KCMC, POCKUS, Tales From Tanzania

Tales from Tanzania #2

Hello, all. Finally back with another Tale from Tanzania. This one was quite striking when I came across it. I was introduced to the patient by Dr. Sofia Nkya, who first asked if I knew what condition the patient had. As it turns out, I have no difficulty recognizing the distinctive facial features associated with Down syndrome, but what was most surprising right away was the patient’s age – she appeared to be in her late 20s or early 30s. Despite her age, however, she did not seem to have any surgical scars on her chest wall. This was a relevant observation because within a few seconds of meeting the patient, I had noticed several signs of overt heart failure – 2-3+ pitting bilateral lower extremity edema, tachypnea, rales so severe I didn’t need my stethoscope to appreciate them. I quickly put these signs together with the patient’s age, condition, and lack of surgical scars, and quickly made a guess at what I would see on her echocardiogram.

While that guess ended up being fundamentally accurate, it still didn’t quite prepare me for the images I obtained:

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Initially normal-appearing LV structure (though severe systolic dysfunction is evident) quickly gives way to a very obvious VSD. Excursion of the anterior leaflet of the mitral valve appears oddly preserved, though this may be artifactual due to the abnormal connections of the valve leaflets.

The VSD was readily apparent on the initial views, as was the degree of LV systolic dysfunction. Having seen this view, the color imaging was much less of a surprise.

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Color doppler imaging of back-and-forth flow between the right and left ventricles. Forgive the quality – color doppler is apparently a bit processor-intensive for my Google Pixel 2 and frequently caused my phone to crash, so I was just getting whatever images I could manage.

It’s honestly hard to even interpret the specifics of such a dysfunctional system, but there’s clearly flow in both directions between the right and left ventricles, and there also appears to be a regurgitation jet shooting retrograde through whatever valve we’re seeing.

Speaking of which, exactly which valve are we seeing, again?

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What exactly is going on here with the valve situation?

It’s very difficult to say for sure which valve we’re seeing in this view. It appears to almost be a combination of the mitral and tricuspid valves, which are bridging what amounts to a single atrium. Unfortunately, I was unable to get enough images in enough planes to fully characterize the valve structure (not being well-versed in valvular pathology certainly didn’t help either), but what is certainly notable in the view above is the appearance of RV wall thickening and chamber dilation due to the chronically elevated RV pressures from the uncorrected VSD.

Anyway, I hope you guys enjoyed seeing this case. If you have thoughts regarding the valvular structure or any other points, definitely let me know in the comments below or on Facebook or Twitter!

Happy scanning!

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