a second opinion alsharqia echo club september 2013 © copyright 2013, saudi aramco. all rights...
TRANSCRIPT
A Second Opinion
ALSHARQIA ECHO CLUB
September 2013
© Copyright 2013, Saudi Aramco. All rights reserved.
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Doc: Would you mind seeing John for a quick second opinion?
• Referred to cardiology clinic March 2009.
• Known case of “cor Pulmonale and heart failure.”
• Needed wheelchair assistance, extremely breathless.
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Medications
• Bumetanide 1mg BD, Metolazone 5mg, Eplerenone 50mg
• Ramipril 10mg, Bisoprolol 10mg
• Warfarin
• Isosorbide 60mg , Atorvastatin 40 mg, Ezetimibe 10m
• Metformin 850mg TID, Lantus Insulin 60units BD, Novorapid 40, 10, 10 daily
• Omeprazole 40mg, Allopurinol 100mg daily, Tamusulin MR 400mics daily, Spirivia inhaler daily
• Amitriptyline 10mg QHS, Quinine So4 300mg
18 Medications5 Volumes of OPD Files
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Background
• 48 yr old former builder, retired 1987 because of back problems.
• Gradually worsening dyspnoea/oedema since 1996.
• 1997:Tachycardia 122/min, BP 170/116 mmHG.
• ECG: atrial tachycardia 2:1.
• Echo reported as showing an enlarged RV, LA enlarged at 6.1 cms.
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1997
• Coronary Angiography: LV function – overall mildly reduced,
especially the anterior wall. Coronary arteries- essentially normal.
• Lung perfusion scan reported as normal.
• Pulmonary function tests reported as hyperventilation.
• DC Cardioversion back to Sinus Rhythm.
• Patient much improved after cardioversion.
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December 1998
• Admitted with increasing dyspnoea for 1 month.
• PO2 8.9KPa ? PE.
• Lung perfusion scan reported as small perfusion defects in the bases not matched with the ventilation scans – intermediate to high probability for PE.
• Warfarin started initially for 3 months but later advised life long anticoagulation.
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2000
• Readmitted with AF and central chest pain.
• Reverted to sinus rhythm post Cardioversion.
• Several Cardioversions 2000 and 2001.
• March 2001 admitted with heart failure – oedema.
• Discharged on ASA, Warfarin, Bumetanide 3mg am and 2 mg pm, Spironolactone 25mg, Metolazone 2.5 mg alt days, Ramipril 5mg, Digoxin 125 daily, Amiodarone 200mg, Valsartan 80mg BD, Colchicine for gout, Quinine So4 300mg, Omeprazole 20mgBD and Sandoz K.
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Follow UP
• 2001 Heart failure clinic : now Permanent AF (3 prior Cardioversions) same medications, follow up heart failure nurse.
• Now diabetic.
• Admitted with dyspnoea and renal impairment May 2001 and Metolazone stopped.
• Readmitted that month with oedema, dyspnoea and pleuritic chest pain.
• Developed A Flutter with 1:1 conduction and was cardioverted to sinus rhythm.
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2001
• September presented to A&E with broad complex tachycardia.
• CCU narrow complex tachycardia 230/min with haemodynamic compromise - Cardioversion.
• Repeat coronary angiography.
• LV function reported as impaired, possibly early cardiomyopathy.
• Normal coronary arteries.
• EPS: no evidence of an accessory pathway but echo beats were induced consistent with AV nodal re-entrant tachycardia. Atrial flutter was also induced. Both were different to initial presentation.
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Background Continued
• Patient readmitted with narrow complex tachycardia and cardioverted and put back on Amiodarone.
• AV Nodal Ablation and permanent pacing carried out Nov 2001.
• Followed up – initially clinical improvement with management of arrhythmia.
• 2005 OPD assessment now much worse with evidence of CCF, felt to be mainly R heart failure (echo showed PA pressure > 50mmHg).
• 2006 pacemaker follow up – permanent AF
• ARB added to ACE, consideration of trial of Sildenafil
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2007• Follow up with repeat echos – patient remains
extremely short of breath, on home oxygen.
• Referred to chest physician for opinion.
• July 2007: chest physician noted O2 sats 99 – 100% on room air and FEV1 of 2.7. CXR large heart and pulmonary congestion.
• Hg 19.8 g/dl and haematocrit of 52%.
• Followed up cardiology and respiratory medicine: presumed cor pulmonale secondary to PEs but extreme breathlessness remained a puzzle.
• Various inhalers and oxygen, heavy doses of diuretics.
• Heart Failure Clinic.
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What more can be done at this stage?
Thought Process
• At least moderate pulmonary hypertension.
• Possibility of CTEPH.
• What about chronic RV pacing?
Work UP
• High Resolution CT.
• PFT & 6 minute walk test.
• Right and left heart catheterization.
• Review Echo and discuss possible CRT
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Pulmonary Hypertension Work Up
• 6 min walk – refused
• PFTs
• High Resolution CT
• Referral for assessment of PHT and possible disease targeted therapy
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High Resolution CT
Cardiomegaly, no pulmonary emboli but mosaic attenuation
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Tricuspid Regurgitant Velocity
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TAPSE
Tricuspid Annular Plane Systolic Excursion
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Right & Left Cardiac Catheterization
Haemodynamics• Aorta 161/79 mmHg
• LV 175 mmHg
• LVEDP 10 mmHg
• RA 20/10 mmHg
• RV 39 mmhg
• RVEDP 2 mmHG
• PA 43/10 mmHG mean 23 mmHG
• Pulmonary Vascular Resistance 0.69 Wood Units
• Systemic Vascular Resistance 21.42 Wood Units
Saturations• Aortic Sat: 98%
• LV Sat: 97%
• SVC Sat: 65%
• IVC Sat: 84%
• High RA 98%
• Mid Ra 97%
• Low Ra 86%
• RV 90%
• PA 90%
• Systemic Flow: 4.67 l/min
• Pulmonary Flow 18.84 l/min
• QP/QS: 4.04
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TOE
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TOE
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Why did so many echoes miss the ASD?
RVRA
LA
Intra AtrialSeptum
LV
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CTPA
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CTPA
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CTPA
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OSTIUM SECUNDUM ASD
Diagnosis
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Success or Failure ?• First seen Cardiology 12 years earlier
• Multiple cardioversions
• Seven Cardiologists
• Several other ..ologists
• 13 Echocardiograms at 2 different hospitals
• Three cardiac catheterizations
• EPS
• AV Nodal Ablation
• Permanent Pacemaker
• Labelled as Pulmonary Emboli/Cor Pulmonale
• Chronic Cardiac Cripple
• Home Oxygen Therapy
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Take Home Messages
Echo Technologists
• Think out of the box.
• Don’t follow the herd!
• Ask yourself why the right side of the heart is dilated.
• Think ASD.
• Inject saline.
Cardiologists
• Don’t follow the herd!
• Think out of the box.
• Always seek a firm diagnosis.
• Beware “known case of.”
• Always look before you burn!
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ASD Closure
ASD Closure under GA 19.07.201024mm Amplatzer DeviceWell tolerated
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Follow UP
• Felt better.
• Less breathless.
• No longer episodes of cyanosis.
• Functional capacity remained limited.
• 10 months later presented with minor stroke.
• Good recovery.
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Repeat TEE Post-Stroke
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• Large amount of thrombus on LA side of Amplatzer device.
• Managed with intensification of anticoagulation and addition of Clopidogrel.