Echocardiography-Unmasked Pulmonary Hypertension in Acute Respiratory Distress Syndrome (ARDS): A Fatal Case of Biventricular Failure

We report a case of a 65-year-old hypertensive male patient admitted to the ICU with altered consciousness, shock, and profound hypoxemia. He met the Berlin criteria for severe acute respiratory distress syndrome (ARDS) and was intubated immediately. Despite mechanical ventilation and vasopressor support (norepinephrine 3.5 µg/kg/min), oxygenation remained critically impaired (partial pressure of arterial oxygen/fraction of inspired oxygen (PaO₂/FiO₂) ratio: 50 mmHg). Early bedside transthoracic echocardiography revealed severe pulmonary hypertension (PH) (pulmonary artery systolic pressure (PASP): 85 mmHg), reduced right ventricular function (tricuspid annular plane systolic excursion (TAPSE): 1.5 cm), and left ventricular systolic dysfunction (left ventricular ejection fraction (LVEF): 30%), indicating acute cor pulmonale and biventricular failure. The patient's course was marked by refractory multiorgan failure, including acute renal injury and neurologic unresponsiveness. Despite full supportive measures, he died within 30 days of admission. This case emphasizes the prognostic value of early echocardiographic assessment in ARDS. Identifying elevated pulmonary pressures and biventricular dysfunction early may aid in risk stratification, guide management, and potentially improve outcomes in critically ill patients.