Cor Pulmonale

 

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This individual has advanced interstitial lung disease that has led to severe pulmonary hypertension and pressure overload on the right ventricle, eventually leading to dilation and cor pulmonale (right heart failure due to a pulmonary etiology). Note how skewed this parasternal long axis view is with the LV compressed by a massively dilated RV. Typically only the RVOT is seen in this view not most of the RV.

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Short axis images show that septal motion is consistent with pressure and volume overload. Here is a representative view from the mid ventricle. The left ventricle is classically D shaped, which is best seen in throughout all of diastole (hence volume overload). In systole, when the LV contracts the septum tries to allow the LV to approximate more of a circular shape, but not fully, suggestive some pressure overload as well. A pericardial effusion is also present, which is not uncommon in Cor Pulmonale.
This pulsed wave Doppler shows several important features consistent with pulmonary hypertension. First the RVOT VTI is notched (white arrow) which is quite abnormal. This is due to reflected waves that return during RV systole. Also note the steep acceleration time to peak velocity (red line) which corresponded to 60ms in this individual. Values under 80ms in this context goes along with high PA pressures.

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This apical 4 chamber shows the right ventricle is severely enlarged and hypertrophied. It is also apex forming meaning that the majority of the ventricular apex is made up by the RV and not LV. The RA is also markedly dilated with the inter-atrial septum bowed into the LA due to elevated right sided pressures.

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The tricuspid annulus is dilated, the leaflets barely coapt, and significant tricuspid regurgitation is present as shown here with color Doppler.
CW Doppler shows a thick dense TR jet. The estimated PA systolic pressure is markedly elevated. Adding on an RA pressure of 15, which this individual had, yields a PA systolic pressure of nearly 90 mmHg.