Hypotension (Biventricular Heart Failure/ Cardiogenic Shock)

Hey everyone!

Welcome to the first CCM POCUS blog post of the new academic year!

Please view the post and reply with your thoughts/comments there!

These come from a patient who had a condition called for hypotension. These ultrasound images were obtained. Please reply with:
• What probe is being used?
• What views are shown in the clips
• What is your interpretation of the images?

Please post your thoughts/ comments/ answers and I will weigh in next week.

-Christopher

Tags: 
Hypotension, Biventricular Heart Failure, Cardiogenic Shock

 

Comments (3)

Shan Modi
says:

It looks like you are using the phased array probe in a cardiac preset. The views that are shown include PSLX, PSSA, AP4 (that occasionally changes into a AP5), Subcostal View, and a view of the IVC. This patient looks to have right ventricular dilation noted in both the PSLX and AP4 views. The patient's systolic function of the LV looks severely depressed on all views with PSSX showing hypokinesis of the anteroseptal walls. There may be a slight McConnell's on the AP4. IVC is plethoric.

Given these findings, it is concerning for biventricular failure with cardiogenic shock leading to hypotension from anteroseptal MI? Atleast that's my guess!

Natsumi Hamahata
says:

I agree with Shan's interpretation :)!

The probe is phase array probe with cardiac view. 1st image: PSLA, 2nd image: PSSA at mitral valve level, 3rd image: A4C, 4th image is poor study but seems like subcostal 4 chamber view? 5th image: IVC
Biventricular systolic dysfunction with severely reduced gross EF. On the PSSA view, I think there is a flattening of the interventricular septum during diastole?, which suggests RV volume overload. The anterolateral wall on PSSA and A4C is not entirely visualized but may have hypokinesis. I totally agree with Shan's opinion of cariogenic shock. Definitely does not appear as distributive or hypovolemic shock, where the heart will usually be hyper dynamic rather than hypo kinetic. If the patient is in obstructive shock, the inter ventricular septum flattening will be more during systole (but cannot totally rule out PE only from this US).
Top DDx: Cariogenic shock with biventricular systolic dysfunction

Hey everyone!

Thank you for those who commented on this post! Thank you Shan & Natusumi!! :) Great work and interpretations!

These images were obtained with a phased array probe in the cardiac preset. In order, they show the following views: Parasternal Long Axis, Parasternal Short Axis, Apical 4 chamber, Subxiphoid/Subcostal and Inferior Vena Cava. Based on each of these views, there appears to be global hypokinesis of the left ventricle and right ventricle. The IVC appears enlarged with minimal respiratory variation (ie “plethoric”), suggesting a higher Right Atrial Pressure (RAP)/ Central Venous Pressure (CVP) in a spontaneously breathing patient. Given the clinical picture, this would be concerning for cardiogenic shock or heart failure.

If you have an interesting case or POCUS findings to share, let me know. We use this forum to highlight cool & unique POCUS applications, findings, review core issues and even highlight limitations/challenges for CCM POCUS. Be sure to check out some of the prior posts!

-Christopher

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