PMC5602492_01
Two projection chest X-rays with the anteroposterior view on the left and the lateral view on the right, showing signs of pulmonary congestion and a right basal pleural effusion.
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An atrial fibrillation with a left bundle branch block (LBBB) was detected on the electrocardiogram (ECG) and a chest X-ray revealed signs of pulmonary congestion and a right basal pleural effusion (Figure 1).
Effective orifice area calculation for the mechanical prosthesis on the transthoracic echocardiography. On the top, the left ventricle outflow tract (LVOT) diameter measurement; on the bottom, the pulse wave analysis on the LVOT on the left and the prosthesis continuous wave analysis on the right.
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The transthoracic echocardiogram (TTE) showed a dilated left ventricle with preserved EF (60%), a dilated right ventricle with normal systolic function, no residual shunt at the interventricular septum, aortic mechanical prosthesis in a correct position, with preserved discs opening, no signs of pathological intra- or periprosthesis regurgitation, increased transprosthetic gradients (mean gradient of 33 mmHg), and an effective orifice area index (EOAi) of 0,4 cm2/m2 suggesting severe prosthesis-patient mismatch (PPM) (Figure 2).
Parenchymal (a) and pulmonary vasculature study (b) on the chest CT scan showing no pathological findings; (c) abdomen CT scan showing a cirrhotic liver with a focal lesion (white arrow), highly suspicious of hepatocellular carcinoma.
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A chest-abdomen CT examination was carried on with evidence of small right pleural effusion, no signs of lung parenchymal disease and pulmonary embolism (Figures 3(a) and 3(b)), cirrhotic liver disease with a focal lesion highly suspicious for hepatocellular carcinoma, splenomegaly, and signs of portal hypertension (Figure 3(c)).
(a) Microbubble transthoracic echocardiography showing a right to left shunt with a delayed opacification (>3 cardiac cycles) of the left atrium and ventricle; (b) macroaggregated albumin lung perfusion scan (MAA scan) showing radioactivity in the lungs (panel 2) as well as in the cerebrum (panel 1) and in the kidneys (panel 3), suggesting right to left shunt.
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TTE (MTTE) and a lung scintigraphy (99 mTc-MAA) were performed with evidence of intrapulmonary right to left shunt (Figures 4(a) and 4(b)). The diagnosis of HPS was confirmed and the patient was transferred to the gastroenterology department for the specific treatment required.