Unilateral cardiogenic pulmonary edema

Abstract

A 45-year-old man presented with fatigue for the previous two days. Because of severe hypoxemia and chest radiograph showing severe consolidation only in the right lung field, he was admitted to a near-by district hospital under the diagnosis of acute pneumonia. Since his respiratory condition rapidly deteriorated, he was transferred to our hospital. The diagnosis of unilateral cardiogenic pulmonary edema was made based upon the echocardiographic examination which showed severe mitral regurgitation secondary to chordal rupture of the posterior mitral valve leaflet (P₂). After successful intensive medical treatment with diuretics and extracorporeal membrane oxygenation, mitral valve repair was performed with quadrangular resection of the posterior mitral leaflet (P₂) and insertion of 28 mm Cosgrove ring. It is important to recognize acute and severe mitral regurgitation as a main cause of unilateral cardiogenic pulmonary edema. Prompt differentiation from acute pneumonia is critical to save lives of the patients. <Learning objective: Unilateral cardiogenic pulmonary edema is an unusual condition and may often be misdiagnosed as acute pneumonia, resulting in an increased risk of mortality. A correct differentiation from pneumonia is critical to save lives of the patients. It is important to recognize acute and severe mitral regurgitation as a main cause of this unusual condition.>.

Keywords: Acute mitral regurgitation; Differentiation from pneumonia; Unilateral cardiogenic pulmonary edema.

Fig. 1

(A) Chest radiograph on admission at the district hospital showing unilateral consolidation of the right lung field. (B) Chest radiograph at transfer six days later showing bilateral severe consolidation resembling “butterfly shadow”.

Fig. 2

Transthoracic echocardiograms in the long-axis view (upper panel) and apical four-chamber view (lower panel). Chordal rupture of the posterior mitral valve P₂ leaflet is shown (A,C: arrow). Severe mitral regurgitation was first directed anterolaterally and then to the right side of the LA (B,D). Ao, aorta; LA, left atrium; LV, left ventricle; RV, right ventricle.

Fig. 3

Upper panel: Transesophageal echocardiograms showing chordal rupture of the posterior mitral valve leaflet (A, arrow) and massive mitral regurgitant flow toward the right side of the pulmonary veins (B). Lower panel: Plain computed tomography scan on admission at the district hospital showing prominent right superior pulmonary vein (C, arrow) and engorged right inferior pulmonary vein (D, arrow) without significant engorgement of the left pulmonary veins. Engorged right pulmonary veins were directly connected to the perihilar consolidation. LA; left atrium, LLA; left atrial appendage, LV; left ventricle.