SHA24/025005

Diaphragm fibrillation diagnosed by transesophageal echocardiography M.Tomaszewski1,2 , K. Stepien3, A.Tomaszewski1, G.Wilczynski4, A. Wysokiński1 1 Dept of Cardiology, 2 Dept of Int. Medicine in Nursing, 4 Dept.of Thoracic Surgery: Med. University of Lublin, Poland 3 Dept. of Clin. Biochemistry and Metab. Medicine, Manchester Royal Infirmary, UK

History  62y. old male with gradual increase in chronic breathlessness and exercise intolerance  History of IHD, hypertension, NYHA III, obesity, prostate hypertrophy  Physical examination: tachypneic, marked dullness on percussion, diminished breath sounds on auscultation of the R side of the chest, oxygen saturation from 82% to 93%

Hospitalisation  On admission chest-X-ray :R pleural effusion and shifting of mediastinum to the left.  Following the drainage 2 liters of blood-stained pleural fluid, a CT of the thorax was performed and confirmed a big mass in the R side of the chest  The histopathology result of lung biopsy: neurilemmoma

Hospitalisation  Three days after the R pnumonectomy his condition deteriorated and he was transferred to Intensive Care Unit  In view of the decreased oxygen saturation and confusion, the patient was sedated and mechanically ventilated  He became pyrexial requiring antibiotics.

Cardiologic consultation  Initially transthoracic echocardiography (TTE) was requested to exclude endocarditis.  TTE was technically difficult and transesophageal echocardiography (TEE) was undertaken (normal LV systolic function, no signififcant valvular incopetence)  TEE revealed right pleural space filled with fluid containing fibrinous material

TEE, four chamber view

Scan from the R pleural space (filled with fluid with fibrin strands) to the heart

Cardiologic consultation  Unexpectedly below the fluid, we visualised in TEE an intrathoracic structure fibrillating with very high frequency…….

???

 Based on initial findings, the diagnosis was meaningless to us  Only after the literature review on similar diagnostic features and the reanalyis of echocardiographic results we concluded that DIAPHRAGM was the fibrillating structure.

Hospital course  On physical examination, the patient had sinus tachycardia 100/min and abdominal wall movements were not present.  The patient’s condition deteriorated and two weeks later he passed away from cardiopulmonary insufficiency and acute kidney injury

Scan from the R pleural space to the left heart

TEE, Left atrial appendage -AF with high frequency

Comparison of two fibrillating structures ???

LAA AF

Diaphragm 600/min.

AF 444/min.

M- mode of high-frequency movement

Scan from the heart to the R pleural space

Van Leeuwenhoek’s disease (respiratory myoclonus)  Antoni van Leeuwenhoek’s describe the disorder for the first time, in 1723, in himself.

This is a rare disorder characterized by rapid, involuntary diaphragmatic contractions.

Antonie Philips van Leeuwenhoek 1632 – 1723 This is the same man commonly known as "the Father of Microbiology", and considered to be the first microbiologist.

Diaphragm fibrillation

Discussion  Diaphragmatic fibrillation was an incidental finding, while TEE was being performed to exclude endocarditis.  The novel feature is the frequency, in the literature there are reported cases of diaphragmatic flutter with an average frequency of 150/min. (max.

480/min).  Our patient was found to have a frequency of approx. 600/min. which could be classified as diaphragmatic fibrillation

Discussion  To our knowledge, this the first case report of diaphragmatic fibrillation diagnosed by transesophageal echocardiography (TEE)  The patophysiological basis of diaphragmatic flutter or fibrillation is tought to be secondary to abnormal excitation of the phrenic nerve, either by disturbance of the central nervous system or by irritation of the phrenic nerve or the diaphragm itself.

Discussion  The incresing breathlessness was initially believed to be a result of CHF, but subsequently it might be related to an advanced lung neoplasm, respirat. insufficiency and diaphragmatic fibrillation.  May be progressive deterioration of his physical condition was rather consequence of the diaphragmatic fibrillation and not of the heart failure (normal syst.LV function).

Diaphragm fibrillation