Echocardiogram reveals unexpected finding in the investigation of murmur in a hypertensive postpartum patient

Abstract

A transthoracic echocardiogram (echo) was requested for a 19-year-old female who required hospital admission for ongoing fevers, tachycardia, and hypertension. She was 10 days postpartum having delivered a healthy baby boy. A new murmur was noted, and she was found to have Escherichia coli bacteraemia prompting the referral for cardiac investigation. The echo was performed less than 24 hours after the referral was received, and the patient was well enough to attend the cardiology department being transported from the ward via wheelchair.The patient had a long history of systemic hypertension and attended a renal clinic regularly for review and management. Previous investigations included renal angiography and echo along with physical examination, which revealed no significant abnormalities.Blood testing showed an elevated aldosterone level for which she was being treated and systolic blood pressure averaged 155 mmHg.The patient was previously asymptomatic, and it was noted that her father was also treated for hypertension from the age of 33. The underlying cause of hypertension was deemed to be familial as no primary cause was identified.Because of longstanding systemic hypertension, the patient was classified as high risk for preeclampsia during her pregnancy. She was monitored closely, and at 37 +4 weeks gestation, the baby was induced and delivered without complication. | CASE DESCRIPTIONFollowing three tachycardic episodes, requiring admission to the Intensive Care Unit, an echo was performed to look for the source of murmur.The departmental routine echo protocol was followed with images obtained from parasternal, apical, subcostal, and suprasternal windows.Cardiac structure and function appeared normal with no evidence of significant valvular abnormality (Figure 1). Colour Doppler using a subcostal window demonstrated continuous flow within the abdominal aorta (Figure 2A). This was confirmed using colour M-mode (Figure 2B). Suprasternal imaging showed only the proximal portion of the upper descending aorta with no abnormality detected on 2D (Figure 3A) or using colour or spectral Doppler as demonstrated in Figure 3B. Nonpulsatile flow in the abdominal aorta is suggestive of coarctation of the aorta and, while there was no evidence of this in the suprasternal images, a CT aortogram was requested to provide more comprehensive imaging of the aorta. 1 The CT aortogram demonstrates clearly the presence of a severe narrowing just distal to the left subclavian artery, which is the typical location for coarctation 2 (Figure 4). The CT report also noted prominent collateral circulation including enlargement of the internal mammary and intercostal arteries. The CT image also demonstrates enlargement of the left subclavian artery.The coarctation site was unable to be crossed during coronary angiography when approached via the femoral artery and, instead, the coronaries were accessed from the right brachial artery.Aortogram demonstrated a failure of contrast to cross the narrowing, and the coarctation was deemed to be e...