Focused Cardiac Ultrasound for the Detection of a Ventricular\nAneurysm
A 60-year-old male with a history of asthma and diabetes mellitus presented to the\nemergency department (ED) with two weeks of worsening cough, shortness of breath and\nwheezing. He reported bilateral lower extremity swelling, orthopnea, paroxysmal nocturnal\ndyspnea, fatigue, dyspnea on exertion and subjective fevers. He denied chills, chest pain,\nnausea and vomiting. The patient was unaware of any history of cardiac disease and denied\nsmoking or recreational drug use.\nPhysical examination on presentation to the ED revealed an uncomfortable appearing male in\nmild distress. The patient’s initial vital signs were: heart rate 112 beats per\nminute, blood pressure 133/83 mmHg, respiratory rate 17, temperature 99.1°F\n(37.3°C), and oxygen saturation 97% on room air. He was noted to have 10 cm\nof jugular venous distension and bilateral pitting edema to his knees. His cardiovascular\nexam revealed a normal S1 and S2, and a loud S3 with no audible murmurs. The\npatient’s lung examination was significant for crackles in all lung fields, mild\nend-expiratory wheezing and no accessory muscle use. Neurologic and abdominal examinations\nwere normal.\nHis electrocardiogram (ECG) was significant for ST segment elevation in leads V1 through V4\nconsistent with an anteroseptal infarct, age undetermined (). Chest radiograph was significant for costophrenic\nangle blunting and hilar prominence bilaterally (). No old studies were available for comparison, leading the emergency\nphysician (EP) to activate the process for urgent PCI (percutaneous coronary\nintervention).\nWhile cardiology was consulted, the EP performed a bedside focused cardiac ultrasound using\na 5-1 MHz phased array transducer (Philips HD11XE, Andover MA) showing reduced left\nventricular contractility, as well as thinning and dilation of the anterior left ventricular\nwall, consistent with an aneurysm of the left ventricle. (). An apical 4 chamber view noting thinning and poor\ncontractility of the distal left ventricle. The proximal ventricle are not thinned and\ndemonstrate normal contractility ( only).\nPoint-of-care laboratory results returned during cardiology consultation. Troponin I was\n<0.01 ng/ml, myoglobin was 280 ng/ml [normal<106 ng/ml] and\nB-type natriuretic peptide was 1152 pg/ml [normal<100 pg/ml]. Based\non the ECG and ED ultrasound findings, the consulting cardiologist concluded that the ST\nelevation was related to a recent anteroseptal myocardial infarction resulting in the left\nventricular aneurysm. The patient was not transferred directly to the cardiac\ncatheterization lab given his history and focused cardiac ultrasound results, and instead\nwas treated with optimal medical therapy. During the hospital course, the patient’s\ntroponin level never increased. A comprehensive echocardiogram confirmed the ED findings of\na ventricular aneurysm.