Medical Image of the Month: Massive Right Atrial Dilation After Mitral Valve Replacement

Figure 1. Chest radiograph demonstrating massive cardiomegaly with pulmonary congestion and markedly dilated right atrium.

Figure 2. Transthoracic echocardiogram demonstrating marked dilation of the right atrium to 9.6 cm in its greatest dimension.

A 92-year-old woman with a history of mechanical mitral valve replacement (+25 years prior to presentation), coronary artery bypass grafting, pacemaker placement and heart failure (EF 25%) presented from a nursing facility for dyspnea of 1 day’s duration. Recently, the patient had experienced a bowel perforation s/p surgical repair 3 weeks prior.

Admission chest radiograph was significant for massive cardiomegaly with pulmonary congestion and markedly dilated right atrium (Figure 1). Formal echocardiography was ordered, which re-demonstrated the patient’s known heart failure with reduced ejection fraction. Additionally, all 4 chambers of the heart were noted to be dilated, but the right atrium was revealed to be severely enlarged to >9 cm (Figure 2). On review of outside records, the patient’s cardiac history was notable for chronic dilation of the RA, RV and LA for several years with low, but stable, LV ejection fraction. Ultimately, the patient was noted to have worsening abdominal distension concerning for acute abdomen. However rather than pursue additional aggressive work up after her recent surgery, comfort measures were preferred.

This case illustrates some of the possible long-term effects of mitral valve replacement. In recent years mitral valve repair has become the preferred method over replacement for degenerative valve disease in western countries (1). While there are documented short term benefits to both mitral valve replacement and mitral valve repair long term data is less available (2). Long-term survival in most studies is reported in 5,10, and 15-year intervals. As was the case with our patient, patients with mitral valve replacement greater than 20 years in age have significantly less information associated with them. Although at this time longitudinal studies suggest benefits for both mitral valve replacement and repair, further investigation into long term complications is warranted (3). As our society continues to age, understanding the risks and complications associated with previous valve repair will help guide therapeutic interventions in the geriatric patient.

Richard Young, MD* and Alexander Ravajy, BS**

*University of Arizona Department of Internal Medicine

**University of Oklahoma Department of Microbiology

Banner University Medical Center

Tucson, AZ USA

References

1. Gammie JS, Sheng S, Griffith BP, Peterson ED, Rankin JS, O'Brien SM, Brown JM. Trends in mitral valve surgery in the United States: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2009 May;87(5):1431-7. [CrossRef] [PubMed]
2. McNeely CA, Vassileva CM. Long-term outcomes of mitral valve repair versus replacement for degenerative disease: a systematic review. Curr Cardiol Rev. 2015;11(2):157-62. [CrossRef] [PubMed]
3. Christina MV, Gregory M, Christian M, Theresa B, Stephen M, Steven S, Stephen H. Long term survival of patients undergoing mitral valve repair and replacement a longitudinal analysis of Medicare fee-for-service beneficiaries. Circulation. 2013;127(18):1870–6. [CrossRef] [PubMed]

Cite as: Young R, Ravajy A. Medical image of the month: Massive right atrial dilation after mitral valve replacement. Southwest J Pulm Crit Care. 2018;18(1):8-9. doi: https://doi.org/10.13175/swjpcc111-18 PDF 

Medical Image of the Month: Chronic Ogilvie’s Syndrome

Figure 1. Coronal view of abdominal CT scan showing a massively dilated colon.

Figure 2. Sagittal view of abdominal CT scan.

Figure 3. Axial view of abdominal CT scan.

A 42-year-old man with chronic encephalopathy secondary to traumatic brain injury (TBI), craniotomy, seizure disorder, chronic alcohol abuse, and chronic Ogilvie syndrome presented to the Banner University Medical Center-South Campus emergency department (ED) after being found in his driveway with altered mental status. He complained of multiple episodes of non-bloody diarrhea for the last day but otherwise altered & unhelpful. He was noted to have to be hypotensive with a blood pressure of 70-90/35-56 mm Hg, afebrile with a temperature of 36  C, an elevated white cell count of 13.3 X 10⁹ cells/L, a hemoglobin of 4.4 g/dL, a creatinine of 2.6 mg/dL, a BUN of 30 mg/dL, and an elevated lactic acid to 5.4 mmol/L. Physical exam showed a massively dilated tympanic abdomen. Resuscitation and broad-spectrum antibiotics were initiated, a CT scan ordered (Figures 1-3) and he was admitted to the medical intensive care unit (MICU) for further work up and management.

On chart review, it was shown that he had presented to the same ED twice in the past with episodes of chronic constipation. Gastroenterology and general surgery consults concluded that he had developed a chronic pseudo-obstruction pattern due to likely decreased gastrointestinal motility presumed secondary to TBI and immobility. He was evaluated and deemed to not qualify for neostigmine treatment due to finding of stool acting as a mechanical obstruction. During this MICU visit, he was treated for septic shock but unfortunately did not survive the hospital stay.

Learning Points/Take Home Message:

1. Ogilvie syndrome is an acquired dilation of the colon in the absence of any mechanical obstruction in severely ill patients characterized by abnormalities affecting the involuntary, rhythmic muscular contractions within the colon. The symptoms of Ogilvie syndrome mimic those of mechanical obstruction of the colon, but no physical obstruction is present.
2. Studies have shown that intravenous administration of neostigmine has led to rapid decompression of the colon in individuals with Ogilvie syndrome who did not respond to conservative management. 
3. Colonoscopic decompression, in which a thin, flexible tube is inserted into the anal passage and threaded up to the colon, may be used in refractory cases. Although colonoscopic decompression has not undergone clinical study, numerous reports in the medical literature cite it as an effective method for removing air from the colon and, potentially, reducing the risk of perforation. 
4. Surgery is used when affected individuals have signs of perforation or ischemia or have failed to respond to other treatment options. Surgery can be associated with significant morbidity and mortality.

Michael Bernaba MD, Emilio Power MD, Sidra Raoof MD, Babitha Bijin MD, Yuet-Ming Chan MD

Department of Internal Medicine

University of Arizona College of Medicine at South Campus

Tucson, AZ USA

References

1. McNamara R, Mihalakis MJ. Acute colonic pseudo-obstruction: rapid correction with neostigmine in the emergency department. J Emerg Med. 2008;35:167-70. [CrossRef] [PubMed]
2. Saunders MD, Kimmey MB. Systemic review: acute colonic pseudo-obstruction. Aliment Pharmacol Ther. 2005;22:917-25. [CrossRef] [PubMed]
3. Maloney N, Vargas HD. Acute intestinal pseudo-obstruction (Ogilvie's syndrome). Clin Colon Rectal Surg. 2005;18:96-101. [CrossRef] [PubMed]
4. De Giorgio R, Knowles CH. Acute colonic pseudo-obstruction. Br J Surg. 2009;96:229-39. [CrossRef] [PubMed]

Cite as: Bernaba M, Power E, Raoof S, Bijin B, Chan Y-M. Medical image of the month: chronic Ogilivie's syndrome. Southwest J Pulm Crit Care. 2018;17(6):146-8. doi: https://doi.org/10.13175/swjpcc117-18 PDF