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Objectives: Data about COVID-19 patients treated with veno-arterial-ECMO (VA-ECMO) is limited. Reported survival rates range from 27.9% to 77.8%, depending on VA-ECMO indication. A subgroup of patients suffers from circulatory failure due to a COVID-19 associated hyperinflammatory state (CovHI). In these patients, differentiation between inflammation and sepsis is difficult but important. In this retrospective case series, differential diagnoses of COVID-19 associated refractory circulatory failure and survival rates in different indications for VA-ECMO are investigated. Method(s): Retrospective analysis of 28 consecutive COVID-19 patients requiring VA-ECMO at the University Hospital Regensburg between March 2020 and May 2022. Specific treatment for COVID-19 was in accordance with respective guidelines. Mycotic infections were either invasive or met current definitions of COVID19-associated-pulmonary aspergillosis. Result(s): At VA-ECMO initiation, median age was 57.3 years (IQR: 51.4 - 61.8), SOFA score 16 (IQR: 13 - 17) and norepinephrine dosing 0.53mug/kg/min (IQR: 0.32 - 0.78). Virus-variants were: 61% wild-type, 14% Alpha, 18% Delta and 7% Omicron. Survival to hospital discharge was 39%. 17 patients were primarily supported with VA-ECMO only (survival 42%), 3 patients were switched from VV to VA-ECMO (survival 0%), and 8 patients were converted from VA to VAV or VV-ECMO (survival 50%). Indications for VA-ECMO support were pulmonary embolism (PE) (n=5, survival 80%), right heart failure due to secondary pulmonary hypertension (n=5, survival 20%), cardiac arrest (n=4, survival 25%), acute left heart failure (ALHF) (n=11, survival 36%) and refractory vasoplegia (n=3, survival 0%). Inflammatory markers at VA-ECMO initiation were higher in patients with ALHF or vasoplegia;in these patients a higher rate of invasive fungal infections (10/14, 71% vs. 4/14, 29%;p=0.023) compared to the other patients was found. Conclusion(s): Survival on VA-ECMO in COVID-19 depends on VA-ECMO indication, which should be considered in further studies and clinical decisions making. Circulatory failure due to vasoplegia should be considered very carefully as indication for VA-ECMO. A high rate of mycotic infections mandates an intense microbiological workup of these patients and must be considered as an important differential diagnosis to CovHI.
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Objectives: To describe institutional experience using Oxygenated Right Ventricular Assist Device (OxyRVAD) Hybrid ECLS for adolescents with respiratory failure due to SARS-CoV-2 pneumonia. Method(s): Between September and December 2021, 44 Covid-19+ patients were admitted to our regional Pediatric Intensive Care Unit (PICU), including 4 adolescents who required Extracorporeal life support (ECLS) due to refractory hypoxemia. Two patients were initially cannulated onto Veno-Venous (VV) ECLS and converted to Oxy-RVAD ECLS due to refractory hypoxemia;the others were cannulated directly onto Oxy-RVAD ECLS. Two patients had observed right ventricular (RV) dysfunction or failure on echocardiography. Cannulations were performed in the cardiac catheterization suite by an interventional cardiologist using percutaneous technique under fluoroscopy. Circuit construction was varied and included the use of a dedicated RVAD cannula or standard cannula used for VA/VV ECLS. All patients were connected to Cardiohelp systems with built in centrifugal pumps and oxygenators. Result(s): Two patients were initially placed on VV-ECLS and converted to Oxy-RVAD ECLS days into their course due to severe, refractory hypoxemia with one having improvement in hypoxemia after the conversion. Two patients received renal replacement therapy (RRT) without complications, the others did not have indications for renal support. Two patients underwent tracheostomy on ECMO though none were able to separate from mechanical ventilation. Three patients survived to discharge. No incidents of circuit air or clotting were noted. The patient with the longest ECLS run required one circuit change and was the only patient to develop a superinfection: a successfully-treated fungal infection. All patients were mobilized on ECLS to sitting in a chair;one was able to ambulate. Conclusion(s): Oxy-RVAD hybrid ECLS can be used to effectively support adolescents with severe respiratory disease from conditions associated with RV dysfunction. Pediatric providers can collaborate with adult critical care colleagues to use novel methods to support these patients. RRT can also be used with this circuit. While more experience and data on this modality is needed, Oxy-RVAD ECLS should be considered in patients with severe RV dysfunction and associated refractory hypoxemia. (Figure Presented).
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Background: We reviewed patients with COVID-19 ARDS managed with VV-ECMO support at our center from March 2020 until February 2022. Material(s) and Method(s): We extracted data from electronic health records (Metavision and DIPS). We registered premorbid health status, ventilator-settings before initiation of ECMO, the time-course, and hospital mortality. Result(s): Thirty patients were managed at our hospital, with a median age of 57.2 years (28-65) and median BMI 28 (22-40). No patient had any serious comorbidity. Twenty-two patients received non-invasive ventilation prior to intubation (1-10 days). The median time on ventilator were 8.0 days (1-19) prior to ECMO and median tidal volume was 5.8 mL/kg PBW (3.1-7.5). Hypoxemia (median PaO2-FiO2 ratio 8 kPa, range 6-12 kPa) and hypercapnia (median PaCO2 11.9 kPa, range 4.2-18.5) [SEP1] despite lung protective ventilation were the main indications for VV-ECMO. Two patients had severe respiratory acidosis without hypoxemia. 18 patients developed serious complications while managed with ECMO (acute renal failure, clinically significant bleeding, sepsis, right ventricular heart failure, dislocation of cannulae). Seven patients received renal replacement therapy. Sixteen patients (53%) died. Thirteen patients (43%) died on ECMO, three (10%) after weaning, Twelve (40%) were discharged from hospital, two are currently in ICU (7%). The median duration of ECMO and ventilator treatment, was 27 (6-50) and 37 (9-78) days, respectively. Conclusion(s): Management of patients with COVID-19 ARDS with VV-ECMO is very resource-intensive, and accompanied by serious complications and high mortality. In-hospital mortality in our cohort was 53%, which is comparable with reports from other centers. However, the duration of ECMO, and pre-ECMO mechanical ventilation, were longer than typically reported.
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Objective: To describe institutional experience using Oxygenated Right Ventricular Assist Device Oxy-RVAD) Hybrid ECLS for adolescents with respiratory failure due to SARS-CoV-2 pneumonia. Method(s): Between September and December 2021, 44 Covid-19+ patients were admitted to our regional Pediatric Intensive Care Unit (PICU) including 4 adolescents who required Extracorporeal life support (ECLS) due to refractory hypoxemia. Two patients were initially cannulated onto Veno-Venous (VV) ECLS and converted to Oxy-RVAD ECLS due to refractory hypoxemia;the others were cannulated directly onto Oxy-RVAD ECLS. Two patients had observed right ventricular dysfunction (RV) or failure on echocardiography. Cannulations were performed in the cardiac catheterization suite by an interventional cardiologist using percutaneous technique under fluoroscopy. Circuit construction was varied and included the use of a dedicated RVAD cannula or standard cannula used for VA/VV ECLS. All patients were connected to CardiohelpTM systems with built-in centrifugal pumps and oxygenators. Result(s): Two patients were initially placed on VV-ECLS and converted to Oxy-RVAD ECLS days into their course due to severe, refractory hypoxemia with one having improvement in hypoxemia after the conversion. Two patients were cannulated directly to Oxy-RVAD ECLS support. Two patients received renal replacement therapy (RRT) without complications, the others did not have indications for renal support. Two patients underwent tracheostomy on ECMO though none were able to separate from mechanical ventilation. Three patients survived to discharge. No incidents of circuit air or clotting were noted. The patient with the longest ECLS run required one circuit change and was the only patient to develop a superinfection: a successfully-treated fungal infection. All patients were mobilized on ECLS to sitting in a chair;one was able to ambulate. Conclusion(s): Oxy-RVAD hybrid ECLS can be used to effectively support adolescents with severe respiratory disease from conditions associated with RV dysfunction. Pediatric providers can collaborate with adult-focused colleagues to use novel methods to support these patients. RRT can also be used with this circuit. While more experience and data on this modality is needed, Oxy-RVAD ECLS should be considered in patients with severe RV dysfunction and associated refractory hypoxemia.
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Background Current recommendations suggest oxygen (O2) supplementation in patients with pulmonary hypertension (PH). The effect of long-term O2 administration is though merely investigated among these patients. Thus, the aim of this study is to investigate the effect of long term O2 treatment in patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) on exercise capacity, clinical parameters and hemodynamics. Methods In this prospective, randomized, controlled trial, 20 patients with PAH or CTEPH under stable PH therapy experiencing O2 desaturations at rest and/or during physical activity will be randomised to receive O2 or standard of care (SoC) for 12 weeks. To patients receiving SoC, O2 therapy will be offered after 12 weeks (cross over design). The primary endpoint is the change of the distance walked in 6 minutes after 12 weeks of treatment. Secondary endpoints include change in clinical parameters and hemodynamics. Results Overall 20 patients (O2 n = 10 vs. SoC n = 10) have already been randomized and 15 have completed the study. Two patients died, one patient due to SARS-CoV2 pneumonia in the oxygen arm and one due to right heart failure in the SoC arm. The O2 therapy is so far well tolerated by all patients. Further results are expected in due course. The study is expected to be completed by the end of December 2022. Conclusion Oxygen therapy is well tolerated. Further results are expected soon. The effect of long-term oxygen supplementation should be furtherly investigated in larger controlled-trials.
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Introduction: COVID-19 infection has been associated with right ventricular (RV) dysfunction and poor prognosis. This association is thought to be due to either a direct effect of COVID-19 infection on the myocardium or indirect damage to the lung parenchyma or vasculature. Limited echocardiography protocols for operator protection against COVID-19 has made the evaluation of the RV challenging. The purpose of this study is to evaluate if RV dysfunction by qualitative assessment can be used to predict all-cause mortality. Method(s): This is a single-center retrospective analysis from March 2020 to August 2021. Patients who were older than 18 years old, hospitalized with a positive RT-PCR for COVID-19, and had an echocardiogram while inpatient were included in the study. RV parameters, including RV dilation and dysfunction, were obtained by qualitative assessment. Data analysis was performed with STATA and SPSS. Result(s): A total of 223 patients were included in the analysis. 59.6% were male with a mean age of 64.3 years (SD +/- 16). 67.7% were Hispanic, 11.7% were non-Hispanic White, and 20.6% were Black. Severe COVID-19 infection requiring intensive care unit level of care made up 54.7% of cases (n=122) and the mortality rate was 27.8% (n=62). RV dysfunction and dilation was present in 13.5% (n=28) and 15.2% (n=33) of patients, respectively and occurred more often in patients with severe COVID-19 infection (p<0.01). Logistic binomial correlation showed an exponential increase in the probability of mortality related to RV dysfunction (OR 2.03, p=0.270;graph 1) and a mild decrease in mortality in patients with RV dilation (OR 0.88, p=0.794). However, both associations were not statistically significant. Conclusion(s): RV dysfunction by qualitative assessment could be a potential marker of mortality in patients with COVID-19 infection. The association may be stronger in studies with more power. Interestingly, RV dilation was associated with a mild decrease in mortality in this patient population;however, this may be a biased result due to the small sample size.Copyright © 2022
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Background We present a case of a young male with new severe cardiomyopathy requiring critical care within 24 hours. Case A Latino male with alcoholism was admitted for COVID and severe liver injury due to alcohol-induced hepatitis. Within hours, he developed hypoxia, worsening metabolic acidosis with undetectable bicarbonate level and partial respiratory compensation, coagulopathy, acute kidney injury, right lower lobe infiltrates without pulmonary embolism. Reduced ejection fraction heart failure at 15-20% with a large left ventricle apical thrombus was also found. Worsening signs of cariogenic shock despite sustaining normal blood pressure was identified on a physical exam. The patient was transferred to ICU with confirmation of cardiogenic shock with right ventricular failure with Swan-Ganz Catheter. With Concern for impending fulminant liver failure, transfer to a tertiary care center for emergent liver transplant was initiated. Decision-making The dichotomy of requirement for anti-coagulation for LV thrombus with cardiogenic shock and worsening coagulopathy due to liver failure was a challenge. Decision was made to transfuse blood products as needed with goal fibrinogen of 150 mg/dl, later changed to 100-120 mg/dl with heparin. Liver enzymes were down-trending, but it was difficult to determine if this was due to recovery or worsening of liver failure with stabilization of hemodynamics. While awaiting transfer, he developed acute cerebrovascular accident requiring emergent mechanical thrombectomy of a left MCA occlusion with suspension of heparin complicated by acute large intraventricular and intraparenchymal hemorrhage with rapid decline in neurological function. The family declined decompressive craniotomy with evacuation of parenchymal hemorrhage and the patient was transitioned to comfort care measures. Conclusion There are no clear guidelines for transfusion of plasma-based blood products in the setting of cardiogenic shock and liver disease. Expert opinion recommends maintaining fibrinogen levels above 100-200 mg/dl, however, this is in the setting of acute blood loss and is not studied in patients with liver disease. Further studies are needed.Copyright © 2023 American College of Cardiology Foundation
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Aim: To study the systolic function (SF) and diastolic function (DF) of the heart and to assess subclinical myocardial right ventricular (RV) dysfunction in pts after severe COVID-19. We examined 23 males aged 46-70 years (mean age - 58.8 +/- 12.6 yrs) discharged after COVID-19 (50-75% of the parenchymal damage) with exertional dyspnea. We performed transthoracic echocardiography (TTE) with assessment of RV global longitudinal strain (RV-GLS) and right ventricular free wall longitudinal strain (RVLS) using speckle tracking echocardiography. Result(s): The SF of the RV assessed by the excursion of the tricuspid valve ring (TAPSE) was preserved (2.1 +/- 0.6 cm) in all pts under study after severe COVID-19. The left ventricular (LV) ejection fraction was also preserved (62.1 +/- 4.7%) in all pts. TTE revealed normal ventricular and atrial dimensions: LV end-diastolic volume index (62.5 +/- 8.4 ml/m2) and RV end-diastolic diameter (2.7 +/- 0.6 cm), left atrial (LA) volume index (26.7 +/- 3.1 ml/m2) and right atrial (RA) volume index (20.2 +/- 4.5 ml/m2). LV DD was also detected: Grade I in 17 (74%) pts, and Grade II in 6 (16%) pts. Moderate pulmonary hypertension (PH) was present in all pts (time of acceleration of systolic flow in the pulmonary artery (AcT - 85.0 +/- 7.9 msec) as a consequence of significant pulmonary parenchymal involvement. We found reduced RV-GLS (-17.4 +/- 2.7%) and free wall RVLS (-18.9 +/- 3.1%) in 23 (100%) pts. Conclusion(s): Preserved LV and RV SF with Grade 1 and Grade 2 LV DD and moderate PH were established in pts after severe COVID-19. RV wall motion abnormalities with reduced RV-GLS and free wall RVLS were found, indicating the presence of subclinical RV myocardial dysfunction.
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Background Massive pulmonary embolus (PE) is a life-threatening condition, however thrombus in transit in the setting of patent foramen ovale (PFO) poses catastrophic risk including systemic thromboembolism. Case An 88 year-old with history of COVID-related PE in 2020 previously on anticoagulation (AC) presented with chest pain & dyspnea. She was found to have lower extremity DVTs & extensive PE in the main pulmonary arteries & its branches. Transthoracic echo (TTE) revealed severe right ventricular dysfunction & right atrial (RA) thrombus in transit that extended into a PFO with right to left shunt. She was hemodynamically stable, but hypoxic on 4L/min of oxygen with a ProBNP 7712 pg/L, Troponin T 104 ng/dl, & pulmonary embolism severity (PESI) score of 104 (10% risk of 30 day mortality). Decision-making Due to the high PESI score & thrombus burden with risk of systemic thromboembolism, a multidisciplinary PE Response Team reached a consensus to pursue urgent mechanical thrombectomy. Inari FlowTriever system was successfully used for thrombectomy & retrieval of the RA clot in transit, with rapid improvement in right sided pressures. Repeat TTE showed no residual clot or shunting. Patient was placed on AC with plan for future PFO closure. Conclusion A multidisciplinary team approach was pivotal in managing this complex case with potential for hemodynamic compromise & systemic thromboembolism. We also demonstrate that mechanical thrombectomy is a feasible strategy for retrieving RA clot in transit. [Formula presented]Copyright © 2023 American College of Cardiology Foundation
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Objectives: There has been a significant increase in pulmonary embolism (PE) cases during the coronavirus disease of 2019 (COVID-19) pandemic. In this study, we aimed to compare the effects of COVID-19 positivity on morbidity and mortality in patients treated with a diagnosis of high-risk PE. Method(s): In this single-center and observational study, patients who were referred to our center with the diagnosis of PE between January 1, 2019 and 2021 were retrospectively evaluated. Patients with moderate- and low-risk PE according to the European Society of Cardiology PE guidelines, those who did not undergo computed tomography pulmonary angiography (CTPA) or the ones who did not accept treatment were excluded from the study. The patients included in the study were divided into two groups, as those with and without COVID-19, and compared in terms of demographic data, comorbidities, symptoms, thromboembolism in vessels other than the pulmonary artery, laboratory parameters, treatments, and prognosis. Result(s): A total of 384 PE cases were identified during the study period. Among them, 322 cases that were in the intermediate or low-risk category, 21 cases who did not undergo CTPA, and one case who did not accept thrombolytic therapy were excluded from the study. A total of 40 cases were included in the study. The groups with and without COVID-19 consisted of 23 and 17 patients, respectively. In the group of patients with COVID-19, inflammatory markers were higher, Wells score was lower, and thromboembolism was seen in vessels other than the pulmonary artery. The two groups were similar in terms of other laboratory parameters, demographic data, comorbidities, symptoms, treatment, and prognosis. Conclusion(s): While the involvement of COVID-19 in PE etiology does not change mortality, it may cause more thrombosis development in both venous and arterial systems outside the pulmonary area by significantly increasing inflammation. However, the lower Wells scores in COVID-19 PE cases in our study indicate that new clinical assessment tools are needed to detect PE risk in COVID-19 patients.©Copyright 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care.
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Current recommendations suggest oxygen (O2) supplementation in patients with pulmonary hypertension (PH). The effect of long-term O2 administration has not been investigated much among these patients. Thus, the aim of this study is to investigate the effect of long term O2- treatment in patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) on exercise capacity, clinical parameters and hemodynamics. In this prospective, randomized, controlled trial, 20 patients with PAH or CTEPH under stable PH therapy experiencing oxygen desaturations at rest and/or during physical activity will be randomized to receive oxygen or standard of care (SoC) for 12 weeks. To patients receiving SoC, O2 therapy will be offered after 12 weeks (cross-over design). The primary endpoint is the change in the distance walked in 6min after 12 weeks of treatment. Secondary endpoints include change in clinical parameters and hemodynamics. Overall, 20 patients (O2 n=10 vs. SoC n=10) are planned to participate. So far, 12 patients have already been randomized and nine have completed the study. Two patients died, one patient owing to SARS-CoV2 pneumonia in the oxygen arm and one owing to right heart failure in the SoC arm. So far, the O2 therapy is being well tolerated by all patients. Further results are expected in due course. The study is expected to complete recruitment by the end of September 2022. Oxygen therapy is well tolerated. Further results are expected soon. The effect of long-term oxygen supplementation should be investigated further in larger controlled trials.
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Purpose: Little is known about the development of Human Leukocyte Antigen antibodies with the use of the new Impella 5.5 temporary mechanical circulatory assist device. Method(s): The prevalence and strength of HLA Class I and II antibodies were assessed prospectively from 6 patients with the Impella 5.5 and 10 control patients with no device support. Single antigen beads (One Lambda) were used to detect HLA antibodies in serum samples pre- and post-implantation of the device up to the time of heart transplantation. 6-month analysis for de novo HLA antibodies, rejection, rehospitalization and deaths were analyzed. Result(s): Baseline characteristics are shown in table 1A. 3/10 and 2/6 patients had pre-transplant HLA antibodies in the control and Impella groups, respectively. Additionally cross match results are shown in Table 1B. There was no increase in the prevalence of HLA antibodies detected post-transplant. None of the patients were admitted for concern of rejection, nor required outpatient optimization of immunosuppression. In the control group, 3 patients were hospitalized within 6 months post-transplant for non-rejection (COVID infection, pericardial effusion and right ventricular failure). There were no re-admissions within the Impella group. There was one death in the Impella group prior to discharge at index admission for transplant due to CMV viremia and stenotophomonas maltophilia infection post-transplant. There were no deaths in the control group. (Table 1C). Conclusion(s): The use of the new Impella 5.5 MCS assist device does not appear to increase the risk of development of de novo HLA antibodies nor appear to increase the risk of allograft rejection. Larger studies are needed to validate these preliminary findings.
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SESSION TITLE: Studies on COVID-19 Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: COVID-19 associated morbidity and mortality are largely related to hypercoagulability events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), with right ventricular (RV) dysfunction playing a likely role in the severity of outcomes. The purpose of this study is to correlate right ventricular parameters on echocardiography in patients who developed DVT and PE while admitted with COVID-19 infection, and to determine if PE and DVT were related to a higher incidence of adverse outcomes. METHODS: Single-center retrospective study from March 2020 to August 2021 including patients older than 18 years old hospitalized with confirmed COVID-19 by RT-PCR, who had an echocardiogram performed while inpatient. Right ventricular parameters were obtained mostly by linear measurements, with a limited COVID-19 protocol determined by the institution. The presence of PE and DVT were confirmed by chest CT angiography and venous ultrasound, respectively. RESULTS: A total of 223 patients were included in the study (mean age 64.3 +/- 16, 59.6% male, 67.4% Hispanic). Baseline characteristics did not differ when stratified for the outcomes of interest. DVT occurred in 9.4% (n=21) and PE in 19.6% (n=44) patients. PE and DVT were related to a higher rate of ARDS, ICU admission, non-fatal stroke and prolonged length of stay (38.9 vs 16.9 days, p<0.05). Although there was a higher rate of intubation in patients admitted with DVT (p<0.05), it was non-significant for patients with PE. Mortality was similar to patients without thromboembolic events. For PE and DVT, RV dilation was present on 25% (p<0.05) and 14%, and RV dysfunction on 21% and 11%, respectively. CONCLUSIONS: PE and DVT in patients with COVID-19 were related to higher morbidity, but not mortality in this patient population. Interestingly, these events were related to a higher rate of non-fatal stroke, suggesting that hypercoagulability plays a major role in the development of some adverse outcomes. Despite only finding RV dilation as a statistically significant marker present in patients who developed PE, the study was potentially underpowered to find significant differences between groups. CLINICAL IMPLICATIONS: Development of PE and DVT in patients admitted with COVID-19 infection are markers of increased morbidity and higher length of stay. RV dilation might be used as a marker of potential thromboembolic events in this patient population, but more studies with controlled variables are needed to determine it's utility. DISCLOSURES: No relevant relationships by Sharon Andrade-Bucknor No relevant relationships by Mikayla Bowen No relevant relationships by Alexis Jones No relevant relationships by Sukhpreet Kaur No relevant relationships by Neal Olarte No relevant relationships by Beatriz Rivera Rodriguez No relevant relationships by Crystal Yan
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SESSION TITLE: Pathology Under the Microscope SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Rosai-Dorfman disease (RDD) is a rare, idiopathic, nonmalignant lymphohistiocytic proliferative disorder that presents with lymphadenopathy and less commonly with extranodal involvement (1). This is a case of a patient found to have a pulmonary artery mass and bone lesions consistent with RDD. CASE PRESENTATION: A 33-year-old female with COVID pneumonia presented with one week of dyspnea, myalgias, and chills. She developed hypoxia requiring 2L of supplemental oxygen. Physical exam was benign and without lymphadenopathy. CT angiography demonstrated a well circumscribed 2.3cm x 2.1cm eccentric filling defect concerning for a pulmonary embolism versus vascular mass. She had a normal troponin and brain natriuretic peptide. Echocardiogram showed normal left ventricular ejection fraction and right ventricular size and function. Lower extremity dopplers were negative for acute deep venous thrombosis. Cardiac MRI demonstrated a mass in the posterior aspect of the proximal main pulmonary artery superior to the pulmonic valve measuring 1.9cm x 1.6cm that was consistent with a benign cardiac tumor. Patient was discharged and underwent sternotomy and excision of the mass one week later. Pathology showed histiocytosis consistent with RDD. Post-operatively she developed recurrent fevers and imaging showed bony lesions in her lumbar spine, maxilla, and skull base. Pathology from an IR guided biopsy of the lumbar lesion was suggestive of RDD. DISCUSSION: RDD is a rare, nonmalignant lymphohistiocytic proliferative disorder that usually involves lymph nodes. Concurrent nodal and extranodal involvement has been reported in 43% of cases while isolated extranodal involvement has been reported in 23% of cases. Common extranodal sites include cutaneous, soft tissue, upper respiratory tract, bone, and central nervous system (1). There are only a few cases reported of pulmonary artery involvement. These cases include a patient with RDD invading the pulmonary trunk and aorta who required surgical resection and reconstruction due to impending right ventricular failure (2) and a young woman with RDD causing nearly complete obstruction of the main pulmonary artery resulting in severe pulmonary hypertension and heart failure who required debulking (3). This case demonstrates RDD involving the main pulmonary artery and bones which was incidentally discovered when the patient was hospitalized for COVID pneumonia. RDD has a benign course but when the pulmonary artery is involved, patients often require surgical excision. CONCLUSIONS: RDD is a benign proliferation of histiocytes that most commonly presents with cervical lymphadenopathy. Extranodal involvement has been reported but pulmonary artery involvement is rare. RDD has a benign course, but pulmonary arterial involvement often requires surgical excision. Reference #1: Gaitonde, S. (2007). Multifocal, extranodal sinus histiocytosis with massive lymphadenopathy: an overview. Archives of pathology & laboratory medicine, 131(7), 1117-1121. Reference #2: Prendes, B. L., Brinkman, W. T., Sengupta, A. L., & Bavaria, J. E. (2009). Atypical presentation of extranodal Rosai-Dorfman disease. The Annals of thoracic surgery, 87(2), 616-618. Reference #3: Walters, D. M., Dunnington, G. H., Dustin, S. M., Frierson, H. F., Peeler, B. B., Kozower, B. D., … & Lau, C. L. (2010). Rosai-Dorfman disease presenting as a pulmonary artery mass. The Annals of thoracic surgery, 89(1), 300-302. DISCLOSURES: No relevant relationships by Veena Dronamraju Advisory Committee Member relationship with Nabriva Please note: 1 day Added 03/14/2022 by Rohit Gupta, value=Consulting fee No relevant relationships by MARUTI KUMARAN no disclosure on file for Bilal Lashari;No relevant relationships by Parth Rali No relevant relationships by Stephanie Tittaferrante No relevant relationships by Yoshiya Toyoda
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SESSION TITLE: Medications and Pulmonary Rehabilitation in COVID-19 Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: The use of inhaled epoprostenol (iEPO) has demonstrated improvement in outcomes for patients with pulmonary hypertension and right heart failure. iEPO has been used as a rescue therapy for acute respiratory distress syndrome (ARDS) and has been shown to improve oxygenation, reduce shunting, and decrease pulmonary artery pressures. However, pulmonary vasodilators do not improve mortality in patients with ARDS. Furthermore, there is currently little data on the efficacy of iEPO via high flow nasal cannula (HFNC) for ARDS patients. Here, we describe our experience with iEPO in our patients with COVID-19-related ARDS on HFNC in a Northern California county hospital. METHODS: From March 2020 to December 2021, 74 patients with COVID-19 infection and related ARDS were placed on HFNC and received iEPO, at a public tertiary care center. A positive response to iEPO was defined as an increase P/F ratio of 10%, increase in PaO2 of 20%, decrease in FiO2, or reduced flow rate within 24 hours of initiation of iEPO. Non-parametric statistics were used to compare groups. RESULTS: 21 women and 53 men with COVID ARDS ranging from 30-86 years of age (mean age 60.1 ± 13.9) received iEPO while on HFNC. The mean hospital length of stay was 36.3 ± 43 days. All patients received steroids and 83.8% received antibiotics. 55.4% of all patients in the study (n=41) progressed to mechanical ventilation and 58.1% (n=43) survived to discharge, mean age 57 ± 14 years. 20.3% (n=15) of patients showed a response to iEPO. Patients who responded to iEPO were significantly less likely to progress to mechanical ventilation (13% vs 66%, p=0.0003) and more likely to survive to discharge (93% vs 49%, p=0.0021). CONCLUSIONS: Among patients with COVID ARDS on HFNC, patients who respond to iEPO are less likely to progress to mechanical ventilation and more likely to survive to discharge. Our study is limited by small sample size and lack of randomization. Use of iEPO in the right subset COVID ARDS on HFNC may improve outcomes. CLINICAL IMPLICATIONS: Patients on HFNC selected for initiation of iEPO had a poor overall prognosis, with 41.9% not surviving to discharge and 55.4% requiring mechanical ventilation. iEPO response correlates with not requiring mechanical ventilation and with increased likelihood of survival to discharge. DISCLOSURES: No relevant relationships by Heng Duong No relevant relationships by Craig Ivie No relevant relationships by Neharika Khurana No relevant relationships by Connie Park No relevant relationships by Natasha Puri No relevant relationships by Adam Thompson No relevant relationships by John Wehner
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SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Human cytomegalovirus (CMV) is a herpesvirus with a high prevalence that causes latent disease in immunocompetent hosts. It is an important opportunistic infection with a variety of clinical manifestations, including pneumonia, in immunocompromised patients.[1] CASE PRESENTATION: A 45-year-old man with no past medical history presented with fever and dyspnea and was positive for coronavirus disease 2019 (COVID-19). He developed acute respiratory distress syndrome (ARDS) and was intubated 13 days after presentation, but developed refractory hypoxemia requiring veno-venous extracorporeal membrane oxygenation (ECMO) (cannulated 16 days after presentation). He received a 5-day course of remdesivir and 10 days of dexamethasone 6 mg daily. His course was complicated by acute renal failure requiring continuous renal replacement therapy, septic shock due to a pseudomonal ventilator-associated pneumonia, right ventricular failure, heparin induced thrombocytopenia, and right pneumothorax requiring chest tube thoracostomy. After 4 weeks of ECMO there was lung recovery with ECMO sweep gases <1L/minute, improved radiographic appearance and tidal volumes, and decannulation was anticipated. However, he subsequently developed profound shock of unknown etiology with a rapid worsening of his lung function requiring increased ECMO support. Care was withdrawn at ECMO day 46 due to multiorgan failure. Pathology of his lungs at autopsy showed prominent intranuclear viral inclusions and positive immunohistochemistry in alveolar macrophages consistent with a diagnosis of CMV pneumonia. DISCUSSION: While CMV typically causes latent disease it can reactivate in the setting of immunosuppression and/or critical illness.[1] Patients with severe COVID-19 frequently are treated with immunosuppressive therapies, such as corticosteroids, anti-interluekin-6 therapies, and JAK inhibitors. Due to this immunosuppression, opportunistic infections have been reported in these patients.[2] It can be difficult to differentiate COVID-19 pneumonia from other respiratory infections based on imaging and lab studies alone, especially in patients with prolonged mechanical ventilation and with severe parenchymal disease requiring ECMO support. Little is known about the incidence of CMV and COVID-19 coinfection. There are several cases of biopsy-proven CMV pneumonia in immunocompromised critically ill patients with COVID-19, but this is the first reported case in an immunocompetent patient. CONCLUSIONS: This case highlights the need to maintain a high degree of suspicion for CMV pneumonia in patients with severe COVID-19 pneumonia who receive immunosuppressive therapies. While the diagnosis was made at autopsy in this case, it may be possible to arrive at an earlier diagnosis with CMV polymerase chain reaction (PCR) assays sent from the serum and bronchoalveolar lavage (as lung biopsies are usually impractical in ARDS). Reference #1: de la Hoz RE, Stephens G, Sherlock C. Diagnosis and treatment approaches of CMV infections in adult patients. J Clin Virol. 2002 Aug;25 Suppl 2:S1-12. doi: 10.1016/s1386-6532(02)00091-4. PMID: 12361752. Reference #2: Abdoli A, Falahi S, Kenarkoohi A. COVID-19-associated opportunistic infections: a snapshot on the current reports [published online ahead of print, 2021 Aug 23]. Clin Exp Med. 2021;1-20. doi:10.1007/s10238-021-00751-7 DISCLOSURES: No relevant relationships by Nancy Law No relevant relationships by Mazen Odish No relevant relationships by Robert Owens No relevant relationships by Travis Pollema No relevant relationships by Alyssa Self No relevant relationships by Cassia yi
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SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Multiple pleural complications have been well described during COVID-19 infection including pneumothorax, pleural effusion and empyema. While many infections have been described as complications, here we present a case of empyema secondary to Enterococcus faecium in a patient with COVID-19 after Extra-corporeal membrane oxygenation (ECMO). CASE PRESENTATION: A 33-year-old male presented with acute respiratory distress syndrome secondary to COVID-19. He was intubated 10 days after symptom onset and subsequently placed on veno-venous ECMO, with reconfiguration to add an arterial return limb and eventually pulmonary artery return limb. During his care he was treated with remdesivir, dexamethasone and tocilizumab. His course was complicated by right heart failure requiring mechanical support, acute renal failure requiring hemodialysis, superior vena cava thrombus, multi-drug resistant Pseudomonas, Enterococcus faecalis, Klebsiella and methicillin sensitive Staphylococcus aureus infections. Eventually he was removed from ECMO on day 130. The patient remained in the ICU on positive pressure ventilation via tracheostomy. He eventually developed worsening respiratory status as well as signs concerning for an emerging infection. Broad spectrum antibiotics were initiated, and a CT chest/abdomen/pelvis was obtained that showed right pleural effusion with concern for empyema. Pleural sampling was consistent with empyema with glucose <5 mg/dL, pH <7.2, lactate dehydrogenase >200 U/L and an elevated neutrophil count. A percutaneously placed 14 french chest tube was placed and pleural irrigation with normal saline was trialed given patient need for continuous systemic anticoagulation. However, this did not sufficiently resolve the empyema and patient was started on pleural TPA/Dornase with close monitoring while on anticoagulation with clinicoradiographic improvement after a total of 6 days of therapy. Cultures eventually speciated as Enterococcus faecium and he was continued on a 6 week course of ampicillin for his empyema. DISCUSSION: Classically, Enterococcus empyema has been primarily linked with intra-abdominal infections which was not found in our patient and has not been correlated with COVID-19 infection or ECMO. Additionally, there is a significant paucity of data with regards to safety of TPA/Dornase pleural irrigation use while patients are on full dose systemic anticoagulation as was our patient. In this case he required two 3-day courses of TPA/Dornase which was tolerated well without significant complication. CONCLUSIONS: Here we describe a rare causative organism of empyema that has not been previously described in the literature as associated with COVID-19 or ECMO. Additionally, we demonstrate the safety of intra-pleural TPA/Dornase in this patient on full dose anticoagulation which is a frequent consideration when determining the method of treating empyema in complex medical patients. Reference #1: Ayad S, Gergis K, Elkattawy S, et al. Loculated empyema and SARS-COV-2 infection: A report of two cases and review of the literature. European journal of case reports in internal medicine. July 2021;8(7):002706. doi:10.12890/2021_002706. Reference #2: Bergman R, Tjan DH, Schouten MA, Haas LE, van Zanten AR. Pleural Enterococcus faecalis empyema: an unusual case. Infection. Feb 2009;37(1):56-9. doi:10.1007/s15010-007-6359-6 Reference #3: Rahman NM, Al. E, Author Affiliations From the United Kingdom Clinical Research Collaboration Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection: Nejm. New England Journal of Medicine. Nov 2011;365:518-526. doi:10.1056NEJMoa1012740. DISCLOSURES: No relevant relationships by Joshua Boster No relevant relationships by Mary Gadarowski No relevant relationships by Stephen Goertzen No relevant relationships by Amanda Hall No relevant relat onships by Erik Manninen
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SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Since the start of Covid-19 pandemic, several respiratory microorganisms have been identified that cause coinfection with Sars-Cov-2. Bacteria like Staphylococcus aureus and viruses like influenza are some of the identified pathogens. Rarely, fungal infections from Aspergillus are also being reported. CASE PRESENTATION: 59-year-old male with past medical history of hypertension and hyperlipidemia was admitted for shortness of breath and was found to be positive for Covid-19. He received Remdesivir, dexamethasone & tocilizumab. He required non-invasive ventilation via continuous positive airway pressure but continued to remain hypoxemic with elevated procalcitonin, he was treated with cefepime for bacterial pneumonia. Patient required emergent intubation and eventually underwent tracheostomy. He developed methicillin-resistant Staphylococcus aureus pneumonia for which he received vancomycin. He was eventually discharged to long term acute care facility. Patient was readmitted after 2 months due to worsening respiratory status. Computed Tomography Angiography of chest was negative for pulmonary embolism but showed pleural effusion. He underwent thoracentesis which showed exudative effusion with negative cultures. Echocardiogram showed right heart failure. Patient's symptoms were believed to be due to Covid-19 fibrosis. He required home oxygen and also received pulmonary rehabilitation. One year after the initial Covid-19 infection, he developed pulmonary hypertension and was referred for lung transplant consultation. However, he developed severe hemoptysis requiring intubation and vasopressors. Galactomannan was positive, Karius digital culture revealed Aspergillus Niger for which he received voriconazole. He was not deemed a suitable candidate for lobectomy. Patient developed arrhythmia and had prolonged QT interval so voriconazole was switched to Isavuconazole. He continued to have hemoptysis and his condition did not improve so family requested to transition care and patient passed away. DISCUSSION: Several studies have proven co-infection of Aspergillus with Covid-19. This case highlights Aspergillus infection approximately 1 year after initial Covid-19 infection. Sars-Cov-2 causes damage to airway lining which can result in Aspergillus invading tissues. IL-6 is increased in severe Covid-19 infection. Tocilizumab is an anti-IL-6 receptor antibody that has been approved for treatment of Covid-19 pneumonia. However, IL-6 provides immunity against Aspergillus so use of tocilizumab decreases protection against Aspergillosis which is usually the reason for co-infection. However, in this case patient developed fungal infection later during Covid-19 fibrosis stage. CONCLUSIONS: Recognizing fungal etiology early on is important in Covid-19 patients as mortality is high and appropriate intervention can reduce morbidity and mortality. Some patient may eventually require lung resection. Reference #1: Kakamad FH, Mahmood SO, Rahim HM, Abdulla BA, Abdullah HO, Othman S, Mohammed SH, Kakamad SH, Mustafa SM, Salih AM. Post covid-19 invasive pulmonary Aspergillosis: a case report. International journal of surgery case reports. 2021 May 1;82:105865. Reference #2: Nasrullah A, Javed A, Malik K. Coronavirus Disease-Associated Pulmonary Aspergillosis: A Devastating Complication of COVID-19. Cureus. 2021 Jan 30;13(1). Reference #3: Dimopoulos G, Almyroudi MP, Myrianthefs P, Rello J. COVID-19-associated pulmonary aspergillosis (CAPA). Journal of Intensive Medicine. 2021 Oct 25;1(02):71-80. DISCLOSURES: No relevant relationships by Maria Haider Baig
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Introduction: During the pandemic, various guidelines were developed for the utilization of extracorporeal membrane oxygenation (ECMO) for COVID-19 ARDS. However, once patients were cannulated for ECMO, the timeframe for lung recovery and referral for lung transplantation was less clear. To date, there are few reported cases of successful long-term (>28 days) ECMO as a bridge to lung recovery. Method(s): We present three patients who were referred for lung transplantation for severe COVID-19 associated respiratory failure and ultimately achieved successful lung recovery following long-term venovenous ECMO support. Patients presented at different stages of the pandemic, were of different ethnicities, aged 35-54 years old, average BMI of 27.6 and two were male. Prior to cannulation, all patients failed mechanical ventilation, prone positioning, neuromuscular blockade and pulmonary vasodilators. Patients were cannulated within 7 days of intubation, underwent early tracheostomy and participated in ambulatory physical therapy. Complications during ECMO included acute renal failure requiring renal replacement therapy, pneumothorax, right ventricular dysfunction and concomitant bacterial pneumonia with bacteremia. The median duration of ECMO was 104 days (range 84-142 days). Radiographic imaging reported end stage restrictive changes in all patients. Survival to hospital discharge was 100%. All patients had complete renal recovery, resolution of RV dysfunction and functional independence without oxygen. Radiographic changes and pulmonary function continued to improve after decannulation. Conclusion(s): Long-term ECMO is an effective strategy for lung recovery in severe COVID-19 ARDS. Duration of ECMO support and radiographic findings should not be used alone to determine recoverability or need for lung transplantation.
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Pericardial cysts are a scarce cause of mediastinal masses. They are usually asymptomatic, even in large sizes. Accurate diagnosis of pericardial cysts is possible with multiple diagnostic imaging modalities. A 41-year-old woman complaining of bilateral lower limb edema, exertional dyspnea, and recurrent palpitations was admitted to our emergency department. She had experienced a syncope state. Echocardiography showed a reduced right-side heart function due to a large cystic-like mass at the supradiaphragmatic right paracardiac region with a compressive effect on the right heart. A computed tomography scan confirmed the presence of a giant pericardial cyst. The patient underwent cardiac surgery to excise the mass, 15x13.5x3.5 cm in size. This case report shows that huge right-sided pericardial cysts must be considered in the differential diagnosis of right-sided heart failure. The preferable and reasonable approach to a patient with a huge pericardial cyst is surgical excision for symptom alleviation, early identification, and removal. (Iranian Heart Journal 2022;23(4): 109-114). Copyright © 2022, Iranian Heart Association. All rights reserved.