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A case of cardiogenic pulmonary edema

Nephrology was consulted for acute kidney injury and hypervolemia in a chronically ill nursing home resident. You decide to perform lung POCUS to assess extravascular lung water.

Multiple B-lines per rib interspace are noted bilaterally consistent with pulmonary edema. Chest X-ray shown for comparison.

But would you stop there? No. Focused cardiac ultrasound (FoCUS) may give an idea if the pulmonary edema is caused by pump failure or a result of other structural abnormalities of the heart. Here are the apical 4 chamber and 2 chamber views.

The left ventricle seems dilated and there is a mobile echodensity (yellow arrow, merged clip) on the anterior mitral valve leaflet. LV systolic function appears fine, may be hyperdynamic actually. Color Doppler images revealed severe mitral regurgitation along with a separate regurgitant jet across the leaflet coaptation line suggestive of leaflet perforation (yellow arrow, still image).

So the cause for pulmonary edema is severe mitral regurgitation secondary to valve destruction caused by endocarditis. Cardiothoracic surgery was consulted but unfortunately, the patient was too sick to be a surgical candidate.

Learning point: Multi-system POCUS often provides management-changing information.


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