A Lifesaver Trinity for Unilateral Pulmonary Edema in a Cardiac Intensive Care Unit

Keywords: intra-aortic balloon pump, IABP, mitral valve flail, unilateral pulmonary edema, UPE

A 72-year-old man with chronic obstructive pulmonary disease (COPD) complained of worsening dyspnea. Physical examination revealed a soft systolic murmur best heard at the apex, third cardiac sound, hypoventilation of the right lung, and bilateral basal crackles. Body temperature was 36.9 °C, blood pressure 140/85 mm Hg, and oxygen saturation was 91%. Leukocytosis and increased C-reactive protein were marked. Chest computed tomography depicted right middle lobe air-bronchogram (Figure 1A). The patient was put on noninvasive positive-pressure ventilation and intravenous antibiotics on the basis of COPD exacerbation. Hemodynamic instability ensued 24 hours later. The patient went cold and wet, hypotensive, and severely tachypneic, and a holosystolic murmur was auscultated. Bedside x-ray showed total right lung opacification (unilateral pulmonary edema) (Figure 1B).

Transesophageal echocardiography (Figure 1C) confirmed cardiogenic shock due to mitral valve (MV) flail of the posterior leaflet, leading to acute MV regurgitation with an asymmetric jet directed toward the septal wall of the left atrium into the right upper pulmonary vein (Figure 1D). Myxomatoid degeneration and prolapse of the P2 scallop of the posterior leaflet due to spontaneous chordae tendinae rupture were evident (Video 1). Conventional ventilation was preferred over independent lung aeration techniques. Utmost caution was paid to avoid dislodgment of the tube into the (pathological) right lung. High positive end-expiratory pressure (PEEP) was required and urgent ultimate cardiothoracic treatment was pursued following an unremarkable coronary angiography (Video 2). Acute kidney injury necessitated continuous venovenous hemodiafiltration (CVVHDF). Refractory cardiogenic shock demanding inotropic support led to the implantation of an intra-aortic balloon pump (IABP) (Video 3) to limit the regurgitation fraction by reducing afterload, thus increasing cardiac index as a bridge to therapy.

Unilateral pulmonary edema manifests as a classic radiographic image but usually is misdiagnosed. Low-cardiac-output state, unilateral pulmonary infiltrates, and respiratory failure set the diagnosis. The trinity of high PEEP, IABP, and CVVHDF may be life-saving.

Affiliations and Disclosures

From the Cardiology Department, Trikala Hospital, Trikala, Thessaly, Greece.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted March 17, 2022.

Address for correspondence: Dimitrios Karelas, MD, R. Feraiou 13, 43100, Karditsa, Greece. Email: dim.f.karelas@gmail.com