May 2018 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 79-year-old man with a past medical history significant for mild, intermittent asthma since childhood and mild aortic stenosis presents to the Emergency Room with fevers and chills for 5 days, associated with dry cough and dyspnea on exertion. His past medical history was otherwise relatively unremarkable, with coronary artery disease as evidenced by coronary artery calcium at a calcium scoring CT, hypothyroidism, and dyslipidemia. The patient has allergies to dust and penicillin, and his only medications included thyroid replacement, aspirin, and an albuterol inhaler as needed. He was a 15-pack-year smoker, quitting 30 years ago. His past surgical history was remarkable only for tonsillectomy, inguinal hernia repair, meniscal repair, and sigmoid colon resection for diverticular abscess 14 years earlier. The patient was afebrile, his heart rate was 96 beats / minute and regular, decreased breath sounds at the lung bases was noted, and the white blood cell count was normal. Electrocardiography showed no abnormalities. Oxygen saturation was 92% on room air. Frontal chest radiography (Figures 1A and B) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following represents the most accurate assessment of the frontal chest imaging findings? (Click on the correct answer to proceed to the second of nineteen pages)

1. Chest frontal imaging shows bilateral pleural fluid collections
2. Chest radiography shows bilateral lower lobe bronchial wall thickening and patchy consolidation
3. Chest radiography shows cavitary lung disease
4. Chest radiography shows numerous small nodules
5. Chest radiography shows peribronchial and mediastinal lymphadenopathy

Cite as: Gotway MB. May 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(5):254-78. doi: https://doi.org/10.13175/swjpcc062-18 PDF 

Medical Image of the Week: Cardiac Magnetic Resonance Imaging Findings of Severe RV Failure

  

Figure 1. Transthoracic echocardiography, short-axis view (1A) and four-chamber view (1B) demonstrating leftward deviation with flattening of interventricular septum (“D-sign”) due to increased right ventricular pressure and volume overload from severe pulmonary arterial hypertension (PAH). RV=right ventricle. RA=right atrium. LV=left ventricle.

Figure 2. Cardiac Magnetic Resonance Imaging, sagittal view (2A), and cross-sectional view (2B) show the same signs of massive right ventricular (RV) pressure and volume overload with severe RV dysfunction. RV ejection fraction of 13%. RV=right ventricle. RA=right atrium. LV=left ventricle. LA=left atrium.

A 56-year-old man with history a of alcohol abuse presents with progressive shortness of breath on exertion, bilateral lower extremity swelling and 12-pound weight gain over two weeks.

His transthoracic echocardiography (Figure 1) demonstrated severely increased global right ventricle (RV) size, severely dilated right atrium (RA), severe pulmonary artery (PA) dilation, moderate tricuspid regurgitation (TR) and right ventricular systolic pressure (RVSP) estimated at 85 + central venous pressure (CVP) in the context of severely reduced RV systolic function.  Right heart catheterization (RHC) showed PA pressure (systolic/diastolic, mean) of 94/28, 51 mmHg with a PA occlusion pressure of 12 mmHg. After extensive evaluation, our patient’s presentation of right heart failure seemed to be a manifestation of idiopathic pulmonary arterial hypertension.

Our patient subsequently had cardiac MRI (cMRI) with findings shown above (Figure 2). CMRI is a valuable, three-dimensional imaging modality that provides detailed morphology of the cardiac chambers along with accurate quantification of chamber volumes, myocardial mass and transvalvular flow (1). Cardiac MRI is an accurate tool to estimate the RV function at baseline and to follow up response to treatment. RV function at presentation and after treatment are very important determinants of prognosis independent of other hemodynamic indices (2).  

Kelly Wickstrom, DO¹, Huthayfa Ateeli, MBBS², Sachin Chaudhary, MD²

¹Internal Medicine Department and ²Pulmonary and Critical Care Division

Banner University Medical Center

Tucson, AZ USA

References

1. Grünig E, Peacock AJ. Imaging the heart in pulmonary hypertension: an update. Eur Respir Rev. 2015 Dec;24(138):653-64. [CrossRef] [PubMed]
2. Swift AJ, Wild JM, Nagle SK, et al. Quantitative magnetic resonance imaging of pulmonary hypertension: a practical approach to the current state of the art. J Thorac Imaging. 2014 Mar;29(2):68-79. [CrossRef] [PubMed]

Cite as: Wickstrom K, Ateeli H, Chaudhary S. Medical image of the week: cardiac magnetic resonance imaging findings of severe RV failure. Southwest J Pulm Crit Care. 2018;16(5):252-3. doi: https://doi.org/10.13175/swjpcc047-18 PDF