descending aorta.

Color Doppler in the subcostal view can be used to assess for significant paravalvular regurgitation. Acute paravalvular regurgitation is most often due to low placement of the valve prosthesis or migration and is a potential cause of dyspnea following TAVR placement. As seen here, the TAVR prosthesis was in the expected position, with the struts abutting the left ventricular outflow tract and no aortic regurgitation according to color Doppler.

Pulmonary embolism is also possible given the patient’s history of cancer and limited mobility immediately following TAVR. The estimated tricuspid annular plane systolic excursion (TAPSE), right ventricular cavity ratio compared with the left ventricular cavity, and preserved right ventricular systolic function all argue against a submassive pulmonary embolism. With a complete transthoracic echocardiogram, TAPSE is calculated in the apical four-chamber view by measuring the distance the lateral tricuspid valve travels during systole in M-mode. A TAPSE > 2 cm identifies a low-risk pulmonary embolism population and is useful in excluding pulmonary embolism in a population with a low Wells score. In both the apical and subcostal views, the right ventricular systolic function and tricuspid annular excursion are estimated to be normal.

Wall motion abnormalities indicative of coronary ischemia were not fully assessed with the aforementioned ultrasound views and would require the addition of the parasternal long- and short-axis views. In the apical 4-chamber view from Video 2, left ventricular systolic function was normal. Despite this patient’s advanced age, the concern for coronary ischemia was low given normal preoperative coronary angiography and no evidence of coronary compromise immediately following TAVR placement.

In this case, despite resolution of the patient’s critical aortic stenosis, she continues to have increased left ventricular afterload due to elevated systemic vascular resistance. In addition, the left ventricle is still thickened and noncompliant, resulting in elevated diastolic filling pressures and a propensity for pulmonary edema. After initiation of diuresis, chest radiography confirmed fluid overload and the absence of a pneumothorax. Following diuresis of 2 L, the patient was breathing comfortably on room air, and her oral diuretic regimen was adjusted at discharge.

Patients with complex medical histories mandate detailed evaluation. This case illustrates the versatility of handheld ultrasound in augmenting the physical examination to rapidly assess potentially malignant causes of dyspnea and reinforces the notion that complicated does not exclude the common (Discussion Video).

  • 1.

    In the correct clinical context, the constellation of a dilated inferior vena cava and parenchymal B-lines is consistent with elevated right- and left-sided filling pressures, fluid overload, and pulmonary edema.

  • 2.

    Pericardial effusion and pneumothorax are potential complications of pacemaker lead placement and are quickly excluded with handheld echocardiography.

  • 3.

    Color flow Doppler ultrasonography on a handheld device is helpful in ruling out regurgitant lesions.

  • 4.

    Handheld ultrasonography is a rapid diagnostic modality to augment the physical examination, allowing expedited triage and treatment.

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

Agricola E. .Bove T. .Oppizzi M. .et al “Ultrasound comet-tail images”: a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water. Chest. 2005;127:1690-1695 [PubMed]journal. [CrossRef] [PubMed]
 
Kimura B.J. .Shaw D.J. .Amundson S.A. .Phan J.N. .Blanchard D.G. .DeMaria A.N. . Cardiac limited ultrasound examination techniques to augment the bedside cardiac physical examination. J Ultrasound Med. 2015;34:1683-1690 [PubMed]journal. [PubMed]
 
Kircher B.J. .Himelman R.B. .Schiller N.B. . Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol. 1990;66:493-496 [PubMed]journal. [CrossRef] [PubMed]
 
Brennan J.M. .Blair J.E. .Goonewardena S. .et al Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr. 2007;20:857-861 [PubMed]journal. [CrossRef] [PubMed]
 
Lichtenstein D.A. .Menu Y. . A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest. 1995;108:1345-1348 [PubMed]journal. [CrossRef] [PubMed]
 
Spencer K.T. .Kimura B.J. .Korcarz C.E. .Pellikka P.A. .Rahko P.S. .Siegel R.J. . Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26:567-581 [PubMed]journal. [CrossRef] [PubMed]
 
Vassiliades T.A. .Adams D.H. .Popma J.J. . Two cases of heart failure after implantation of a CoreValve prosthesis. N Engl J Med. 2015;372:1080-1081 [PubMed]journal. [PubMed]
 
Pruszczyk P. .Goliszek S. .Lichodziejewska B. .et al Prognostic value of echocardiography in normotensive patients with acute pulmonary embolism. JACC Cardiovasc Imaging. 2014;7:553-560 [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]
 
Yotti R. .Bermejo J. .Gutiérrez-Ibañes E. .et al Systemic vascular load in calcific degenerative aortic valve stenosis: insight from percutaneous valve replacement. J Am Coll Cardiol. 2015;65:423-433 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Agricola E. .Bove T. .Oppizzi M. .et al “Ultrasound comet-tail images”: a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water. Chest. 2005;127:1690-1695 [PubMed]journal. [CrossRef] [PubMed]
 
Kimura B.J. .Shaw D.J. .Amundson S.A. .Phan J.N. .Blanchard D.G. .DeMaria A.N. . Cardiac limited ultrasound examination techniques to augment the bedside cardiac physical examination. J Ultrasound Med. 2015;34:1683-1690 [PubMed]journal. [PubMed]
 
Kircher B.J. .Himelman R.B. .Schiller N.B. . Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol. 1990;66:493-496 [PubMed]journal. [CrossRef] [PubMed]
 
Brennan J.M. .Blair J.E. .Goonewardena S. .et al Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr. 2007;20:857-861 [PubMed]journal. [CrossRef] [PubMed]
 
Lichtenstein D.A. .Menu Y. . A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest. 1995;108:1345-1348 [PubMed]journal. [CrossRef] [PubMed]
 
Spencer K.T. .Kimura B.J. .Korcarz C.E. .Pellikka P.A. .Rahko P.S. .Siegel R.J. . Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26:567-581 [PubMed]journal. [CrossRef] [PubMed]
 
Vassiliades T.A. .Adams D.H. .Popma J.J. . Two cases of heart failure after implantation of a CoreValve prosthesis. N Engl J Med. 2015;372:1080-1081 [PubMed]journal. [PubMed]
 
Pruszczyk P. .Goliszek S. .Lichodziejewska B. .et al Prognostic value of echocardiography in normotensive patients with acute pulmonary embolism. JACC Cardiovasc Imaging. 2014;7:553-560 [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]
 
Yotti R. .Bermejo J. .Gutiérrez-Ibañes E. .et al Systemic vascular load in calcific degenerative aortic valve stenosis: insight from percutaneous valve replacement. J Am Coll Cardiol. 2015;65:423-433 [PubMed]journal. [CrossRef] [PubMed]
 
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