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Echo Rounds

Echo Case

Stephen M. McHugh, MD1; Robert H. Boretsky, MD2; Michael L. Boisen, MD1; Kathirvel Subramaniam, MD MPH3

  1. Clinical Assistant Professor, Department of Anesthesia and Critical Care, University of Pittsburgh, Pittsburgh, PA
  2. Clinical Associate Professor, Department of Anesthesia and Critical Care, University of Pittsburgh, Pittsburgh, PA
  3. 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).

Videos

Questions

  1. The TTE image is consistent with which of the following diagnoses?
    1. Acute myocardial infarction
    2. Chronic non-ischemic cardiomyopathy
    3. Apical hypertrophic cardiomyopathy
    4. Stress-induced cardiomyopathy
  2. What is the best management option at this point?
    1. Postpone surgery; immediate cardiac catheterization and percutaneous coronary intervention
    2. Proceed with surgery for ischemic leg; medical management of cardiac problem; invasive hemodynamic monitoring
    3. Impella insertion for stabilization of hemodynamics before surgery
    4. Cardiology consultation to confirm your TTE findings
  3. All of the following are the characteristic features of this clinical entity except
    1. Presence of a transient abnormality in left ventricular wall motion beyond a single coronary artery perfusion territory
    2. Absence of obstructive coronary artery disease or angiographic evidence of acute plaque rupture
    3. New ECG abnormalities (ST elevation or T wave inversion) or modest elevation in troponin
    4. Confirmation of diagnosis of myocarditis is mandatory.
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