Inferior vena cava and pulmonary artery diameters for prognosis of Coronavirus disease Pulmonary vascular diameters in Coronavirus disease

Aim: In this study, we aimed to analyze the relationship between pulmonary artery (PA) and inferior vena cava (IVC) diameters in non-contrast chest computerized tomography (CT) images of patients with coronavirus disease 2019 (COVID-19) and overall survival. Material(s) and Method(s): This retrospective study consisted of 404 consecutive patients who underwent chest CT after admission to the emergency department between May 1 and June 31, 2021. CT measurements were performed by two radiologists. The prognostic value of PA and IVC diameters, the computerized tomography severity score (CT-SS), quick sequential organ failure assessment (qSOFA), and confusion, urea, respiratory rate, blood pressure, and age >=65 years (CURB-65) score on overall survival were examined. Result(s): The median age of the participants was 62 years (49-72), and 196 (48.5%) were male. Of the 404 patients, 61 died after admission. While main-PA, left-PA, right-PA (p < 0.001) and IVC-transverse (IVC-Tr) (p = 0.045) diameters were larger and statistically significant in the patients who died (AUC;0.686, 0.722, 0.746, and 0.581, respectively), a statistically significant difference was not detected in terms of IVC anteroposterior diameter (IVC-AP) (p = 0.053) and the IVC-Tr/AP (p = 0.754) ratio. There was a statistical difference in mortality in qSOFA, CURB-65, and CT-SS values (AUC;0.727, 0.798, and 0.708 p < 0.001, respectively). Discussion(s): PA diameters measured from chest CT images at admission (main-PA >= 26.5 mm, right-PA >= 22.9 mm, and left-PA >= 21.6 mm) and the IVC-Tr diameter (>=34.5 mm) can be used as mortality predictors for COVID-19, along with other prognostic scores.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Predictive Role of Echocardiographic Pulmonary to Left Atrial Ratio for in-Hospital Death in Patients with Covid-19

Background and aims: Echocardiographic Pulmonary to Left Atrial ratio (ePLAR, tricuspid regurgitation Vmax/mitral E/e') represents an accurate and sensitive non-invasive tool to estimate trans-pulmonary pressure gradient, showing a sensitivity for pre-capillary pulmonary obstruction higher than traditional echocardiographic measures. The prognostic value of ePLAR in patients with coronavirus disease-2019 (COVID-19) remains unknown. We aimed to investigate the predictive role of ePLAR on mortality in COVID-19 patients. Method(s): One hundred consecutive patients admitted in two Italian institutions for COVID-19 undergoing early echocardiographic examination were included. ePLAR was determined from the maximum tricuspid regurgitation velocity at continuous wave Doppler (m/s) divided by the transmitral E-wave: septal mitral annular Doppler Tissue Imaging e'-wave ratio (TRVmax/E:e'). Main outcome measure was inhospital death. Result(s): Patients who died during hospitalization had a higher prevalence of tricuspid regurgitation, higher ePLAR and right-side pressures, lower Tricuspid Annular Plane Systolic Excursion (TAPSE)/Pulmonary Artery Systolic Pressure (PASP) ratio and reduced inferior vena cava collapse than survivors. Patients with ePLAR >0.28 m/s showed increased in-hospital mortality compared to those having ePLAR <=0.28 m/s (27% vs 10.8%, p=0.05, Figure). A Cox model of multivariate analysis demonstrated that an ePLAR >0.28 m/s was independently associated with increased risk of death (HR 5.07, 95% CI 1.04-24.50, p=0.043), particularly among patients with increased pulmonary arterial pressure. Conclusion(s): A high ePLAR value at baseline predicts in-hospital death in patients with COVID-19, especially in those with elevated pulmonary arterial pressure. These results support an early ePLAR assessment in patients admitted for COVID-19 to identify those at higher risk and potentially to guide strategies of diagnosis and treatment. (Figure Presented).

Aspiration mechanical thrombectomy in acute and subacute iliofemoral deep vein thrombosis in the COVID era: challenges and outcome

BACKGROUND: Catheter directed thrombolysis (CDT) proved to be effective treatment in deep venous thrombosis (DVT), However, there is some concerns about the associated bleeding risk. We assessed the safety and efficacy including technical and clinical success in resolution of iliofemoral DVT after one session treatment with penumbra aspiration mechanical thrombectomy catheter as an alternative CDT. METHOD(S): This is a retrospective study that was conducted on patients presented to Aseer Central Hospital and Saudi German Hospital in Saudi Arabia from January 2019 to December 2020 with symptomatic acute iliofemoral DVT. Patients were treated with Indigo continuous aspiration mechanical thrombectomy 8 system (Penumbra Inc, Alameda, CA, USA). Secondary end point was treatment complications, DVT recurrence and postphlebetic syndrome occurrence within 1 year follow-up. RESULT(S): Our study included twenty-three patients with sixteen females (59.6%) and seven males (30.4%) with a median age of 38 years (18-60years). Indication for treatment was primary DVT in seventeen patients (73.9%), recurrent DVT in six patients (26.1%). Provoked DVT was present in fifteen patients (65.2%) with nine of them was tested positive for COVID-19 while non provoked DVT in eight patients (4.8%). Seven patients (30.4%) had underlying May-Thurner Syndrome after thrombus removal and needed stenting for left common iliac vein (CIV) and two patients (8.7%) with recurrent DVT has significant residual Left common iliac vein stenosis that needed stenting. Two patient (8.7%) have thrombosis extending to inferior vena cava. Initial technical success using Penumbra was 82.6%. All patients in whom aspiration thrombectomy was not successful underwent further treatment with CDT which was successful in further three cases with failure in one case making overall technical success was 95.7%. Recurrent iliac occlusion after successful recanalization was seen in two patients (8.7%) at 6 months follow up. One patient (4.3%) developed pulmonary embolism that required full anticoagulation with no further treatment. No patient develops postphlebetic syndrome at 1 year follow-up. CONCLUSION(S): Penumbra aspiration thrombectomy catheter was safe, effective and promising technique in treatment of acute iliofemoral DVT and allowed definitive treatment in one session with no need for the use of thrombolysis in the majority of cases with no risk for bleeding complications, shorter hospital stay, no need for ICU admission and lower cost. COVID infection does not seem to alter the outcome. Copyright © 2022 EDIZIONI MINERVA MEDICA.

RARE CASE OF MASSIVE DVT AFTER MRNA COVID-19 VACCINATION IN A PATIENT WITH CONGENITAL IVC ANOMALY

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Deep vein thrombosis (DVT) formation is widely recognized as Virchow's Triad of hypercoagulability, venous stasis, and endothelial injury. Based on this definition, congenital aberrations of the inferior vena cava (IVC) such as atresia or coarctation classify as major risk factors to incite a DVT (1). A congenital IVC anomaly with evidence of post-COVID-19 vaccination hypercoagulability (2) suggests a risk association with thrombotic episodes. We present a case of congenital IVC interruption with development of a DVT nine days after Pfizer COVID-19 booster administration. While it is known that IVC anomalies may contribute to DVT development (1), there is scarce data identifying a COVID-19 mRNA vaccine as a direct source of massive DVT in a young adult. CASE PRESENTATION: A 28 year old male with a history of repaired coarctation of the aorta presented with severe right thigh pain that began days after the Pfizer COVID-19 booster. Four days prior, an outpatient ultrasound (US) was negative for DVT. Physical exam revealed a dusky right foot with good distal pulses. Sensation was intact throughout. The left lower extremity (LE) had no edema or tenderness. An US of the right LE showed a DVT extending from the common femoral vein to the posterior tibial vein and DVT of the greater saphenous and deep femoral vein. Left LE US showed an anterior tibial DVT. Attempted thrombolysis was made with tissue plasminogen activator therapy and thrombectomy. Given the patient's atretic IVC anatomy, some residual clot remained in the common iliac vein, and was treated with anticoagulation therapy. After two extensive surgical lyses and aggressive medical lysis, the DVT's were resolved and the patient slowly improved. Upon follow up, he is feeling much better with no further pain. Ultimately this patient will require lifelong anticoagulation and may require an IVC stent to prevent future thrombotic events. DISCUSSION: Coarctation of the aorta is a common congenital heart defect and is often coupled with additional cardiovascular anomalies (1). In our patient, imaging showed a small and near-occluded IVC, which predisposed him to vasculitic events. There is no literature describing a massive DVT in a young adult patient within days of an mRNA COVID-19 vaccine. While these thrombotic events are rare (2), this report portrays one case in which the Pfizer COVID-19 mRNA vaccine may have prompted a vascular event in a susceptible patient. CONCLUSIONS: It has been previously established that congenital IVC anomalies may contribute to increased risk of DVT (1). In this case, we observe an association of the mRNA COVID-19 vaccine with massive DVT in a young male. While this is not meant to discourage patients with congenital IVC anomalies from receiving the COVID vaccine series, it prompts the need for open discussion with healthcare providers to discuss possible adverse effects. Reference #1: Chee, Y.-L., Culligan, D.J. and Watson, H.G. Inferior vena cava malformation as a risk factor for deep venous thrombosis in the young. British Journal of Haematology. 2001;114:878-880. doi.org/10.1046/j.1365-2141.2001.03025.x Reference #2: Bilotta C, Perrone G, Adelfio V, et al. COVID-19 Vaccine-Related Thrombosis: A Systematic Review and Exploratory Analysis. Front Immunol. 2021;12:729251. doi:10.3389/fimmu.2021.729251 Reference #3: Ruggeri M, Tosetto A, Castaman G, Rodeghiero F. Congenital absence of the inferior vena cava: a rare risk factor for idiopathic deep-vein thrombosis. The Lancet. 2001;357(9254):441. doi.org/10.1016/S0140-6736(00)04010-1 DISCLOSURES: No relevant relationships by Melanie Krongold no disclosure on file for Majed Samarneh;No relevant relationships by Elena Tran No relevant relationships by Lakshmi Sheetala Vijaya

A RARE CASE OF HISTOPLASMA CAUSING OBLITERATION OF THE SUPERIOR VENA CAVA AND SUBSEQUENT DEVELOPMENT OF COLLATERAL CIRCULATION

SESSION TITLE: Critical Cardiovascular Disorders SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Physicians are educated on the traditional pathways of sanguineous return of the head and neck through the superior vena cava (SVC). There are known causes of disruption of this system such as SVC syndrome and malignancy causing compression, delayed transit or invasion of these vessels. While compensatory angiogenesis is not a new concept, it has been primarily documented in cases involving coronary artery circulation or congenital heart defects. Here, we present a rare case of the development of left-sided collateral flow in lieu of a right sided SVC with connection to the IVC as a complication of histoplasma infection. CASE PRESENTATION: Our patient was a 67-year female with a past medical history of histoplasmosis, asthma and diabetes who presented with a chief complaint of shortness of breath. Shortly following admission, she was diagnosed with COVID19. In the course of her diagnostic evaluation, she was noted to have significant abnormalities of her thoracic vasculature. More specifically, she had developed calcified granulomas that included a large old calcified granuloma of her right hilum that caused a complete obliteration of her SVC and right middle lobe airways. Her right middle lobe airways had evidence of chronic scarring with development of left sided collateral circulation. Her collateral flow went through her innominate vein into her azygos system and from there into her inferior vena cava and back to her heart. DISCUSSION: It is well established in the literature that histoplasma can lead to scarring and granulomatous changes within lung parenchyma. Our case is unique in the location where the patient developed a granuloma. The close proximity to the SVC over time led to the complete obliteration of the vessel and as a compensatory mechanism her body developed collateral circulation to the left side via her azygous vein and IVC. While we were unable to find similar cases in the literature specifically caused by histoplasma, other phenomena have led to the development of collateral circulation within the lungs. Specifically, Genta et. al. published a case report of an acute pulmonary vein occlusion leading to the development of collateral circulation through the patients' bronchial veins and into the azygous & hemiazygos system similar to our patient. One of the clinical implications for this patient during her hospitalization was the severity of her illness with COVID19. She did require treatment in the intensive care unit. This prompted a discussion among the treatment team regarding developing a plan of action for central line placement should this patient have required vasopressor support. CONCLUSIONS: This case stresses the importance of understanding primary anatomy in order to comprehend potential variants and predict future consequences for patients. It also highlights how sequela of chronic conditions can impact treatment plans. Reference #1: Yu CH, Chen MR. Clinical investigation of systemic-pulmonary collateral arteries. Pediatr Cardiol. 2008 Mar;29(2):334-8. doi: 10.1007/s00246-007-9086-y. Epub 2007 Sep 18. PMID: 17876652. Reference #2: Schaper W. Development of the collateral circulation: History of an idea. Exp Clin Cardiol. 2002 Fall;7(2-3):60-3. PMID: 19649224;PMCID: PMC2719163. Reference #3: Genta PR, Ho N, Beyruti R, Takagaki TY, Terra-Filho M. Pulmonary vein thrombosis after bilobectomy and development of collateral circulation. Thorax. 2003 Jun;58(6):550-1. doi: 10.1136/thorax.58.6.550. PMID: 12775876;PMCID: PMC1746717. DISCLOSURES: No relevant relationships by Alessandra Carrillo No relevant relationships by Chetachi Odelugo No relevant relationships by Shil Punatar No relevant relationships by Ravi Sundaram

MANIFESTATIONS OF SCIMITAR SYNDROME IN AN ADULT

SESSION TITLE: Anatomical Cardiovascular Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Scimitar Syndrome is a rare congenital disorder characterized by partial or complete anomalous pulmonary venous drainage to the inferior vena cava, right lung hypoplasia and displacement of the cardiac structures into the right hemi-thorax (1) The name Scimitar Syndrome is derived from the resemblance of the anomalous pulmonary vein to a curved Middle Eastern sword known as a scimitar (1). Some patients experience no symptoms while others may have severe pulmonary hypertension and dyspnea (2) (3). Cases may be discovered in infancy although some patients are not diagnosed until early adulthood. Here we present a case of a woman who was discovered to have symptomatic scimitar syndrome in her teenage years and opted to forego correction. CASE PRESENTATION: Patient was a 38 year old female with past medical history of Scimitar Syndrome who presented to the pulmonary clinic after a short hospitalization with mild COVID-19. Prior to contracting COVID-19 she had experienced worsening dyspnea over one year and now becomes short of breath after walking one half block. Open surgical correction was offered at diagnosis but was not pursued due to patient preference. A CT Angiogram of the chest was performed while she was hospitalized which showed an anomalous right pulmonary vein draining to the hepatic IVC, minimal bilateral patchy opacities and displacement of the heart into the right hemi-thorax. Echocardiography showed normal right ventricular size and function and did not show evidence of pulmonary hypertension. She was referred to the adult congenital heart disease clinic and continued to have severe dyspnea and fatigue. 6 months later, repeat echocardiography and cardiac MRI demonstrated borderline dilation of the right ventricle and atrium but no echocardiographic evidence of pulmonary hypertension. The patient remains hesitant to undergo invasive procedures or interventions. She has been offered a right heart catheterization to better characterize her volume status and obtain direct measurement of her pulmonary artery pressures. DISCUSSION: Although generally discovered in infancy and childhood, Scimitar syndrome may not be discovered until adulthood. Various treatments are available for correction of scimitar syndrome including open surgical approaches with direct implantation of the scimitar vein into the left atrium, trans-catheter occlusion of aorto-pulmonary collaterals and re-routing of the anomalous vein into the left atrium via endoscopic graft placement (4) (6) (7) (8). If left uncorrected worsening left to right shunting and pulmonary hypertension may occur (5). Our patient has developed borderline right ventricular dilation and has experienced severe functional limitation. A right heart catheterization is indicated to determine her pulmonary artery pressures. This case illustrates the potential consequences of deferring early treatment for Scimitar Syndrome CONCLUSIONS:. Reference #1: Frydrychowicz A, Landgraf B, Wieben O, François CJ. Images in Cardiovascular Medicine. Scimitar syndrome: added value by isotropic flow-sensitive four-dimensional magnetic resonance imaging with PC-VIPR (phase-contrast vastly undersampled isotropic projection reconstruction). Circulation. 2010 Jun 15;121(23):e434-6. doi: 10.1161/CIRCULATIONAHA.109.931857. PMID: 20547935 Reference #2: Abdullah A. Alghamdi, Mansour Al-Mutairi, Fahad Alhabshan, Scimitar syndrome: restoration of native pulmonary venous connection, European Heart Journal Supplements, Volume 16, Issue suppl_B, November 2014, Pages B41–B43, https://doi.org/10.1093/eurheartj/suu025 Reference #3: Khan A, Ring NJ, Hughes PD. Scimitar syndrome (congenital pulmonary venolobar syndrome). Postgrad Med J. 2005 Apr;81(954):216. doi: 10.1136/pgmj.2004.027813. PMID: 15811882;PMCID: PMC1743239 DISCLOSURES: No relevant relationships by John Prudenti No relevant relationships by Anthony Smith

Can point of care ultrasound (POCUS), in the general ward and in primary care, reduce 30-day hospital readmission (HR) in a heart failure (HF) population?

Background: about 25% of patients admitted for HF are readmitted to hospital within 30 days. Fluid congestion is the leading cause for short-term readmission. Lung ultrasound (LUS) has become widely used to assess pulmonary congestion of cardiac origin for hospitalized patients on admission and before discharge but also for patients with HF undergoing outpatient follow-up. Inferior vena cava ultrasonography (IVCUS) seems also to be a useful tool in the care of patients with chronic HF. General practitioners (GPs) can safely use POCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients. Furthermore, they have expressed a need for greater training to diagnose and manage HF. An effective advanced fluid management programme, consisting in an intervention providing tailored therapy guided by intravascular volume assessment, is associated with improving readmission and mortality in HF. However, experts report long waiting lists for HF clinics and emphasize that scheduled follow-up appointments with a cardiologist do not regularly occur within two weeks of discharge, as recommended in guidelines. Purpose: to assess if POCUS, including LUS and IVC collapse index (IVCCI), can help in-hospital management in the general ward and if GPs can early identify signs of fluid overload after discharge, providing early referral and optimal therapy according to 2021 ESC guidelines. Methods: observational pilot study to test routine POCUS performed on hospital admission, before discharge and after 2 weeks in the GP ambulatory setting, after an in-hospital training period. 30-day HR was retrospectively compared to the clinical standard. Results: among 250 consecutive SARS-CoV-2 negative patients admitted to the department of internal medicine, 56 (22.4%) have been hospitalized for acute decompensated HF (17.8% HFrEF, 26.8%, HFmrEF, 55.4% HFpEF). 17 patients (30% M/F 6/11: group 1) underwent POCUS, while 39 patients (70% M/F 25/14, group 2) the standard management. Mean age difference (group1: 80.6±9.6 vs group2: 82.8±8.2) as well as comorbidities were not significant among groups (t-test p<0.19), while mean length of stay (MLS) for group1 (6.5±2.9 days) vs group2 (12±6.2 days) was significant (t-test p<0.001). LUS on discharge excluded persistent congestion in 76.5% (B-lines ≥ 3: 23.5%, yet 75% of these patients had no findings on ascultation), while IVCCI was >50%, 30-50%, <30% respectively in 52.9%,17.6% and 29.4%). 3 patients were evaluated after 2 weeks by GP. The 30-day HR was 5.8% (group1) vs 12.8% (group2) (χ2 test p<0.0012). Conclusions: POCUS seems to have contributed to reduce MLS, encouraging attainment of an optimal volume status at discharge and prescription of an optimal therapy. LUS and IVCUS are simple tools which may be performed soon after discharge by GP, contributing to reduce 30-day HR improving post discharge quality of care.

From Inferior Vena Cava to Right Atrium: A Rare Case of a Unique Large Burden Thrombus in a Patient with Antiphospholipid Syndrome

Introduction: Antiphospholipid Syndrome is a condition where self-antibodies are directed against phospholipid binding proteins resulting in thrombosis and/or pregnancy loss. Diagnosis is made via history, physical, positive anticardiolipin and anti-beta-2-glycoprotein antibodies. We describe a case of a large thrombus in a previously diagnosed patient with antiphospholipid syndrome and discuss the need for prophylaxis in these patients. Case Report: 34-year-old G7P1161 Hispanic female with past medical history of uncontrolled diabetes mellitus type 2 presents with an acute onset of sharp abdominal pain radiating to the back associated with nausea, non-bloody non-bilious emesis and dysuria. Vital signs on admission are significant for tachycardia and hypertension. Labs are noteworthy for elevated Creatinine at 1.7 mg/dl, thrombocytopenia, transaminitis, elevated Ddimer at 14272 ng/ml. Urine analysis is positive for nitrites, trace leukocytes and bacteria. Her serum pregnancy test and COVID PCR are negative. CT Abdomen/Pelvis with contrast revealed an extensive thrombus in the Inferior Vena Cava (IVC) to the Right Atrium (RA), also extending into the hepatic veins and upper lumbar veins. Moderate perinephric fat stranding is also noted around bilateral kidneys. Ultrasound of the abdomen reveals cholelithiasis without evidence of acute cholecystitis. Venous Doppler of lower extremities reveals patent deep veins. Patient was started on heparin drip immediately and intravenous Cefepime. Interventional Radiology performed mechanical thrombectomy. Hematology was consulted and converted patient to Warfarin with an INR goal of 2.5-3. Patient was discharged and instructed to follow up with hematology. Discussion: There are few case reports of extensive thrombi ranging from IVC to RA with most cases occurring in elderly population. We present a unique case of an extensive thrombus ranging not only from the IVC to RA but also extending into the hepatic veins and the upper lumbar veins. The patient described has a history of multiple spontaneous abortions with her only successful preterm birth required daily therapeutic Lovenox during pregnancy. Her recurrent pregnancy loss and current large burden thrombus can be attributed to her antiphospholipid syndrome. This begs the question whether these patients should be started on prophylaxis anticoagulation. There have been limited studies with aspirin and warfarin which at times demonstrated positive results. Our patient had her thrombus identified incidentally due to an admission for pyelonephritis. If her thrombus was not recognized in time, outcomes could have been devastating. In conclusion, there should be further studies to determine the efficacy of anticoagulation prophylaxis in patients with positive antiphospholipid antibodies. (Figure Presented).

Hyponatremia in brain injured patients: differential diagnosis between Cerebral Salt Wasting Syndrome and Syndrome of Inappropriate Antidiuretic Hormone secretion based on volemic state evaluation

Cerebral Salt Wasting Syndrome (CSW) is an uncommon cause of hypotonic hyponatremia associated to central nervous system disease (especially subarachnoid hemorrhage) and characterized by hypovolemia due to renal sodium loss. The main differential diagnosis is SIADH, a much more common form of hyponatremia without signs of hypovolemia. The treatment is based on filling with isotonic or hypertonic saline. We report the case of a 50-year-old chinese man with a history of arterial hypertension presenting to the ER for headache and fever after vaccination for SARS-CoV-2. In the ER he was hemodynamically stable without neurological deficits. Blood tests showed severe hypoosmolar hyponatremia. Brain CT revealed multiple hypodense oval areas of uncertain nature with peripheral contrast enhancement. The main microbiological tests were negative. In the suspicion of paraneoplastic SIADH, water restriction was prescribed and a total body CT scan was performed, resulting normal. Nevertheless, hyponatremia got worse. Brain MRI revealed signs of subacute intracranial bleeding and angiography showed an anterior cerebral artery aneurysm. An echocardiography revealed collapse of the inferior vena cava, therefore, given the hypovolemia, hypotonic hyponatremia and the signs of recent brain injury, diagnosis of CSW was made. Treatment was based on endovascular coiling of the aneurysm and correction of hypovolemic hyponatremia using isotonic saline. It is essential to differentiate between CWS and SIADH since the treatment is categorically different. Their key distinguishing feature is volemia.

Syncope as the initial presentation of pulmonary embolism in a patient with asymptomatic COVID-19: a case report

Syncope is a common clinical presentation, often may remain unexplained. PE is thought to be an uncommon cause of syncope. Hormone therapy (HT) is a known risk factor for thromboembolic disease (TD). The new coronavirus SARS-CoV-2 (COVID-19)pandemic has emerged in China and spread around the world. A higher prevalence of PE has been described in critically ventilated patients with COVID-19 but few data exist on the prevalence of TD in asymptomatic patients. We present a case of insidious development of PE probably promoted by the COVID19 infection. A previously healthy 51 year old female, obese (BMI 34 kg/m2), was admitted to the emergency department for syncope (third generation assays negative for Covid19). She reported HT for 4 months. She was tachypnoic (22 breaths/min), peripheral oxygen (SpO2) was 94% (room air). EKG: sinus tachycardia (137 beats/min) with S1Q3T3 aspect;arterial blood gases: moderate hypoxemia (PaO2 61.2 mmHg). ETT: dilated and hypocontractile right ventricle, D-shape aspect of the IVS, dilated inferior vena cava (23 mm), estimated PAP65 mmHg. We administered parenteral anticoagulant therapy and O2 therapy. We suspected PE, which was confirmed by contrast chest CT;no lung parenchymal involvement was documented.Later, we found RT-PCR assays positive for Covid19. PE should be suspected in all patients with syncope. The prevalence of TD in Covid19 asymptomatic patients is partially studied. Although current guidelines do not recommend the use of thromboprophylaxis in outpatient COVID-19, we believe that each case must be evaluated individually. More studies are needed to evaluate the risk-benefit ratio.

ENDOVASCULAR RECONSTRUCTION FOLLOWING IVC AND BILATERAL LOWER EXTREMITY THROMBOSIS IN AN ADOLESCENT

Background: Inferior Vena Cava (IVC) abnormalities are a risk factor for the development of lower extremity deep vein thrombosis (DVT). Abnormalities can be congenital or acquired and include IVC atresia, a rare and lesser known problem for adolescents. Adolescents with IVC atresia are at high risk for DVT's that are often refractory to standard anticoagulation methods, including thrombolysis. Objectives: The purpose of this report is to highlight a young patient with extensive lower extremity DVT in the setting of underlying IVC atresia and describe the complex care required. The patient is a 16-year-old with a history of venous insufficiency who presented with low back pain and lower extremity swelling. Thrombotic risk factors included factor V Leiden heterozygosity, oral contraceptive use, and recent COVID-19 vaccination. An MRI completed by the orthopedist for back pain was concerning for abnormal signal in the IVC as well as an IVC aneurysm. A contrast enhanced CT was obtained and demonstrated atresia of the suprarenal IVC, subacute thrombosis of the infrarenal IVC along with an IVC aneurysm, and subacute thrombosis of the bilateral iliac veins. Design/Method: A retrospective chart review of the patient's initial presentation, imaging, and treatments was conducted along with a review of the literature involving similar cases. Results: Initial treatment was intravenous heparin and t-PA mediated thrombolysis. After overnight thrombolysis, venography revealed significant clot lysis;thus, she was transitioned to subcutaneous enoxaparin and discharged home with therapeutic anti-Xa levels. Follow up imaging 3 days later revealed recurrent thrombosis of the deep veins in both lower extremities. She was readmitted, placed on intravenous heparin, and received catheter directed t-PA thrombolysis. Clot burden was so extensive it was further reduced using Angio jet thrombectomy and balloon angioplasty. Because the recurrent clots were attributed to lack of outflow from the underlying IVC atresia, interventional radiology completed endovascular reconstruction of the IVC. She then transitioned from intravenous heparin to therapeutic enoxaparin, clopidogrel, and aspirin. At three month follow up, imaging was negative for clot and her vasculature was widely patent. Conclusion: Pediatric patients with bilateral lower extremity DVTs are uncommon and underlying IVC abnormalities should be considered in the evaluation. Optimal treatment strategies are evolving and include aggressive anticoagulation and endovascular reconstruction.

Congenital Portosystemic Shunts in Children: A Case Series From Single Centre

Background: Congenital portosystemic venous shunts (CPSS) are uncommon foetal vascular developmental anomalies where splanchnic venous flow bypasses liver. Four cases of CPSS are reported at our centre. Case Summary (1) Eight years old female child presented with Dengue with no features of chronic liver disease and normal liver function test (LFT). Ultrasonography (UGS) abdomen reported an incidental finding of abnormal vascular shunt in liver. Further imaging revealed an anastomosis between portal vein and intrahepatic part of inferior vena cava (IVC), hypoplastic portal vein and multiple nodules in bilateral liver lobes. Interventional Radiologist closed the anastomosis using vascular plug. Child sustained the procedure well. (2) Two months old female patient presented with high GGTP cholestasis, dysmorphism and deranged LFT. On USG abdomen there was intrahepatic portosystemic shunt. MDCT abdomen revealed 2 vascular shunts between left portal vein to middle hepatic vein and left portal vein. Cholestasis responded with symptomatic treatment, hence being followed-up for observation till 1year of age for complications and possibility of spontaneous closure. (3) Twenty-two days old, full term female child presented with convulsions and high GGTP cholestasis with multiple hematomas in brain. LFTs were deranged. 2D-ECHO showed small PFO. USG abdomen suggested a channel between left portal vein and hepatic vein. Patient tested COVID positive hence quarantined now and further evaluation is awaited. (4) One day old, late preterm male baby presented with respiratory distress and pulmonary hypertension with antenatal scan suggesting ductus venous agenesis with hepatic vascular malformation. Patient developed cholestasis with deranged LFT. 2D-ECHO showed PDA and ASD. MDCT abdomen revealed connection between main portal vein and intrahepatic IVC. Conclusions: CPSS has heterogeneous presentation. It can be diagnosed antenatal or postnatal, may be asymptomatic or may present as neonatal cholestasis and may be associated with anomalies. Management may vary from case to case and mainly depends on complications and age of presentation.

Preintubation echocardiographic assessment using subcostal-only view (easy) exam: A case series

INTRODUCTION/HYPOTHESIS: Induction and intubation can cause cardiovascular instability, hypoxemia, and cardiac arrest. The EASy exam is a subcostal four-chamber view (SC4C), followed by inferior vena cava (IVC) and upper lung field views performed in quick succession. The goal of this study was to evaluate the impact of single-day EASy training on management prior to induction and intubation. METHODS: EASy training consists of a combination of a web-based curriculum, live lecture, and 10 exams performed under direct supervision. The EASy protocol was performed before emergency intubation on five critically ill patients. In this case series, we describe findings and management based on the EASy phenotypes (pattern recognition). RESULTS: Five resident-obtained EASy studies were performed in the ICU for emergency intubation. Two patients had COVID-19. Three had hyperdynamic ventricles with a small left ventricular (LV) cavity size with a < 1.5cm fully collapsible IVC consistent with hypovolemia (two of which had thickened LV walls indicating likely diastolic dysfunction). These three patients received a 10 mL/kg IV fluid bolus to counteract vasodilation and decreased venous return, and were started on phenylephrine. The fourth had normal contractility and diastolic cavity size with a normal-sized collapsible IVC. The fifth patient had biventricular dilation with reduced systolic function and a plethoric IVC. For this patient, no fluid bolus was given, and a vasopressor with inotropic properties (norepinephrine) was started. Etomidate was used for induction and intubation. The mean time for completion was 3 minutes (range 2 to 4 minutes). Three studies were deemed “good” quality and two were deemed “adequate” by an attending physician proficient in critical care ultrasound. Vitals were monitored for 15 minutes post-intubation, and all patients maintained hemodynamic stability with MAP ≥ 65 mmHg. CONCLUSIONS: EASy exam aids clinical decision-making in the pre-induction and intubation period, where interventions can have deleterious and even fatal consequences.

COVID-19 pneumonia in a child. A surprise finding

Background: Coronavirus disease 19 (COVID-19) tends to be milder in children, but severe cases have been reported. We described a case report of a toddler admitted to our department with additional findings, highlighting the importance of assessing the patient as a whole. Case Presentation: A previously healthy, 15-month-year-old girl presented with fever and dry cough for 10 days, respiratory distress and PCR SARS-CoV-2 was positive. At admission, she presented with hypoxemia (SpO2 89-90% in room air), global retraction and bilateral bronchospasm. She was treated with bronchodilators, methylprednisolone, remdesivir and also amoxicillin/clavulanic acid. Her complete blood count revealed leucocytosis 16,160x109/L, 41% lymphocytes, C-reactive protein 57,9 mg/L, procalcitonin 0,13 ng/mL, sedimentation rate 44 mm/h, ferritin 218,4 ng/mL. Chest computed tomography (CT) scan revealed bilateral peripheral areas of ground glass, coexisting consolidation areas at inferior lobes but also revealed a 6 cm supra-renal mass. Abdominal ultrasound and CT confirmed an heterogeneous right supra-renal gland mass of 5,5cm along the greatest diameter with diffuse calcifications, evolving the inferior vena cava and the renal vascular pedicle, no signs of liver, bone, cutaneous or ganglionic metastization. These features were suggestive of neuroblastoma in stage L2. Vanillylmandelic acid, normetanephrine/creatinine ratio and metanephrine/creatinine ratio were elevated. The metaiodobenzylguanidine (Mibg) scan showed a localized disease. The total excision of the tumour mass was performed, and the histology confirmed neuroblastoma with no N-myc oncogene amplification, nor other bad prognosis chromosomal abnormalities. She is currently under oncological surveillance, with no signs of recurrence. Learning Points Discussion: Neuroblastoma is the most common extracranial solid tumour of childhood. It is known for its broad spectrum of clinical behaviour and outcome. In this case, although this toddler was admitted due to COVID-19 pneumonia, it allowed to identify a localized tumour, perform excision and due to the favourable biology tumour, she has a very good chances of being cured and free of disease.