Stephen M. McHugh, MD1; Robert H. Boretsky, MD2; Michael L. Boisen, MD1; Kathirvel Subramaniam, MD MPH3
- Clinical Assistant Professor, Department of Anesthesia and Critical Care, University of Pittsburgh, Pittsburgh, PA
- Clinical Associate Professor, Department of Anesthesia and Critical Care, University of Pittsburgh, Pittsburgh, PA
- Associate Professor, Department of Anesthesia and Critical Care, University of Pittsburgh, Pittsburgh, PA
A 48-year-old female with history of anxiety presented to the emergency department with a painful, cold, and discolored left lower extremity. She also reported fatigue for several weeks and recently had started taking escitalopram for anxiety surrounding psychosocial problems. A chest radiograph showed small bilateral pleural effusions, bibasilar opacities, and an enlarged cardiac silhouette—all new compared to a prior study. An electrocardiogram (ECG) showed sinus rhythm with anterolateral Q-waves not present on a historical ECG. Serum troponin was normal. A transthoracic echocardiogram (TTE) ordered for syncope less than 1 year prior was normal. Vascular surgery was consulted and scheduled the patient for emergency lower extremity thrombectomy.
On entry to the operating room, heart rate was 125 beats/minute, blood pressure 135/95 mmHg, and SpO2 77%. Because of her abnormal vital signs, chest X ray, and ECG, the anesthesiologist performed focused TTE (Video 1). Patient also had transesophageal echocardiogram (TEE) subsequently (Video 2).
- The TTE image is consistent with which of the following diagnoses?
- Acute myocardial infarction
- Chronic non-ischemic cardiomyopathy
- Apical hypertrophic cardiomyopathy
- Stress-induced cardiomyopathy
- What is the best management option at this point?
- Postpone surgery; immediate cardiac catheterization and percutaneous coronary intervention
- Proceed with surgery for ischemic leg; medical management of cardiac problem; invasive hemodynamic monitoring
- Impella insertion for stabilization of hemodynamics before surgery
- Cardiology consultation to confirm your TTE findings
- All of the following are the characteristic features of this clinical entity except
- Presence of a transient abnormality in left ventricular wall motion beyond a single coronary artery perfusion territory
- Absence of obstructive coronary artery disease or angiographic evidence of acute plaque rupture
- New ECG abnormalities (ST elevation or T wave inversion) or modest elevation in troponin
- Confirmation of diagnosis of myocarditis is mandatory.