February 2019 Imaging Case of the Month: Recurrent Bronchitis and Pneumonia in a 66-Year-Old Woman

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 66–year old woman presented with complaints of a non-productive cough worsening over the previous several weeks. She complained that her cough had also occurred several months earlier, but resolved, and then subsequently returned.

The patient indicated that she has had bouts of bronchitis off and on for many years. Her smoking history included only 3 cigarettes / day for two years, quitting 20 years earlier. She did not note any allergies and her list of medications included only vitamin supplements, baby aspirin, omeprazole, and lisinopril. Her surgical history was remarkable only for remote tonsillectomy and hysterectomy.

Her physical examination was largely unremarkable, although some course breath sounds were detected over the medial right base. Her vital signs showed normal pulse rate and blood pressure, breathing at 12 breaths / minute. Her room air oxygen saturation was 97%.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Initial frontal chest x-ray.

Which of the following represents the most accurate assessment of the chest radiographic findings? (Click on the correct answer to be directed to the second of sixteen pages)

1. Chest radiography shows a vague solitary pulmonary opacity
2. Chest radiography shows basilar fibrotic opacities
3. Chest radiography shows cavitary pulmonary lesions
4. Chest radiography shows marked cardiomegaly
5. Chest radiography shows numerous small nodular opacities

Cite as: Gotway MB. February 2016 imaging case of the month: Recurrent bronchitis and pneumonia in a 66-year-old woman. Southwest J Pulm Crit Care. 2019;18(2):31-49. doi: https://doi.org/10.13175/swjpcc006-19 PDF

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