PMC5425844_01
(a) At baseline, the transthoracic echocardiogram demonstrates moderately depressed LV function (LVEF-40%) with significant concentric and septal LV hypertrophy (LV mass 367 grams, IVSd-2.1 cm, PWT-1.5 cm, RWT-0.67). (b) There is further evidence of elevated filling pressures. There is left atrial enlargement (LA dimension-4.6 cm), mildly elevated estimated right ventricular systolic pressure (RVSP~36 mmHg), and restrictive filling on mitral inflow Doppler (E/A-2.3, deceleration time 190 milliseconds).
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The transthoracic echocardiogram was significant for moderately depressed left ventricular (LV) function, left atrial dilation, normal ventricular chamber dimensions, increased LV mass, and global hypokinesis (Figure 1).
Atrial fibrillation with rapid ventricular response (ventricular rate 127 bpm) with evidence of prior septal infarct and nonspecific ST-T wave abnormalities in the precordium. There are low QRS voltages noted across leads likely due to chronic obstructive pulmonary disease.
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The patient presented to the emergency department hypertensive (169/79 mmHg) and tachycardic with a ventricular rate of 127 beats per minute (Figure 2).
At the time of clinical deterioration, pulse Doppler of the LVOT and continuity equation calculated SV/CO (LVOT dimension-2.0 cm, VTI-8.1 cm) suggested low stroke volume (25 ml) and cardiac output (2.22 L/min).
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A pulse wave Doppler across the LVOT suggested diminished stroke volume after calculation of the LV velocity time integral (Figure 3).
Atrial fibrillation with fairly regular R-R intervals (ventricular rate 113 bpm) and slower rate while on beta-blocker. The QRS morphology and voltages remain unchanged from prior tracing.
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An EKG at the time demonstrated improvement of the ventricular rate without evidence of ST-T wave changes (Figure 4).