Unilateral cardiogenic pulmonary edema associated with acute mitral regurgitation

Unilateral Pulmonary Edema in Patients With Acute Mitral Regurgitation Caused by Chordal Rupture

Background: Cardiogenic unilateral pulmonary edema (UPE) has been reported as an unusual condition and to occur in association with severe mitral regurgitation (MR). However, the prevalence of UPE in patients with severe MR remains unknown. Methods and Results: Among 143 consecutive patients with chordal rupture and significant MR, 38 patients with acute severe MR were studied. The prevalence of UPE was 50% (19 patients); all these patients had right-sided UPE. Eight (21%) patients had bilateral pulmonary edema (BPE). All 8 patients with BPE and 18 of 19 patients with UPE had chordal rupture of the posterior leaflet. All patients with UPE and BPE had severe MR with similar left atrial size. Chest radiographs taken ≤48 h from symptom onset diagnosed UPE in 15 of 19 (79%) patients and BPE in 3 of 8 (38%) patients (P=0.037). Chest radiographs taken >48 h from symptom onset diagnosed UPE in 4 (21%) patients and BPE in 5 (62%) patients (P=0.037). Conclusions: The prevalence of UPE was estimated as 50%; it was most frequently right sided and almost always associated with chordal rupture of the posterior leaflet. UPE is not rare, but common, particularly shortly after the development of acute severe MR caused by chordal rupture.

Acute Mitral Valve Regurgitation Presenting With Right Upper Lobe Opacification

There is literature describing unilateral or focal pulmonary edema due to mitral regurgitation. The proposed mechanism is a regurgitant jet propelling blood towards the orifice of a particular pulmonary vein within the left atrium, which selectively pressurizes that vein. The increased hydrostatic pressure is transmitted to the pulmonary capillaries that drain into that vein, causing focal consolidation. A 62-year-old female presented with acute hypoxic respiratory failure. Her dyspnea started suddenly and she was unresponsive when she arrived at the emergency department via emergency medical services. Her initial oxygen saturation was 23% and she was immediately intubated. Sequential chest radiographs demonstrated dense consolidation in the right upper lung field and then opacification of the right hemithorax. These asymmetric lung findings were suspicious for infectious etiology but she was afebrile with no respiratory secretions and had normal inflammatory markers. Echocardiography showed a ruptured anterior papillary muscle causing a flail mitral valve leaflet with severe mitral regurgitation. The patient developed cardiogenic shock; she had an intra-aortic balloon pump placed for afterload reduction and was taken to the operating room for an emergency mitral valve replacement. Her clinical status rapidly improved and she made a full recovery. As in this case, acute mitral regurgitation can present with sudden life-threatening respiratory failure and cardiogenic shock so prompt diagnosis is critical. This is often misdiagnosed as pneumonia or other respiratory illnesses. Awareness, early diagnosis, and treatment of this entity could provide significant morbidity and mortality benefits for patients.

A case of unilateral pulmonary oedema associated with severe acute mitral regurgitation

A 44-year-old woman presented to the emergency department with sudden chest tightness and breathlessness, and a chest X-ray revealed unilateral pulmonary oedema (UPO). Colour Doppler echocardiography showed that the leaflet prolapsed with severe regurgitation, and the regurgitant jet tended to blow rightward within the left atrium. With the assistance of mechanical ventilation and venoarterial extracorporeal membrane oxygenation, the patient underwent mitral valve replacement. UPO is easily misdiagnosed, which leads to delays in treatment. Therefore, accurate diagnosis and immediate treatment are crucial.

Unilateral cardiogenic pulmonary edema caused by acute mitral valve prolapse: A case report

RATIONALE

Unilateral cardiogenic pulmonary edema is a rare disease. A common cause is mitral valve and asymmetrical blood regurgitation that is primarily directed toward the upper right pulmonary vein, causing mean capillary pressure to increase on the right side and leading to right pulmonary edema.

PATIENT CONCERNS

A 41-year-old man was diagnosed with pneumonia after presenting with a 2-day history of cough and shortness of breath. Computed tomography indicated right pulmonary edema. He was managed with noninvasive ventilation; however, his condition continued to deteriorate, and he was transferred to the intensive care unit after tracheal intubation.

DIAGNOSIS

Acute posterior mitral valve prolapses; unilateral cardiogenic pulmonary edema.

INTERVENTION

Emergency mitral valve replacement was performed. During the operation, 2 ruptures of the chordae tendineae in the P2 scallop of the posterior mitral valve were found, and a No. 29 St. Jude mechanical mitral valve was implanted.

OUTCOMES

Cardiotonic and diuretic drugs were administered postoperatively. Tracheal intubation was removed on day 7; the patient was transferred to the general ward on day 11 and discharged on day 23 postoperatively.

LESSONS

Unilateral cardiogenic pulmonary edema is easily misdiagnosed. Computed tomographic (CT) imaging presentation, brain natriuretic peptide, and cardiac color Doppler ultrasound can assist in determining a differential diagnosis. Early surgical treatment is recommended for patients with acute mitral valve prolapse.

Unilateral pulmonary edema in acute aortic regurgitation: A complication of infective endocarditis

Cardiogenic unilateral pulmonary edema (UPE) is an uncommon clinical entity and it represents just 2% of cardiogenic pulmonary edema with inclination for the right upper lobe and it is most commonly associated with severe mitral regurgitation. In our review, the literature does not include any UPE cases that are associated with severe aortic regurgitation (AR). Herein, we present a case with UPE, that includes a patient diagnosed with infective endocarditis who presented with shortness of breath. Initial chest imaging revealed UPE. Severe acute AR was diagnosed clinically and confirmed by echocardiogram, caused by vegetations on the non-coronary cusp of the aortic valve. The patient was transferred for emergent surgical intervention. This case underscores the importance of emergently evaluating valvular pathology to reduce the mortality rate that is associated with this condition. <Learning objective: In this study, we are highlighting the importance of having a high suspicion index to consider the diagnosis of unilateral pulmonary edema, as this condition is rare and hard to diagnose and carries a high mortality as well.>.

Unilateral pulmonary edema and acute severe mitral regurgitation associated with operatively repaired aortic coarctation

Cardiogenic pulmonary edema classically presents bilaterally and with a symmetric distribution. Occasionally, cardiogenic pulmonary edema can present unilaterally, which carries an independent risk for mortality, possibly due to the delayed diagnosis. The most common cardiogenic cause of unilateral pulmonary edema is acute mitral regurgitation, frequently described in the setting of acute coronary syndrome. Here we describe a case of unilateral pulmonary edema caused by acute mitral regurgitation outside the setting of acute coronary syndrome.

Unilateral pulmonary edema: a case report and review of the literature

Background

Unilateral pulmonary edema is an uncommon condition and is a rare clinical entity that is often misdiagnosed at the initial stages. In a majority of patients it occurs in the upper lobe of the right lung. There are many causes of unilateral pulmonary edema, but the commonest is the presence of a grade 3 mitral regurgitation. Due to its rare presentation, a high index of suspicion is required, and correct management is necessary to reduce the morbidity and mortality.

Case presentation

We present a case of right-sided unilateral pulmonary edema in an 86-year-old Sinhalese Sri Lankan woman who presented with acute onset dyspnea with cardiogenic shock due to acute non-ST elevation myocardial infarction, complicated with grade 3 mitral regurgitation. She had clinical features of heart failure and pulmonary edema, but a chest X-ray showed unilateral infiltrates only on the right side. Distinguishing pneumonia from pulmonary edema according to chest X-ray findings was a challenge initially, and she was therefore initially treated for both conditions. She had remarkable clinical and radiological improvement after 12 hours of intravenously administered furosemide and glyceryl trinitrate therapy. Her brain natriuretic peptide level was elevated and further supported and confirmed the diagnosis retrospectively.

Conclusions

Unilateral pulmonary edema is a completely reversible condition with good patient outcome if it is suspected early and treated early. Even in the absence of readily available echocardiogram skills, a clinical examination is of paramount importance in making a clinical decision in low-resource settings to reduce mortality.