Echocardiographic Diagnosis of SBE With Severe Acute AR and Decompensated HF
A 76-year-old man with a prior history of hypertension, hyperlipidemia, benign prostatic hypertrophy, and no known heart disease presented with a 5-week history of generalized malaise, intermittent fevers, loss of appetite, weight loss, and progressive dyspnea on exertion. He was brought to the emergency department by his wife after he became lethargic.
On admission, he was febrile to 38.5°C (101.5°F). His blood pressure was 130/50 mmHg. His heart rate was regular at 110 bpm, and oxygen saturation was 89% on room air. The lungs exam revealed diffuse rales with decreased breath sounds at both bases. A soft systolic murmur at the right upper sternal border was noted. There was bilateral pretibial pitting edema.
Laboratory findings were notable for an elevated white blood count of 17,000/mcl with 93% neutrophils, normocytic anemia with hemoglobin of 9.1 g/dL, and an elevated erythrocyte sedimentation rate of 75 mm/hour. All 6 blood cultures promptly grew Streptococcus gordonii, a viridans member of the human oral flora.
The clinical diagnosis of subacute bacterial endocarditis with acute decompensated heart failure was established. The patient was referred for a transthoracic echocardiogram and transesophageal echocardiogram that revealed severe aortic regurgitation (AR) (Video 1), preserved left ventricular (LV) ejection fraction (Video 2), and marked pulmonary hypertension with an estimated pulmonary artery systolic pressure of 65 mmHg.
Figures 1-5 include four still echocardiographic images from this patient with severe acute AR and one still echocardiographic image from another patient without severe AR.
Which of these figures does NOT support the diagnosis of severe acute AR?