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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: 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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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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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.
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Background: In clinical practice, cardiac tamponade is not an all-or-none phenomenon, but rather a continuum of hemodynamic impairment. Diagnosis depends on an overall assessment of clinical and echocardiographic findings, hemodynamic measurements, and other corresponding patient-level variables must be considered to make a diagnosis to initiate timely intervention.1 The identification of cardiac tamponade in the presence of severe pulmonary hypertension and right ventricular failure can be even more challenging, because the classic findings are often not observed. Our patient clearly had hemodynamic compromise (orthostatic collapses and then persistent hypotension from a large pericardial effusion but did not exhibit the common features of tamponade on ECHO. This can be explained by the preexisting, markedly elevated right-sided pressures, which prevented typical findings of pulsus paradoxus, right atrial and ventricular diastolic collapse, and equalization of diastolic pressures.1 Case presentation: 44 Years old lady background of Interstitial lung disease, pulmonary artery hypertension, Right heart failure and anti-synthetase syndrome. Recently required Intensive care admission for COVID pneumonitis and was discharged on home oxygen. Now admitted to hospital after she boarded the flight without oxygen and became unwell. She was treated on lines of exacerbation of interstitial lung disease, Right heart failure and moderate pericardial effusion without signs of tamponade in ECHO and was given adequate diuresis and responded very well to it. Her oxygen requirement came down and she clinically improved. Few days after, she developed diarrhea and prerenal Acute kidney injury while in ward and became borderline hypotensive which improved after her diuretic doses were reduced and then held. She then after few days started to develop orthostatic collapses with hypotension and then became persistently hypotensive. Her CT Pulmonary angiogram showed unchanged moderate circumferential pericardial effusion, and no Pulmonary embolism. She was reviewed by Critical care outreach team and an urgent bedside Echocardiogram was performed to rule out features of tamponade which showed moderate pericardial effusion, severely dilated Right heart with massive Right ventricular pressures compressing her Left ventricle. She was urgently reviewed by cardiology and was taken to Intensive care unit for invasive hemodynamic monitoring, where she was given inotropes and inhaled pulmonary artery vasodilators. The decision was taken to cautiously diurese and not to drain the pericardial effusion due to risk of developing further instability by increasing right ventricular expansion causing further collapse and pressure on Left ventricle. Discussion and conclusion: Our case stresses on the importance of Bedside Echocardiogram in timely identifying the atypical features of cardiac tamponade and to understand the different hemodynamics and mechanism of obstructive shock in patients with pre-existing right sided heart failure. After the establishing that patient was in obstructive cardiogenic shock with atypical findings of tamponade, the next most important step was to decide whether to drain the pericardial effusion or not. In our literature search, we found that the drainage of a large pericardial effusion in patients with pulmonary hypertension has been accompanied by catastrophic, sudden hemodynamic collapse and it has been postulated that the presence of pericardial fluid limits right ventricular distension in response to pressure and volume overload. When the pericardial fluid is removed, rapid enlargement of the right ventricle causes: (1) reduced right ventricular systolic function due to muscle fiber distension;and (2) compression of the left ventricle, which leads to impaired diastolic filling and left ventricular outflow track obstruction.1.
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Introduction: Inhaled nitric oxide (iNO) can be utilized as a rescue treatment option in refractory hypoxaemia and in the potential reversal of pulmonary vascular resistance by pulmonary vasodilation.1 Its use remains controversial due to limited evidence regarding efficacy and potential side effects.2 Furthermore, it requires additional equipment and consumables and its infrequent use means staff may be relatively unfamiliar with the treatment. Objectives: Investigate use of iNO within our adult critical care unit in order to identify potential quality improvements that could be made to the delivery of this therapy. Clarify the proportion of patients who demonstrated a favourable PaO2/FiO2 (PF) response to iNO. Methods: We conducted a single-centre retrospective analysis of consecutive patients treated with iNO on the General & Cardiac Intensive Care Unit at Manchester Royal Infirmary between 01/01/2018 and 25/06/2021. Data was extracted from electronic patient records on patient characteristics, indication for iNO, starting dose, ventilatory characteristics, change in PF ratio and ICU outcome. Results were recorded at iNO initiation, 2, 6, 12 and 24 hours. A responder was defined by improvement in the PF ratio of ≥20% at any point up to 6 hours after initiation. Results: 37 patients were identified, mean age 51 years (SD 14). 84% were male and 16% were female. 27 patients (73%) had a diagnosis of COVID-19 pneumonitis (Figure 1). Primary indication for iNO was acute respiratory failure (ARF) in32 (86%) and right ventricular failure in 5 (14%)patients. Prior to iNO, patients had been in ICU for 11 days (SD 11) and had received invasive mechanical ventilation for 163 hours (SD 188). PF ratios at initiation were 12.8kPa (SD 5.0), in keeping with severe ARDS and 13 (39%) were already proned at initiation. Median troponin result prior to therapy was 21[IQR 14-81]. 12 patients (32%) had ECHO evidence of raised pulmonary artery pressures. A starting dose of 20ppm iNO was observed for each patient. By 6 hours, 14/37 patients (37%) were classified as positive responders. There was a significant increase in PF ratios at 6 hours compared to baseline in responders (15.9kPa vs 12.0kPa, p=0.04) but no significant difference at any other time point. There was no difference in the duration of therapy in responders vs non responders (76 vs 85 hours, p=0.72). Conclusion: iNO therapy may offer short-term improvement in oxygenation in <40% of patients at 6 hours. Duration of therapy was similar regardless of response. This may suggest reluctance to discontinue therapy once started possibly through fear of precipitating deterioration, belief that iNO has halted decline or reluctance to recognize futility when there are few other therapeutic options. iNO is typically commenced when patients have already been invasively ventilated for several days. It is unknown whether earlier initiation would affect response. Use of iNO has increased markedly since the start of the COVID-19 pandemic which should prompt units to evaluate their own practice with this therapy.
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The proceedings contain 226 papers. The topics discussed include: identification of biomarkers sensitive to pulsatile and continuous flow for identification of promising continuous flow VAD modulation protocols to mitigate non-surgical bleeding events;comprehensive machine learning analysis of pre-implantation risk factors for right heart failure after LVAD implantation;combining VA-ECMO And Impella (EC-Pella) before reperfusion mitigates left ventricular loading and injury due to VA-ECMO in acute myocardial infarction;platelet function at the intersection of the COVID-19 'cytokine storm' and mechanical circulatory support;a dialysate free portable artificial kidney device;durable right heart mechanical support system: a multi-day proof-of-concept study in pulmonary hypertension sheep;a dual-action nitric oxide-releasing slippery surface coating for extracorporeal organ support: first evaluation at clinically relevant blood flow rate for partial lung support;cannula add-on for pressure and flow measurement in VADs;and comparison of interlaboratory CFD simulations of the FDA benchmark blood pump model.
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BACKGROUND: Cardiac injury is a prevalent complication and is associated with worse prognosis in COVID-19 patients. The increased cardiac workload resulting from respiratory failure and hypoxemia is a common mechanism of cardiac injury, and the right ventricle may bear the brunt of its impact. AIM: The present study aimed to determine the incidence and prognostic value of right ventricular (RV) dysfunction in COVID-19 patients admitted to the intensive care unit using conventional echocardiography parameters. METHODS: Patients were subjected to full history taking and clinical examination, computed tomography (CT) of the chest was done for all patients to assess the severity of lung infiltration, all patients received standard treatment according to Ministry of Health and Population COVID-19 treatment protocol recommendations. The echocardiographic assessment was done on all patients. RESULTS: The mean age of the patients was 61.10 ± 9.64 years (range 42–80 years). There were 36 (60%) males and 24 (40%) females. The nonsurvivor group consisted of 28 patients (46.7%), and the survivors consisted of 32 patients (53.3%). There was a statistically significant association between mortality and RV function regarding tricuspid plane systolic excursion, fractional area change %, RV basal diameter, and expiratory positive airway pressure. CONCLUSION: We concluded that in COVID-19 patients, RV function must be assessed and its prognostic importance recognized. RV dysfunction is not only a symptom of high pulmonary pressures, but it also contributes to cardiac insufficiency.
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CASE: We describe a case of isolated acute right ventricular (RV) strain not attributable to pulmonary embolism (PE) or Acute Respiratory Distress Syndrome (ARDS) in the setting of recent COVID-19 infection. A 77-year-old male with medical history notable for type 2 diabetes, obesity, chronic kidney disease, obstructive sleep apnea, and chronic hypoxemic respiratory insufficiency with a last known left ventricular ejection fraction (LVEF) of 77% on admission with preserved RV function, and recent COVID-19 infection was admitted for septic shock secondary to a post-viral MRSA pneumonia 12 days after diagnosis with COVID-19. On day 5 of admission, after completion of antibiotic therapy and resolved shock, the patient developed relative hypotension and an oliguric acute kidney injury with creatinine of 1.9 (previously 1.0) and urine microscopy findings consistent with acute tubular necrosis. EKG at the time showed new incomplete right bundle branch block. On day 8 of admission, relative hypotension continued with an uptrend in creatinine to 4.8 despite adequate fluid resuscitation. EKG showed new complete right bundle branch block with high-sensitivity troponin peaking at 550 (previously 15). A transthoracic echocardiogram showed enlarged RV and isolated severe hypokinesis of the RV mid-free wall consistent with “McConnel's sign” and acute right heart strain, with poorly visualized left ventricle, but without regional wall motion abnormalities. CTA Chest evaluating through the segmental arteries ruled out acute PE. Acute coronary syndrome was ruled out with traditional and right-sided EKG. Oxygen requirements remained unchanged throughout the course of his admission. The patient was transferred to the ICU for undifferentiated shock requiring triple pressor therapy and eventually died from acute renal failure and volume overload. IMPACT/DISCUSSION: While RV strain secondary to ARDS and PE has been implicated in COVID-19 and found to be an independent predictor of mortality, there is limited literature describing isolated RV dysfunction in their absence. Increasing reports showing cardiac microthrombi in autopsies of COVID-19 patients suggest alternate etiologies of RV injury and suggest potential utility of empiric therapeutic anticoagulation in all patients presenting with COVID-19. Alternatively, direct viral injury isolated to the RV may be unique in COVID19. Additionally, “McConnell's sign” combined with enlarged RV is traditionally considered a specific marker of PE, with reported specificity of 94% in the original report. However, there are increasing reports shedding doubt on the specificity of this finding. CONCLUSION: This case demonstrates the need to consider alternate etiologies for RV dysfunction in COVID-19, including microthrombi and direct viral injury. Additionally, this case adds to the growing literature demonstrating the limitation of “McConnell's sign,” even in patients with high suspicion for PE.
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The new coronavirus (COVID-19) epidemic caused by SARS-CoV-2 has emerged as perhaps the biggest medical problem of our century. Although COVID-19 mainly affects the lungs, it also affects many organs, especially the cardiovascular system. Pulmonary hypertension (PH) is a pulmonary vascular disease described by pulmonary arterial vasoconstriction and remodeling, which may lead to an increased pulmonary artery pressure with varying clinical course and severity depending on the etiology and eventually to right heart failure. Because of associated comorbidities, patients with PH are likely to face a potential risk of severe complications and mortality and unfortunately, they may have worse outcomes than other patients. The COVID-19 pandemic has brought us new and different challenges in the follow-up and treatment processes of patients with PH. For patients admitting to the hospital, it is important to balance the risk of exposure to COVID-19 with ongoing care and treatment services. However, the COVID-19 outbreak has brought serious challenges to PH centers to weigh the risks and benefits of diagnostic research, including potential exposure to COVID-19, and the timing of initiation of PH-specific treatment in high-risk patients. In this article, the management of PH patients during the COVID-19 pandemic;problems encountered in diagnosis, clinical follow-up and treatment processes;the different difficulties experienced during hospitalizations have been compiled.
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Coronavirus disease 2019 (COVID-19) has been associated with a wide spectrum of cardiovascular manifestations. Since the beginning of the pandemic, echocardiography has served as a valuable tool for triaging, diagnosing and managing patients with COVID-19. More recently, speckle-tracking echocardiography has been shown to be effective in demonstrating subclinical myocardial dysfunction that is often not detected in standard echocardiography. Echocardiographic findings in COVID-19 patients include left or right ventricular dysfunction, including abnormal longitudinal strain and focal wall motion abnormalities, valvular dysfunction and pericardial effusion. Additionally, some of these echocardiographic abnormalities have been shown to correlate with biomarkers and adverse clinical outcomes, suggesting an additional prognostic value of echocardiography. With increasing evidence of cardiac sequelae of COVID-19, the use of echocardiography has expanded to patients with cardiopulmonary symptoms after recovery from initial infection. This article aims to highlight the available echocardiographic tools and to summarize the echocardiographic findings across the full spectrum of COVID-19 disease and their correlations with biomarkers and mortality.
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Background: Extracorporeal membrane oxygenation (ECMO) is a form of cardio-pulmonary life support used for patients with respiratory and/or cardiac failure. Hybrid ECMO is a sophisticated circuit to match the exact hemodynamic demands in patients who are refractory to traditional ECMO settings. Case: A 43-year-old male presented with dyspnea for four days. On physical examination, he exhibited increased work of breathing and decreased breath sounds bilaterally. Pulse oximetry was 70% on room air, minimally improved to 75% on maximum high flow nasal cannula. He was found to be COVID-19 positive and demonstrated diffuse bilateral lung consolidation on CT chest consistent with severe acute respiratory distress syndrome. Patient was intubated but continued to show poor oxygenation with P/F ratio of 71 (Normal: >400). Veno-Venous (VV) ECMO was started with cannulations into the right femoral vein (RFV) and right internal jugular vein (RIJV);this resulted in an initial improvement of partial pressure of oxygen (pO2) in arterial blood gas. However, within a few days, pO2 started to decrease with visual evidence of recirculation of oxygenated blood into the venous drainage line. A transthoracic echocardiography revealed severe pulmonary artery (PA) hypertension secondary to respiratory failure with PA pressure of 116mmHg (Normal: 18-25mmHg). This prompted a revision of the ECMO circuit to offload the right ventricle. Revised circuit included a cannula in the RFV for venous drainage and oxygenated venous return through two pathways: cannula in the RIJV (approximately 1 liter return), and a third cannula inserted through the left subclavian vein terminating into the main PA (approximately 4 liters return). Hereon, patient was able to maintain adequate pO2 for the remainder of his hospital stay until he was transferred to a lung transplant center. Conclusion: Our case illustrates the clinical sophistication of hybrid VV-PA ECMO-especially in patients with PA hypertension and impending right-sided heart failure. As respiratory failure secondary to COVID-19 becomes more prevalent, hybrid ECMO may provide a practical solution to protect the right heart in the journey to lung transplant.
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Rhinoviridae are the most common cause of upper respiratory tract infections, especially in children, and often referred to as “the common cold”. Symptoms are usually mild, nasopharyngeal in nature;they have, however, been implicated in cases of infantile viral pericarditis. Its role in the presentation of adult viral pericarditis remains unclear. We present the case of a 45-year-old male with a past medical history of pre-diabetes, hyperlipidemia and hypertension with complaints of severe left-sided chest pain that worsened with movement and coughing but improved when lying supine. Two weeks prior to presentation, he had developed an intermittent cough, treated with antibiotics and steroids. On presentation to the ED, the patient was afebrile but hypotensive to 80/52 mmHg, tachycardic to 116 BPM, hypoxic to 88% on room air, improving to 91% with 3L nasal cannula. Physical examination was notable for wheezing and egophony. Laboratory findings were concerning for WBC 19.97x10-3/uL, Hgb 13.4 g/dL, CRP 176 mg/L, Ferritin 772 ug/L, D-dimer 3.70 ug/mL FEU;procalcitonin 0.2 ng/mL and troponin <0.015 ng/mL. Respiratory viral panel revealed negative COVID-19 test but positive for rhinovirus/enterovirus. Electrocardiogram showed sinus tachycardia. Chest computed tomography demonstrated moderate pericardial effusion, ground glass attenuation of the lungs bilaterally with moderate left pleural effusion and reflux of contrast into the hepatic veins, suggestive of right heart failure. Echocardiogram demonstrated small to moderate pericardial effusion. The patient was admitted with the diagnosis of acute rhino/enteroviral-associated pleuropericarditis. Broad-spectrum antibiotics, prednisone, colchicine and indomethacin were commenced. Upon clinical stabilization of his condition, steroids were discontinued and he was discharged home with close follow-up. While rhinovirus has been associated with infantile viral pericarditis, it is implicated in pneumonia and COPD exacerbations in adults but rarely reported as a cause of adult pericarditis. A case-control study of adults diagnosed with acute idiopathic pericarditis had an independent association with an upper respiratory tract infection or gastroenteritis in the month preceding pericarditis diagnosis but did not delineate causative viruses. Therefore in cases of unknown causes of viral pericarditis, thorough history is vital. Steroids as part of the treatment algorithm for pleuropericarditis management has long been debated. Older literature has not favored the use of steroids due to high recurrence rate. However, Perrone et al refuted this point, noting that low-dose steroids with gradual tapers have equal efficacy and recurrence rates as compared with NSAIDs/colchicine. Therefore, steroids may be a reasonable option for patients with contraindications to NSAIDs/colchicine.
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ECMO has become a widely recognized support modality for patients with severe cardiac or respiratory failure, and has been increasingly utilized in the ongoing severe acute respiratory syndrome due to coronavirus-2 (SARS-CoV-2) pandemic. Long-term support on ECMO for acute respiratory distress syndrome (ARDS) is also becoming more commonplace with eventual lung recovery, obviating the need for lung transplantation. However, long-term ECMO support has not been well studied for SARS-CoV-2 ARDS patients. We report the case of a 39-year-old female with severe SARS-CoV-2-induced ARDS successfully supported on venovenous ECMO (V-V ECMO) for 5,208 hours (217 days) in a high ECMO-volume, quaternary care children's hospital in 2021. At the time of this writing, this is the longest reported patient successfully supported on ECMO for SARS-CoV-2 ARDS. Our patient was initially cannulated at our children's hospital with dual-site V-V ECMO, via the right internal jugular vein (RIJ) and right common femoral vein. Bedside tracheostomy was performed on ECMO day 40, for early mobility, oral feeding, interaction, and pulmonary rehabilitation planning. Unfortunately, during her course she suffered multiple complications including bacterial co-infections, bleeding requiring anticoagulant changes from unfractionated heparin (UFH) to bivalirudin, multiple ECMO circuit changes due to blood product consumption and coagulopathy, and pneumothoraces requiring thoracostomy tube placements. Approximately 1.5 months into her ECMO course, she suffered acute hypoxemia and echocardiography revealed indirect evidence of pulmonary hypertension with right heart failure. Initial right heart catheterization while on V-V ECMO revealed elevated right ventricular end-diastolic pressure (RVEDP=15-20 mmHg) and severe systemic desaturation with main pulmonary artery (MPA) pressure of 30 mmHg. Pulmonary hypertension and right heart support was initiated in the form of inhaled nitric oxide (iNO), inotropes, phosphodiesterase inhibitors, nitrates, angiotensin-converting enzyme inhibitors, and diuresis. Ultimately, due to necessity of right-heart decompression and support, on ECMO day 86 she was transitioned to single-site V-V ECMO utilizing a 31 Fr dual-lumen venovenous cannula (ProtekDuo (LivaNova, UK)) placed via her RIJ through her right atrium (RA) into the MPA in the cardiac catheterization laboratory. Subsequent heart catheterization more than 2 months later revealed severe right ventricular (RV) diastolic dysfunction (RVEDP=35 mmHg) and moderate left ventricular (LV) diastolic dysfunction (pulmonary capillary wedge pressure (PCWP=24 mmHg)). During her course, multiple trials off ECMO were attempted with varying lengths of time off ECMO support, but ultimately required ongoing ECMO support. She developed evidence of end-organ dysfunction from her cor pulmonale, including oliguric renal failure requiring renal replacement therapy (RRT), hepatic injury with elevated transaminases and hyperammonemia leading to depressed mental state, feeding intolerance, and coagulopathy. Additionally, due to long-term nasogastric enteral tube placement for caloric supplementation and enteral medication administration, she developed concerns for invasive sinusitis with erosion into ethmoid and maxillary sinuses. As she was an adult patient being cared for in a free-standing academic children's hospital, multiple adult medicine consultants were involved in her care. Specifically, adult nephrology, cardiology, cardiothoracic surgery (for ProtekDuo cannula placement), and gastroenterology/ hepatology were integral into her care, along with our pediatric critical care medicine and ECMO teams. Notably, this was the first patient supported on ECMO to receive tracheostomy, RA-MPA dual-lumen VV cannula, and full autonomous mobility outside of the ICU at our well-established ECMO program, which has served as the index patient leading to future advances in the care of our ECMO patients. Over time and with multiple therapies to alleviate her cor pulmonale, the patient's echocardiograms evealed improved, half-systemic right-sided cardiac pressures. She was ultimately decannulated from ECMO at our center before being transferred back to the referring adult facility, and discharged to home 8 months after her initial presentation with acute respiratory failure.