Man 55, BMI 32, DM2, 2012 PCI LAD, Cx, RCA, now cath because of chest pain, occl RCA dist 1/3, near complete collat filling of RDP. Sent for stress echo, before decision about CTO. Presents with this picture at rest. What's going on? #fellowsfirst
RCA angiogram
Short axis view. #fellowsfirst
It's easier to see when things happen if you reduce replay speed. This is especially important in stress echo. Her short axis agin in half replay rate. Thoughts?
But of course, where applicable, M-mode, because of superior temporal resolution, is the best for timing events. So, what happens here? #fellowsfirst
This is pseudodyskinesia of the diaphragmatic wall.
1: Looking at SAX, there is diastolic flattening, not systolic dyskinesia is evident. Analogous with the paradoxical septal motion in large TR, but here It's external force from the diaphragma. Reduce replay speed.
M-mode shows all. Inward displacement of inf wall in diastole. Atrial systole pushes it outward. During IVC, LVP⬆️ > abdominal pressure, inf wall resumes normal position and LV normal configuration (circular). Wall thickening during ejection is normal in pseudodyskinetic wall.
The angio was a trap. There was nearly complete retrograde filling of RDP. It's easy to be distracted😉. And there was no ischemia in the wall during stress.
Finally, closer examination of history revealed that CP was constant, with no activity relation, worsening for days with chronic stressful situations, and elements of depression. #historyfirst
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