Undiagnosed Cardiomyopathy after Pregnancy

Stacie Zelman, MD, Matthew Belford, MD, Bahram  Kiani, MD, Mary Wittler, MD

The patient is a 46-year-old woman with a past medical history of hypertension (HTN), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and an unknown congenital heart lesion, that presents by EMS with chest pain and shortness of breath (SOB). The patient reports acute onset of severe chest pain radiating into her back. The pain is described as sharp, pressure pain with a pleuritic component and no aggravating or alleviating factors. Associated symptoms include nausea, diaphoresis, and moderate SOB. The patient notes baseline chronic 3 pillow orthopnea, paroxysmal nocturnal dyspnea, and lower extremity edema controlled with Lasix. EMS provided nebulized albuterol en route and placed her on continuous positive airway pressure (CPAP). The patient thinks her ejection fraction is 20% and reports that her heart lesion was never surgically corrected. Her current medications include albuterol, Advair, furosemide, lisinopril, metoprolol, and spironolactone.

On exam, the patient is in moderate distress; initial exam is somewhat limited secondary to BiPAP. Vital Signs include: BP 134/92 mmHg, HR 112 bpm, RR of 35/min, Sats 100% on BiPAP (EPAP: 5 cmH2O/IPAP: 12 cmH20). She has pink conjunctiva and appears well perfused. No appreciable jugular venous distension (JVD) is noted. Cardiac exam is regular rate and rhythm with no murmurs, gallops, or rubs. Her lungs have mild end-expiratory wheezing bilaterally, but otherwise clear. Her abdomen is soft, nontender, and nondistended with no hepatosplenomegaly. She has no cyanosis, clubbing, or edema. Pulses are equal in her bilateral upper and lower extremities. Immediate concerns included acute coronary syndrome (ACS), CHF exacerbation, COPD exacerbation, pulmonary embolism, aortic dissection, and complication from the unknown congenital (acyanotic) heart lesion.  

The initial EKG showed a sinus tachycardia with a left bundle branch block (LBBB). Comparison to previous ECG was unchanged. Selected views of her CXR, ECG, and CT chest are shown: 

 UCAP CX RAP View  UCAP Chest CT Axial Proximal
CXR: AP view      Chest CT: axial, proximal
 UCAP Chest axial distal  UCAP Chest CT Coronal
Chest CT: axial, distal      Chest CT: coronal
 ECG showing sinus tachycardia with LBBB
 ECG showing sinus tachycardia with LBBB

Q1: Based on the patient’s history and provided imaging, what acyanotic congenital heart lesion does this patient likely have?


Q2: Patients with the isolated form of this lesion usually present later in life secondary to:


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