History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute...

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History: 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea

Case of the Month 3September 2015

Authors: Paola Franchi Anna Rita Larici

9th Jan 2013

Case of the Month 3 11th Jan 2013

11th Jan 2013

Case of the Month 3

30th Jan 2013Case of the Month 3

30th Jan 2013

Case of the Month 3

Case of the Month 3Diagnosis

What is your diagnosis ?

History: 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute dyspnea

Question: Which are the abnormalities on this chest X-ray?

Case of the Month 3September 2015

Authors: Paola Franchi Anna Rita Larici

9th Jan 2013

Alveolar opacity in the right parahilar region with air bronchogram (arrows)

Case of the Month 3

The opacity is predominantly located in the right upper lobe (RUL)

Case of the Month 3

Thickening of the minor fissure

Enlargement of the pulmonary arterial vessels

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Cardiomegaly

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Predominantly of the left heart chambers

Aortic dilation

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Question: What is shown on the CT images?

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GGO with air bronchogram mainly located in the RUL

Relative sparing of the subpleural areas

11th Jan 2013

Question: Some days later… what is shown on the CT images?

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Areas of GGO in the RUL

Smooth interlobular septal thickening in the RUL

30th Jan 2013

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Bilateral pleural effusion, greater on the right

30th Jan 2013

Question: Which information adds the use of the contrast medium?

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Pulmonary artery dilatation

Reflux of contrast medium in the IVC and hepatic veins due to cardiac ovreload

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28th Feb 201320th Feb 2013

… after mitral valve replacementBefore and…

Unilateral Pulmonary Edema secondary to severe mitral

valve regurgitationDifferential Diagnosis - Pulmonary infection- Alveolar hemorrhage- Carcinomatous lymphangitis- Aspiration pneumonitis

Case of the Month 3Discussion

Cardiogenic unilateral pulmonary edema (UPE) is a rare entity, frequently leading to initial misdiagnosis

UPE represents about 2.1% of cardiogenic pulmonary edema

UPE is always associated with severe mitral regurgitation

UPE is related to an independent increased risk of mortality and should be promptly recognized to avoid delays in treatment

Left ventricle, mitral valve, left atrium, right superior pulmonary vein, and the RUL are aligned along the path expected for a regurgitant jet caused by mitral insufficiency, with a resulting increase in hydrostatic pressure in the right superior pulmonary vein

Asymmetric pulmonary edema concentrated in the right upper lobe is typically associated with mitral regurgitation resulting from a flail posterior leaflet, which can be caused by rupture of the chordae tendineae or papillary muscle

CHEST RADIOGRAPHY Loss of definition of segmental and subsegmental

vessels Enlargement of peribronchovascular spaces and

peribronchial cuffing Kerley lines Areas of increased opacity Pleural effusion All findings are more conspicuous on the right

HIGH-RESOLUTION CT Ground-glass opacity Smooth interlobular septal thickening Peribronchovascular interstitial thickening Increased vascular diameter Pleural effusion All findings are more conspicuous in the RUL

Case of the Month 3Further Reading

UNILATERAL PULMONARY EDEMA DUE TO MITRAL VALVE REGURGITATION1) Gurney JW, Goodman LR. Pulmonary edema localized in the right upper lobe accompanying mitral regurgitation Radiology 1989;171:397-92) Alarcón JJ et al. Localized right upper lobe edema Chest 1995;107:274-63) Raman S, Pipavath S. Images in clinical medicine. Asymmetric edema of the upper lung due to mitral valvular dysfunction N Engl J Med 2009;361:e64) Attias D et al. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema. Circulation 2010;122:1109-155) Bagate F et al. Febrile unilateral pulmonary edema: a potential misdiagnosis Int J Cardiol 2014;174:867-86) Bishara H et al. An 80-year-old man with a right upper lobe opacity Clin Respir J 2015 doi: 10.1111/crj.12293

Unilateral Pulmonary Edema

Differential Diagnosis - Pulmonary infection- Alveolar hemorrhage- Carcinomatous lymphangitis- Aspiration pneumonitis

Cardiogenic unilateral pulmonary edema (UPE) is a rare entity, frequently leading to initial misdiagnosis

UPE represents about 2.1% of cardiogenic pulmonary edema

UPE is always associated with severe mitral regurgitation

UPE is related to an independent increased risk of mortality and should be promptly recognized to avoid delays in treatment

Left ventricle, mitral valve, left atrium, right superior pulmonary vein, and the RUL are aligned along the path expected for a regurgitant jet caused by mitral insufficiency, with a resulting increase in hydrostatic pressure in the right superior pulmonary vein

Asymmetric pulmonary edema concentrated in the right upper lobe is typically associated with mitral regurgitation resulting from a flail posterior leaflet, which can be caused by rupture of the chordae tendineae or papillary muscle

CHEST RADIOGRAPHY Loss of definition of segmental and subsegmental

vessels Enlargement of peribronchovascular spaces and

peribronchial cuffing Kerley lines Areas of increased opacity Pleural effusion All findings are more conspicuous on the right

HIGH-RESOLUTION CT Ground-glass opacity Smooth interlobular septal thickening Peribronchovascular interstitial thickening Increased vascular diameter Pleural effusion All findings are more conspicuous in the RUL

Case of the Month 3Further Reading

UNILATERAL PULMONARY EDEMA DUE TO MITRAL VALVE REGURGITATION1) Gurney JW, Goodman LR. Pulmonary edema localized in the right upper lobe accompanying mitral regurgitation Radiology 1989;171:397-92) Alarcón JJ et al. Localized right upper lobe edema Chest 1995;107:274-63) Raman S, Pipavath S. Images in clinical medicine. Asymmetric edema of the upper lung due to mitral valvular dysfunction N Engl J Med 2009;361:e64) Attias D et al. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema. Circulation 2010;122:1109-155) Bagate F et al. Febrile unilateral pulmonary edema: a potential misdiagnosis Int J Cardiol 2014;174:867-86) Bishara H et al. An 80-year-old man with a right upper lobe opacity Clin Respir J 2015 doi: 10.1111/crj.12293

History : 76-year-old male with severe mitral insufficiency, pulmonary arterial hypertension, acute...

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