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.