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

A-Woman-in-Her-90s-With-Respiratory-Distress-After

Pdf Summary

In the clinical case highlighted by Drs. Colin T. Phillips and Warren J. Manning, a woman in her 90s experienced respiratory distress following transcatheter aortic valve replacement (TAVR) and dual-chamber pacemaker implantation due to persistent heart block. Her medical history included class III heart failure secondary to low-flow, low-gradient aortic stenosis, paroxysmal atrial fibrillation, and bladder cancer. Three days post-procedure, despite resolved aortic stenosis, she developed dyspnea with signs of fluid overload and pulmonary edema, characterized by tachypnea, crackles in the lungs, and a low-grade systolic murmur.<br /><br />A focused evaluation using handheld ultrasound uncovered cardiogenic pulmonary edema, as suggested by B-lines indicating extravascular lung water and a distended inferior vena cava. The ultrasound ruled out complication-related conditions like pneumothorax, significant pericardial effusion, paravalvular aortic regurgitation, and right ventricular dysfunction. The likely cause of her symptoms was attributed to volume overload and elevated diastolic filling pressures due to left ventricular thickness and systemic vascular resistance.<br /><br />Post-evaluation, the patient's condition improved following the administration of diuretics, which relieved the fluid overload. This case underscores the importance of handheld ultrasonography as an efficient diagnostic tool that supplements physical examination by quickly identifying the causes of dyspnea and guiding appropriate management for complex patients. The technique allows simultaneous assessment of multiple potential complications from recent procedures, illustrating that even in complex cases, common diagnoses like pulmonary edema should not be overlooked.

Keywords

transcatheter aortic valve replacement

dual-chamber pacemaker

cardiogenic pulmonary edema

handheld ultrasound

heart failure

fluid overload

diastolic filling pressures

dyspnea

diuretics

diagnostic tool