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case_images: Chest radiography and computed tomography of an 81-year-old woman. Preoperative chest radiography did not reveal any pleural effusion or congestion (A). Computed tomography performed before mammectomy did not indicate any pleural effusion (B). After trastuzumab treatment, bilateral pleural effusion concomitant with Kerley's B-line was apparent (C). A modest amount of pleural effusion, along with an enlarged heart, is clearly depicted on chest computed tomography (D).
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case_images: Chest radiography and computed tomography revealed bilateral pleural effusion with significant cardiomegaly (Figure 1AandB), in comparison with the patient's preoperative images which did not show any pleural effusion (Figure 1CandD).
case_images: M-mode echocardiography at the onset of decompensated heart failure. Left ventricular contraction is preserved without evidence of ventricular remodelling after receiving trastuzumab therapy.
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case_images: Transthoracic echocardiography revealed that LV contraction was preserved without any ventricular remodelling (Figure 2), and the LVEF was calculated at 62% using the bi-plane Simpson's method (see Supplementary material online, Videos S1-S3).
case_images: Polar map presentation of global longitudinal strain of an 81-year-old woman. The global longitudinal strain value did not significantly change from -16.5 to -14.6% after trastuzumab treatment.
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case_images: Moreover, no significant reduction in GLS was observed compared with results obtained before anti-HER-2 targeted therapy (from -16.5 to -14.6%; relative reduction of 11.5%, Figure 3).
case_images: Doppler echocardiograms of an 81-year-old woman at baseline and after receiving trastuzumab. Before receiving trastuzumab, the patient's E/A ratio of the left ventricular inflow was 0.70 and the E/e' ratio was 14.3. The pulmonary venous flow pattern did not indicate an elevated left ventricular filling pressure (left panel). After receiving trastuzumab, both the E/A ratio and E/e' ratio significantly increased to 1.3 and 19.1, respectively. Moreover, pulmonary venous flow converted to a diastolic flow-dominant pattern, indicating an elevated ventricular filling pressure (middle panel). Twelve weeks after the interruption of trastuzumab, Doppler echocardiographic parameters of diastolic function significantly improved (middle panel). Ar, pulmonary venous atrial reversal flow; PV, pulmonary vein; PVD, pulmonary venous flow in diastole; PVS, pulmonary venous flow in systole; TDI, tissue Doppler imaging; TMF, transmitral flow.
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case_images: Doppler echocardiography showed that the transmitral flow pseudonormalized (E/A ratio; from 0.70 to 1.30), e' velocity was reduced (e' septal 5.1 cm/s and e' lateral 6.0 cm/s), E/e' ratio was elevated from 14.3 to 19.1, and pulmonary venous flow changed from a systolic component dominant to a diastolic component dominant pattern (Figure 4), all of which indicated elevated ventricular filling pressure as a result of the development of LV diastolic dysfunction. Association functional Class I; thus, maintenance medication was reduced to 5 mg of amlodipine and 200 mg of sacubitril valsartan. As shown in Figure 4, Doppler echocardiographic parameters of diastolic function, including E/A of 0.60, E/e' of 14.3, and LAVI of 57.1 mL/m2, significantly improved.