Wednesday Image Review

What’s the Diagnosis? By Dr. Julie Calabrese

75 y/o M PMHx of ESRD on HD, pulmonary HTN, HLD presents to the ED with 1 week of progressive fatigue and SOB. Pt on 2L NC home O2 but requiring 4L NC in the ED to maintain saturation > 95%. On exam, pt with increased WOB and RR > 20. Lungs are CTA. Cardiac exam shows RRR with mild JVD, abdominal distention and +1 pitting edema B/L. POCUS was performed and is shown below. What is the diagnosis? 

Answer: Right Heart Strain from Pulmonary Hypertension 

  • Signs in POCUS that are indicative of R heart strain:
    • D-sign: septal flattening seen in the parasternal short orientation that is indicative of increased RV pressures 
    • McConnel’s Sign: seen in the apical 4 chamber view. R ventricular free wall akinesis with sparing of the apex (apical hyperkinesis) 
    • Increased RV:LV ratio, typically should be ⅓:⅔ 
    • Decreased TAPSE: measurement of the vertical motion of the tricuspid valve in the apical 4 chamber view (normal > 16 mm)
  • Causes of R- Heart Strain:
    • Pulmonary Embolism
    • Pulmonary hypertension 
    • Biventricular failure
    • R sided heart failure 
    • Valvular dysfunction (Acute TR) 
  • Pulmonary Hypertension:
    • Type 1: primary arterial pulmonary HTN 
    • Type 2: PH due to L heart failure
    • Type 3: PH due to lung disease 
    • Type 4: PH due to chronic thromboembolic disease 
    • Type 5: idiopathic PH 
  • Acute Treatment for PH includes
    • Optimize RV preload- patients typically euvolemic or hypervolemic and do not respond well to rapid shifts in fluid status (usually avoid fluids). If hypovolemia/sepsis consider small 250 ml boluses with frequent reassessments 
    • Improve cardiac output: consider early ionotropes 
    • Reduce RV afterload: avoid hypoxia, acidosis, hypercapnia 
    • Treat arrhythmias: most common is SVT followed by afib/flutter 


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