Perioperative Use of Pulmonary Artery Catheter in a Patient With Severe Chronic Thromboembolic Pulmonary Hypertension Undergoing Major Gynecological Surgery: A Case Report

Figures

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  Figure 1. No signs of patent foramen ovale on transesophageal echocardiography with color Doppler

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  Figure 2. Transesophageal echocardiography of interatrial septum during bubble study: no signs of passing bubbles through the interatrial septum

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  Figure 3. An abdominal ultrasound of the big tumorous mass in the uterus and the smaller mass next to it

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  Figure 4. Larger right ventricle and D-sign, seen on parasternal short axis

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  Figure 5. Right ventricle at the upper limit of normal size, assessed in the apical four-chamber view

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  Figure 6. Measurement of TAPSE. TAPSE calculation in M-mode, using the four-chamber view TAPS: tricuspid annular plane systolic excursion The value (1.8 cm) has improved compared to the initial examination (1.3 cm); however, it remains at the lower limit of normal

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  Figure 7. Pulsed-wave TDI of the lateral tricuspid annulus in an apical four-chamber view TDI: tissue Doppler imaging; S': systolic; E': early diastolic; A': late diastolic; TV: tricuspid valve The spectral Doppler trace displays the S’, E’, and A’ annular velocities, reflecting right ventricular longitudinal myocardial function. The measured velocities include TV S’ 11.6 cm/s, TV E’ 9.2 cm/s, and TV A’ 14.8 cm/s, respectively. Time intervals for isovolumic contraction, ejection, and relaxation are shown, allowing calculation of the right ventricular myocardial performance index (Tei index = 0.50). These measurements correspond to borderline-normal systolic function of the right ventricle

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  Figure 8. Apical four-chamber view with color Doppler demonstrating a TR jet, with CW Doppler aligned through the regurgitant flow CW: continuous wave; TR: tricuspid regurgitation The CW Doppler spectrum shows a peak TR velocity (Vmax) of 4.79 m/s, corresponding to a calculated peak systolic transtricuspid pressure gradient of 92 mmHg (modified Bernoulli equation). Tricuspid regurgitation duration is 438 ms, and the Doppler-derived Tei index from the TR signal is 0.32, indicating preserved to mildly impaired global right ventricular function despite markedly elevated right ventricular systolic pressure, consistent with compensated pressure overload. Measurements were obtained from an incomplete jet due to a limited acoustic window and represent the best achievable measurement and should be interpreted as an estimated value

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  Figure 9. Enlarged pulmonary arteries are seen on the parasternal short-axis view, with the main pulmonary artery measuring 3.4 cm in diameter