CCCardiol CroatCardiologia CroaticaCardiol. Croat.1848-543X1848-5448Croatian Cardiac SocietyCC_13(11-12)_40410.15836/ccar2018.404Extended Abstract4D strain in pulmonary embolism diagnostics: a case report4D strain u dijagnostici plućne embolije: prikaz slučajahttps://orcid.org/0000-0001-9588-6788FabrisAna*Poliklinika “Sv. Nikola”, Korčula, HrvatskaPolyclinic „Sv. Nikola“, Korčula, CroatiaADDRESS FOR CORRESPONDENCE: Ana Fabris, Poliklinika “Sv. Nikola”, Strećica 6, HR-20260 Korčula, Croatia. / Phone: +385-98-1704-343 / E-mail: poliklinika.nikola@gmail.com1120181311-1240440516102018051120182018Croatian Cardiac SocietyKLJUČNE RIJEČI: 4D strainplućna embolijadijagnozaKEYWORDS: 4D strainpulmonary embolismdiagnosis
Introduction: It is often difficult to diagnose a pulmonary embolism, with or without pulmonary hypertension, without application of a lung perfusion scan or pulmonary arteriography. (1, 2) Namely, without pulmonary infarction, the findings of chest X-ray (CXR) will be normal.
Case report: 78-year-old patient has had hypertension for several years. In September 2016, he was hospitalized for thrombosis in the popliteal and fibular veins of his right leg. CXR in December 2016: no signs of heart failure, rare linear fibrous opacifications in the lower zone. Color Doppler of the veins (February 2017) was normal, after which the anticoagulant therapy was suspended (due to hematuria). In September 2017, he came because of the resistant hypertension and chest pain. The 12-lead ECG recorded the sinus rhythm 59/min, left posterior hemiblock. The first 2D echocardiography showed: initial eccentric left ventricular hypertrophy with normal ejection fraction; Grade 1 diastolic dysfunction; left atrial enlargement and dilated ascending aorta; moderate mitral and tricuspid regurgitation with systolic pulmonary hypertension (PAPS 60mmHg), and minor pericardial effusion. After therapy correction, the 4D ultrasound (Tomtec 4D RV-function) subsequently found a mildly dilated right ventricle of reduced ejection fraction (19.92%) and prominently reduced longitudinal deformation of the right ventricular free wall (-11.29%), and septum (-6.97%) with normal left ventricular ejection fraction (Figure 1). After the applied therapy, there was a regression of pulmonary hypertension and pericardial effusion. Follow-up CXR: phrenicocostal sinus bilaterally discreetly shallower with minimum quantity of effusion and defined small interlobar space. MSCT of the thorax according to the protocol for the detection of pulmonary embolism: partial and full contrast medium filling defects corresponding to blood clots in the lumen of individual segmental or sub-segmental branches of pulmonary arteries for the upper right, medial, lingual, and lower left lung lobe. Treatment with low-molecular-weight heparin and vitamin K antagonists was started immediately.
4D right ventricular systolic function and longitudinal deformation image.
Conclusion: Differential diagnosis of pulmonary embolism (microembolism) is sometimes very demanding, particularly so in patients with unclear clinical manifestations. To start a timely and adequate treatment, it is essential to recognize the disease early, and 4D determination of longitudinal deformation of the septum and the right ventricular free wall and ejection fraction contributes to it.
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