A 56-year-old woman with history of rheumatic valve disease with mitral stenosis and mitral regurgitation, pulmonary hypertension, and diabetes presented with progressive dyspnoea and nausea. Vital signs were normal. On physical exam, markedly dilated jugular veins, clear lungs, a grade 3/6 holosystolic murmur at the apex, hepatomegaly with ascites and severe bilateral pitting oedema were noted. Electrocardiogram demonstrated atrial fibrillation. Portable chest X-ray showed a globular heart with water-bottle configuration. (PanelA) Pericardial effusion was considered, but surprisingly, minimal fluid was found on echocardiogram. Instead, massive biatrial dilation (PanelB) was present with a rheumatic appearing mitral valve, severe mitral regurgitation (PanelsC and D), moderate mitral stenosis and severe tricuspid regurgitation. The vena cava and hepatic veins were distended. Left and right ventricular size and function were preserved. The patient was treated with furosemide, and was evaluated for mitral valve replacement. Later, she suffered from massive spontaneous intraperitoneal bleeding, related to high venous pressures leading to PEA arrest followed by return of spontaneous circulation, multi-organ system failure, and death. The water-bottle sign refers to the radiographic appearance of the cardiac silhouette; and is mostly associated to pericardial effusion, but can be present in other cardiomyopathies and cavity dilation secondary to valvulopathy. (Panel A) Chest X-ray with enlarged cardiac silhouette and clear lung fields. (Panel B) Apical four-chamber view showing massive biatrial dilation, mitral valve thickening, and a small pericardial effusion. (Panel C) Para-sternal long-axis view showing the rheumatic mitral valve in end diastole with doming of the anterior mitral valve leaflet. (Panel D) Severe mitral regurgitation. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: firstname.lastname@example.org. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
European Heart Journal – Oxford University Press
Published: Apr 17, 2018
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