Emergency Ultrasound Diagnosis of Cardiogenic Shock Due to Acute Mitral Regurgitation
Article first published online: 5 NOV 2009
© 2009 by the Society for Academic Emergency Medicine
Academic Emergency Medicine
Volume 17, Issue 1, pages E1–E2, January 2010
How to Cite
Stone, M. B. (2010), Emergency Ultrasound Diagnosis of Cardiogenic Shock Due to Acute Mitral Regurgitation. Academic Emergency Medicine, 17: E1–E2. doi: 10.1111/j.1553-2712.2009.00610.x
- Issue published online: 4 JAN 2010
- Article first published online: 5 NOV 2009
A 66-year-old man with a medical history significant only for hypertension presented to the emergency department with 1 day of dyspnea. He denied fevers, chills, chest pain, leg swelling, and trauma. He was in severe respiratory distress and was frequently coughing and producing pink frothy sputum. His initial heart rate was 89 beats/min, his respiratory rate was 42 breaths/min, his oxygen saturation was 62% while breathing room air, and his blood pressure was 84/50 mm Hg.
After intravenous access was obtained and noninvasive positive pressure ventilation with 100% oxygen was initiated, the patient’s oxygen saturation remained 83% and he was endotracheally intubated for persistent hypoxia. While awaiting portable chest radiography, a bedside lung ultrasound was performed by the emergency physician using a 5-2 MHz curvilinear array transducer (SonoSite MTurbo, Bothell, WA), which demonstrated “B+ lines” consistent with alveolar congestion (Video Clip S1). “B lines” are hyperechoic, “laser-like” vertical reverberation artifacts that begin at the pleural line, extend to the edge of the screen without fading, move with respiration, and erase physiologic “A lines” (horizontal pleural reverberation artifacts). The term “B+ lines” has been used to describe multiple B lines appearing in a single interspace and is felt to represent alveolar-interstitial congestion. These artifacts were more pronounced on the patient’s right side, but still present to a lesser degree on the patient’s left. Cardiac examination with a 5-1 MHz phased array transducer demonstrated normal contractility, but a flail posterior mitral valve leaflet with only moderate left atrial enlargement (Figure 1 and Video Clip S2). Color Doppler examination demonstrated severe mitral regurgitation with a turbulent high-velocity regurgitant jet oriented toward the patient’s right pulmonary veins (Video Clip S3). Chest radiography confirmed acute pulmonary edema more pronounced in the patient’s right lung fields (Figure 2). Central venous and arterial access was obtained and the patient was started on a dobutamine infusion that improved his blood pressure to 111/68 mm Hg. He was transferred emergently to a nearby hospital where an intraaortic balloon pump was placed and angiography was performed, demonstrating nonocclusive coronary artery disease. Several hours later the patient was taken to the operating room where a flail posterior mitral valve leaflet due to ruptured chordae tendineae was identified. He underwent an uncomplicated mitral valve repair and was discharged home the following week after an uneventful postoperative course.
Video Clip S1. Sagittal view of right anterior lung field demonstrating diffuse B lines.
Video Clip S2. Subcostal four-chamber view demonstrating flail posterior mitral valve leaflet.
Video Clip S3. Subcostal four-chamber view with color Doppler demonstrating an eccentric jet of mitral regurgitation oriented toward the right pulmonary veins.
The video clips are in QuickTime.
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