Case of the Month: February Edition
- 79 yr old male with a PMH of prostate CA s/p prostatectomy presents with 1 week of SOB, and 1 day of chest tightness, abdominal pain, and syncope this AM.
- T 36.2 HR 94 RR 18 Sats 90% on RA 135/64
- Physical exam RRR, no m/r/g, lungs CTAB, 2+ pulses, no LE edema, no JVD
IVC 2.3cm–>1.8cm (23% respiratory variation)
Diagnosis based on these findings?
Well it is still up in the air. Obviously PE is getting higher on the differential, but you cannot says yes this has to be a PE… This could also be right heart failure from a number of conditions including pulmonary hypertension, valvular disease, ACS, shunt, and I’m sure there are more.
You CAN say there is a normal LVEF, an enlarged right heart, McConnell’s Sign, the D-Sign, a plethoric IVC, and an abnormal EKG with anterior septal T-wave inversions.
Ok you were right about your initial diagnosis of PE… well PEs as in pleural. Ok great, multiple PEs, signs of right heart strain on the CT read (thanks radiology) as well as some on your bedside ultrasound. Troponin 0.4 and BNP 230. Still hemodynamically stable. Heparin drip has been started. Cardiology consulted for EKOS (catheter directed t-PA).
You saved the day! But wait, are there any other assessments of the right heart that could be useful in evaluating the function? Funny you should ask… Enter at your own risk.
TAPSE (Tricuspid annular plane systolic excursion):
- M-mode through the lateral tricuspid annulus and you measure the amplitude of the displacement during the cardiac cycle
- >17mm good; < 17mm not good (assessing RV systolic fxn)
TV S’ (aka S prime):
- A little more advanced, but you can place your doppler gate over that same spot on the lateral tricuspid annulus and change it to tissue doppler
- This is to measure the velocity of that same point and seeing how fast it gets to the aptitude of your TAPSE
- >10 cm/sec good; <10cm/sec bad (assessing RV systolic fxn)
So TAPSE and S’ are bad. This heart is having a hard time beating against all those clots in the lungs. Now radiology said there was RV strain, cardiology had their formal ECHO done and said you know what there is RV strain, but what if we evaluated RV strain by looking at RV strain…
Wait… RV strain for RV strain? Yes!. There is a new push for using speckle tracking to evaluate for LV strain in assessing different cardiac states like heart failure/cardiogenic shock, etc etc. Well everyone forgot about the right side of the heart, and turns out you can use strain to look at that as well.
Ok basic strain measurements… The more negative the value the better, most of the time a good number is more negative than about -20%. So -25% is better than -23%. Remember this is looking at all the different little speckles of the ventricle on your ECHO image and seeing how well they displace back and forth with respect to each other during the cardiac cycle. More displacement, more negative the number, less displacement that number will be closer to 0. So a bad number would be for instance -10%. It is closer to 0, there is less displacement of those speckles, these speckles correspond to parts of the ventricle, therefore that ventricle must not be working so great, right?
So our strain here on the right is -10.9%… not good confirming what we know based on CT, and all our other ECHO findings. Ain’t it pretty to look at too? Well what to do with RV strain? This is going to be an evolving topic over the next few years as more data and research is generated, stay tuned.
Some ECHOs being done are starting to report these numbers exclusively for the left ventricle. That is a whole other topic that could take its own reviewing. This is only meant to spark your interest in strain… Sorry if I butchered explaining it.
In the end, the patient got his EKOS catheters, tPA and heparin running, vital signs remained stable and he is currently doing well.