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Case-based session - imaging in acute heart failure patients presenting with...

Non-Invasive Imaging

This session had four excellent presentations on patients with acute heart failure due to different conditions.
The first case was presented by A. Fraser (Cardiff, GB) on a patient with acute infective endocarditis of the aortic valve; caused acute aortic regurgitation with severe volume overload of the left ventricle, early cessation of mitral filling and diastolic mitral regurgitation and very increased filling pressures, causing the acute dyspnea and pulmonary congestion. In the emergency room, the working diagnosis was NSTEMI because the troponin level was increased, making the case that not only does an oculo-stenotic reaction exist in interventional cardiology, but that in clinical cardiology also, one sometimes jumps to conclusions just from one or two “clues”. In fact, the early echocardiogram, and more specifically the M-mode, held all information required to come to the right conclusion.
The second case by T. Damy (Creteil, FR) was another illustration of this principle, namely that putting sparse clues together can often lead to the right diagnosis: in this patient with a previous diagnosis of hypertrophic cardiomyopathy, the existence of bi-ventricular hypertrophy and thickened valves on echo, microvoltage and pseudo Q-wave on the ECG, decreased strain values in the basal segments all pointed to amyloidosis; the case made it clear that it is sometimes very difficult to come to the molecular diagnosis (needed for appropriate therapy), requiring a cardiac biopsy and elaborate lab methods, but the primary diagnosis of amyloidosis could be firmly suspected.
The third case by E. Pieper(Groningen, NL) on a pregnant patient with progressive dyspnea had some dramatic decisions, but again the relevant information came from the echocardiogram, showing hypertrophy with deep recesses, and a diagnosis of non-compaction.
JL Merino (Madrid, ES), as an electrophysiologist, tried to put the audience on the wrong foot by moving into the direction of tachycardiomyopathy, while the echo and the MRI showed regional functional abnormalities and subepicardial late gadolinium enhancement , pointing to myocarditis.
So, this session brought a clear message that clinical cardiology is often a detective story where all information needs to be carefully looked at and weighed without jumping to conclusions based on habits and heuristic reasoning.





Case-based session - imaging in acute heart failure patients presenting with...

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.