3 months of Dyspnea

Hey everyone!

Welcome to our 1st CCM POCUS blog post of the New Year!

Case:

40’s patient admitted with complaints of dyspnea for 3 months. The physician scanned bilateral IJ for placing a central line for vasopressor administration. Here are a collection of clips obtained.

I want to leave the discussion pretty open on this one. There are a lot of findings and some interesting takeaways/ teaching points.

Please post your thoughts & comments! I will come back to highlight the notable findings and share my own thoughts on the POCUS images from this case!

-Christopher

Tags: 
POCUS, Dyspnea

 

Comments (4)

Andrew Schoenling
says:

1, 2 & 3: Linear Probe, anatomically medial IJ or mislabel. RIJ with non-occluding echogenic clot ~50% and LIJ with complete occlusion by clot. Bilaterally carotids patent and normal appearing with good doopler flow of R Carotid but doppler evidence of partial occlusion and venous flow of RIJ.
4: Phased Array PLAX with severely depressed LV function and poor excursion of both mitral valves.
5: Phased array PSAX with globally decreased LV wall motion and mitral valve with minimal opening. Bowing of the septum with some semblance of a D sign.
6: Phased array Apical 4 with severely decreased LV function and another view of poor mitral valve excursion.
7: Phased array Apical 2(3?) focused on RV with RV > LV size, dilated and poor function, probably TAPSE <1. Tricuspic with normal function. Moderator band visualized in RV. Unable to visualize wall thickness well.
8: Phased array substernal IVC with surprisingly small IVC < 1cm with complete collapse during inspiration and non visualized/small hepatic vein giving evidence of volume responsiveness.

No sure what to make without more history. Would trial some IV Fluids during the current shock state while preparing vasopressors. Bilateral IJ's clots concerning for a possible PE causing RV findings with decreased LV. But with the poor mitral valve function, possibly a patient with mitral stenosis and chronic pHTN and RV overload currently in a relative hypovolemic state based on IVC.

Jonathan Pelletier
says:

There are many notable findings:
1. LIJ thrombus - ? occlusive thought can't be sure without color
2. RIJ thrombus - large, but non-occlusive based on color images
3. Severe biventricular and biatrial enlargement. Severely depressed LV systolic function. Stroke volume may be partly persevered due to ventricular dilation (as this increases SV when EF is low).
4. I can't tell if the atrial septum is in-tact in the apical 4, but this isn't the optimal view for this assessment, and I didn't see a subxiphoid.

Summary:
Severely depressed BIV systolic function and BIA/BIV dilation. Thrombi in both IJs. Given patient age, consider dilated cardiomyopathy.

Agree with Drew's assessment, except I did not appreciate as much of a D sign.

If I found these findings I would be hesitant about putting a central venous catheter in either IJ, and that's unfortunate because if this patient were in shock with the findings on the cardiac ultrasound a PA cath may be helpful (and could still be placed under fluoro at a different site).

Scary findings for such a young individual.

Hey everyone,

GREAT comments! Very good job picking up on ALL the findings. One of the key teaching points for this case is to not just jump on the first thing you see. When patients have baseline pathology/ co-morbidities, it is important to be able to decipher what is acute from chronic.

In terms of the case, the first finding is the severe biventricular heart failure. However, when attempting to put in the CVC, bilateral IJ’s were noted to have thrombosis. Looking back to the heart, there is a “D sign” seen in the PSSX view. This led to a CTA which demonstrated a massive PE.

Ultimately, the patient was found to have had a baseline cardiomyopathy from alcoholism, but the acute cause of presentation was a massive PE.

Of note, one way to look for acute vs chronic RV failure is to measure the RV free wall thickness in the subxiphoid window. <5 mm suggests an acute process, where as a wall thickness of > 5 mm suggest a more chronic process (ie Pulm HTN).

Again- THANK YOU for reviewing the case and sharing your excellent thoughts & comments.

Another case to come soon!

-Christopher

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