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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Acute SOB and Chest Pain
Case#: 34
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
38 y.o. male with acute onset of SOB and chest pain. He has not other medical diagnoses and
take no medications. He had a herniorraphy 2 days ago morning. His ECG shows
a HR of 100 with inferior ST depression. The patient is hypotensive.

Questions to consider are:

What are the echocardiographyic findings?
What is the diagnosis?
Are there other echocardiographic findings for this diagnosis?
Are there other diseases that may simulate the patient's symptoms?
What is tests can you order to make this diagnosis? Which is the best test?


Case Discussion/CME Questions
The echocardiographic findings in this patient are:

A mass in the pulmonary artery
Right Ventricular Dilation
Right Ventricular Hypokinesis
Tricuspid Regurgitation
Pulmonary Hypertension
Right Atrial Enlargement
Leftward Septal Motion

The diagnosis is an acute, massive pulmonary embolus.

Other echocardiographic findings that could be present are:

Pulmonary Artery Enlargement
Pulmonary Regurgitation
Hepatic Vein Doppler Systolic Reversal
Small Left Atrium
Small Left Ventricle
Pleural Effusion

Other diseases that may simulate this patient's symptoms are:

Acute Myocardial Ischemia
Acute Myocardial Infarction
Pericardial Effusion/Tamponade
Fat Embolus
Atrial Fibrillation
Aortic Stenosis
Cor Pulmonale

The tests that could be ordered are:

Pulmonary Angiogram
Computed Tomographic Angiography (CTA)
V/Q Scan

The pulmonary angiogram has been the old gold standard. A pulmonary angiogram is time consuming, carries a small risk (0.1% mortality), exposes the patient to the risk of dye, and may miss small, subsegmental emboli.

A CTA is the new gold standard. A CTA is widely available, fast, and can show the emboli in the main pulmonary artery or in the segmental arteries. A CTA may miss the subsegmental emboli. A CTA can be used to diagnosis right ventricular dysfunction.
A CTA can also rule out other causes of the patient's symptoms such as a pneumothorax or pericardial effusion.

An MRI is not a widely available as a CTA but has good sensitivity and specificity for a pulmonary embolus. Again, MRI may miss subsegmental emboli. MRIs are usually resevered for patients who have a contraindication o a CTA (dye, radiation).

A V/Q scan is time consuming and may be less reliable in patients with significant ung disease.

An echocardiogram is useful in finding secondary findings of the pulmonary embolus if the emboli are large enough. An echocardiography can only find clot in the large pulmonary arteries. An echocardiogram can rule out other causes of a patient's symptoms such as atrial myxoma, mitral stenosis, aortic stenosis, myocardial infarction/ischemia. An echocardiography may only find the secondary signs of a pulmonary embolus. The apexof the right ventricle may be spared while the free wall of the right ventricle is hypokinetic. In chronic pulmonary hypertension the free wall AND the apex are hypokinetic. RV dysfunction is prognostic of a higher mortality rate and is an indication of agressive therapy.

While a pulmonary angiogram has high sensitivity and specificity, a CTA approaches 90% sensitivity and specificity. The current recommendations are to perform an echocardiography screening exam and if no diagnosis can be made, hen a CTA can be
performed. This protocol decreases the incidence of exposure to radiation and dye for a patient.

Therapy options for a pulmonary embolus are:

IVC Filter

Anticoagulation is the most common therapy. Unfractionated heparing increases the risk of HIT, so low molecular weight heparin or Fondoprax is used.

Thrombolysis is reserved for patients who are unstable and do not have a contraindication to thrombolysis. Interestingly, thrombolytic therapy, while obviously helpful in the unstable patient, did not improve the outcome of patients compared to anticoagulation alone. An IVC filter may improve the outcome if used along with thrombolytic therapy.

Thrombectomy, either by surgical or catheter methods is reserved for patients who have a contraindication to thrombolysis and are unstable or where previously stable and became unstable.

In this case, surgery in the last two weeks is a relative contraindication. That patient underwent a surgical thrombectomy and the resulting echo exam showed resolution of all of the secondary effects from the pulmonary embolus.
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