Emergency department diagnosis of pulmonary hypertension in a patient with left atrial sarcoma

Abstract

Pulmonary hypertension is a disease with many etiologies and is responsible for 200,000 admissions and 25,000 hospitalizations in the United States each year. We report the case of a previously healthy 58-year-old woman who presented to the emergency department with a months-long history of worsening dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Despite the severity of her symptoms, she had no corroborative physical exam findings, including jugular venous distension or peripheral edema. Bedside emergency department ultrasonography revealed a dilated right ventricle and bowing of the intraventricular septum into the left ventricle, consistent with pulmonary hypertension. CT angiography of the chest performed in the emergency department revealed a large left atrial mass, found on pathology to be a left atrial sarcoma. This case illustrates how severely symptomatic pulmonary hypertension can have few to no physical exam findings and the utility of bedside emergency department ultrasound in making the presumptive diagnosis.

Figure 1

Representative image of pulmonary hypertension by bedside echocardiogram. The right ventricle (RV) is dilated and the intraventricular septum (dashed line) is bowing into the left ventricle (LV). (Courtesy of Geoffrey Hayden, MD).

Figure 2

Computed tomography angiogram of the chest exhibiting a left atrial filling defect (asterisk). Note the size of the RV in relation to the LV.