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JAMA Cardiology Clinical Challenge
April 15, 2020

A 38-Year-Old Woman With Worsening Dyspnea After Giving Birth

Author Affiliations
  • 1CardioVascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
JAMA Cardiol. 2020;5(5):609-610. doi:10.1001/jamacardio.2019.5731

A 38-year-old woman without a significant medical history presented with worsening dyspnea and lower extremity edema at 1 week post partum. When at full term, a planned vaginal delivery was complicated by breached position of the fetus, fetal distress, and new onset of fever. The delivery was converted to a cesarean birth, which was uncomplicated. Perioperatively, she had an episode of chest pain that resolved spontaneously. Troponin levels were normal. A vascular ultrasound study ruled out deep vein thrombosis in the lower extremities. A non–electrocardiogram (ECG)-gated computed tomography angiogram showed no pulmonary embolism but was otherwise not diagnostic owing to motion artifacts (Figure 1A). She had progressive dyspnea, mild pulmonary congestion noted on chest radiography, and an elevated brain-type natriuretic peptide level greater than 800 pg/mL (conversion to ng/L is 1:1). Physical examination findings showed a new heart murmur. A transthoracic echocardiogram (TTE) was performed, which showed a normal-sized left ventricle and preserved left ventricular ejection fraction, severe aortic regurgitation (AR), and a mildly dilated aortic root (Figure 1B and Video). The patient was transferred to our institution for further treatment. The patient was afebrile at that point, and her white blood cell count was within normal limits.

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