Auscultation guided imaging is superior to transthoracic and transesophageal echocardiography: a case for \u27sound guides ultrasound\u27

BACKGROUND: Physical examination guided echocardiography can be superior to standard transthoracic (TTE) or transesophageal echocardiography (TEE). CASE: A 36-year-old woman presented with worsening dyspnea, fatigue, cough and leg swelling; she had a history of bioprosthetic tricuspid valve (TV) replacement for endocarditis. Initial workup showed pulmonary infiltrates, and sputum culture grew Staphylococcus aureus; she was treated for pneumonia. Standard TTE imaging revealed a well-seated TV with mild tricuspid regurgitation (TR). Despite treatment of pneumonia, her symptoms worsened. Standard TEE did not add to her management, so the clinician consulted cardiology for evaluation of clinical right-sided heart failure. DECISION-MAKING: Cardiac physical examination revealed markedly elevated jugular venous pressure, tall V waves, pulsatile liver, pitting edema and a holosystolic murmur in an unusual auscultatory location (3 rdintercostal space about 5 cm lateral to the left sternal border). A TTE two-dimensional probe, placed at the location of the murmur, finally revealed a severe, eccentric TR jet, caused by a thickened and retracted anterior leaflet. Severe systolic hepatic vein flow reversal confirmed severe TR. Her symptoms resolved on aggressive medical management of severe TR with intravenous furosemide drip, with loss of 37 pounds. CONCLUSIONS: Imaging guided by auscultation was superior to standard TTE or TEE, emphasizing the continuing relevance of the clinical cardiologist