CHEST Guidelines-A-Woman-in-Her-90s-With-Respiratory-Distress-After (1)

A-Woman-in-Her-90s-With-Respiratory-Distress-After (1)

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The case study details a woman in her 90s who developed respiratory distress following a transcatheter aortic valve replacement (TAVR) and subsequent pacemaker implantation. She had a history of heart failure due to aortic stenosis, atrial fibrillation, and bladder cancer. The TAVR procedure was complicated by complete heart block, necessitating a temporary pacemaker that was later replaced with a permanent dual-chamber pacemaker. On the third day post-surgery, she experienced dyspnea, requiring oxygen support.<br /><br />An examination revealed tachypnea, increased work of breathing, and bibasilar crackles, indicative of pulmonary edema. A handheld ultrasound was employed to confirm these findings and explore potential procedural complications such as pneumothorax, pericardial effusion, paravalvular aortic regurgitation, and right ventricular dysfunction.<br /><br />The ultrasound revealed cardiogenic pulmonary edema, dismissing pneumothorax and pericardial effusion. B-lines in the lung apex suggested volume overload, consistent with extravascular lung water. The expanded inferior vena cava indicated elevated right and left-sided filling pressures.<br /><br />Due to her advanced age and medical history, other serious conditions were considered but excluded using the ultrasound. The resolution of critical aortic stenosis did not prevent increased left ventricular afterload resulting from persistent high systemic vascular resistance and noncompliant left ventricle, which could lead to pulmonary edema. Treatment with diuretics was effective, normalizing the patient's breathing and allowing for discharge.<br /><br />This case underscores the utility of handheld ultrasound as a tool that can quickly augment physical exams, guiding the assessment and management of complex presentations efficiently.

Keywords

TAVR

pacemaker

pulmonary edema

handheld ultrasound

heart failure

aortic stenosis

atrial fibrillation

dyspnea

cardiogenic

diuretics