Case 11 - Can't pump it up

Author: Oliver Hill Reviewer: Nish Cherian

A 45-year old female is brought into the Resus room with a 2-day history of general malaise and feeling feverish. She reports central chest pain which began 4 hours prior to calling an ambulance. She is tachycardic at 120bpm and hypoxic requiring 60% O2 via Venturi with a BP of 102/60. The ECG shows some ST elevations in the precordial leads, not completely meeting STEMI criteria.

She has no significant past medical history. 

A bedside echo is performed showing the following:

Clip 1. PLAX (deep)

Clip 2. PLAX

Clip 3. Apical 4-chamber

Clip 4. Apical 2-chamber

Clip 5. PSAX

• What are the main abnormalities on the echo?

  • Severe LV systolic dysfunction with a regional wall abnormality (RV function is preserved).

  • Trace volume pericardial effusion

  • Sonographic B-lines (seen best in deep PLAX) indicating pulmonary congestion

• What is the broad problem/diagnosis in this patient?

  Cardiogenic shock

• What is the differential diagnosis for these findings?

  Myocarditis or occlusion MI can both lead to reduced LV function and cardiogenic shock with presence of pulmonary oedema and effusions.

  Takotsubo’s cardiomyopathy can also acutely present with chest pain and RMWA of the LV apex predominantly. It can also more rarely cause shock.

• How can echo help differentiate between these conditions?

  The LV function is not globally reduced, there are regions which are affected and some spared. This is congruent with a regional wall motion abnormality of a coronary artery territory, therefore supporting the diagnosis of OMI.

  There is a small pericardial effusion which may be more in keeping with myopericarditis, however LV function is usually globally impaired in this condition (and may also involve both LV and RV).

  Takotsubo’s tends to focally cause RWMA of the LV apex causing a very characterised appearance on echo of apical ballooning and akinesis with preservation of the base - resembling an octopus

• Which coronary artery is likely to be the culprit based on the echo findings?

  Left anterior descending artery (LAD).

  The regions affected are mainly the mid- and distal inferoseptal, apical and distal and mid-anterolateral segments of the LV, which are most in keeping with a LAD territory infarct (likely proximal).

  See the schematics below for coronary artery territory localisation.

Case resolution

The patient was diuresed and discussed with the local PCI centre. The echo helped facilitate her transfer for primary PCI and she was found to have a proximal LAD occlusion.

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Appendix

Left ventricular wall segments and coronary supply

LV wall segments and coronary supply (Core Ultrasound)