Ultrasound of the Month - Is your probe marker switched?

CASE PRESENTATION

A 73 y.o. male with history of diastolic heart failure, type II DM, HTN, and peripheral vascular disease presented to the emergency department via EMS for evaluation of abnormal vital signs. He was found at his living facility to have an oxygen saturations of 57% on room air (RA). EMS found his pulse oximetry to be 80% on RA and he was placed on 5L oxygen via nasal cannula. Upon arrival to the emergency department he remained hypoxic, with an SpO2 of 79% on room air. He improved to the mid 90s with 4L nasal cannula.

He states that he has been having some worsening of his chronic dyspnea on exertion over the past few days. He denies any other symptoms including chest pain, fevers, chills, cough, nausea, vomiting, diarrhea, chest tightness, myalgias. He has received two doses of the COVID vaccine to date and is fully immunized. No recent exposures to COVID-19.

His review of systems is otherwise negative.

His additional vital signs are as follows: BP 99/53, HR 64, T 95.3, RR 19

Physical exam: On exam he is well appearing and in no distress. He has a normal work of breathing and no current complaints. Lung exam notable for significantly decreased breath sounds bilaterally. He has peripheral edema of his bilateral lower extremities. Bedside chest ultrasound showed large bilateral pleural effusions. His echo images are below.

Parasternal long axis view - Notable findings include slightly decreased ejection fraction (EF), large appearing right ventricle (RV) and pleural effusion. Aorta (A), left ventricle (LV), left atrium (LA).

Parasternal short axis view - notable findings include enlarged right ventricle (RV) with septal flattening (“D-sign”), and pleural effusion.

Apical 4-chamber view - Notable findings include dilated right ventricle (RV) with a >1:1 ratio of right ventricle (RV): left ventricle (LV).

A dilated RV on echo indicates that the RV is either receiving too much volume or pressure (or both), and has a broad differential including: pulmonary embolism (PE), pulmonary valve stenosis, dilated cardiomyopathy, pulmonary arterial hypertension, tricuspid regurgitation, atrial septal defect or ventricular septal defect.

In this case the combination of the significantly dilated RV and bilateral pleural effusions helped significantly narrow the differential diagnoses and guide management. His previously known left-sided diastolic heart failure likely contributed to his new right-sided failure as indicated by his RV enlargement and clinical presentation with peripheral volume overload.

CASE RESOLUTION:

Additional diagnostic workup included labs, CTA chest to evaluate for PE. The CTA confirmed large bilateral pleural effusions, without evidence of PE. His labs showed new renal failure and hyperkalemia. During his 1-week admission he had a comprehensive echocardiogram performed confirming his severely dilated right ventricle, mild systolic dysfunction and elevated RV systolic pressures. He was aggressively diuresed during admission with improvement of his oxygen requirement and creatinine prior to discharge.