PERICARDITIS EVOLVING INTO CARDIAC TAMPONADE IN A 76-YEAR-OLD PATIENT WITH COVID-19

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Cardiac tamponade is a medical emergency that requires rapid diagnosis and intervention to prevent hemodynamic collapse. Although COVID-19 typically manifests with pulmonary symptoms, cardiac involvement is becoming better studied through increasingly frequently reported cases [1]. We present a case of COVID-19 cardiac involvement presenting as a rapidly progressive pericardial effusion turning into tamponade. This highlights the importance of a high index of suspicion for patients who develop sudden and atypical respiratory compromise with hypotension in the setting of COVID-19 infection. CASE PRESENTATION: A 76-year-old male with a history of ESRD presented with fatigue after missing hemodialysis. Laboratory investigations revealed a mild troponin elevation and positive SARS-CoV-2 PCR. Initial TTE demonstrated an EF of 60-65% with a small pericardial effusion and thickened calcified pericardium. After a few days, the patient was noted to be encephalopathic and hypotensive. Labs revealed leukocytosis, lactic acidosis as well as an elevated troponin and D-dimer. Chest CTA was significant for a large pericardial effusion with reduced size of the right ventricle, concerning for cardiac tamponade. Repeat TTE had a moderate pericardial effusion and right atrial collapse, consistent with tamponade. Given significantly elevated INR in the setting of anticoagulation, pericardiocentesis was deferred while the patient was transfused FFP. The patient subsequently suffered PEA arrest and expired despite attempted hemodynamic stabilization. DISCUSSION: Cardiac tamponade is a result of accumulating pericardial fluid culminating in decreased cardiac output and shock. Clinicians should be prompted by characteristic findings, including Beck’s triad (JVD, hypotension, and muffled heart sounds) and Kussmaul’s sign of paradoxically elevated JVP with inspiration [2]. However, the diagnosis of tamponade based solely on clinical finding is difficult and may lead to unnecessary intervention [3]. Ultimately, a diagnosis of tamponade requires both hemodynamic instability and pericardial effusion. Echocardiography, including TTE and POCUS, plays a central role in the identification of cardiac tamponade. While it is essential to note the presence of a pericardial effusion, it is important to be familiar with core echocardiographic signs of tamponade: systolic RA collapse (earliest sign), diastolic RV collapse, IVC with minimal respiratory variation, and exaggerated respiratory cycle changes in MV and TV in-flow velocities (a surrogate for pulsus paradoxus) [3]. CONCLUSIONS: Despite the classic association between COVID-19 and pulmonary manifestation, pericardial involvement has been noted in 20% of COVID-19 patients. It is therefore imperative to maintain a high index of suspicion and familiarity of characteristic echocardiogram findings of tamponade to prompt intervention and curtail cardiac hemodynamic collapse. Reference #1: Lala A, Johnson KW, Januzzi JL, et al. Prevalence and Impact of Myocardial Injury in Patients Hospitalized With COVID-19 Infection. J Am Coll Cardiol. 2020;76(5):533-546. doi:10.1016/j.jacc.2020.06.007 Reference #2: Stashko E, Meer JM. Cardiac Tamponade. [Updated 2021 Dec 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431090/ Reference #3: Alerhand S, Carter JM. What echocardiographic findings suggest a pericardial effusion is causing tamponade?. Am J Emerg Med. 2019;37(2):321-326. doi:10.1016/j.ajem.2018.11.004 DISCLOSURES: No relevant relationships by Christopher Allahverdian No relevant relationships by John Javien No relevant relationships by Vishal Patel No relevant relationships by Sarah Youkhana

CARDIAC TAMPONADE AS A DEADLY COMPLICATION OF TENSION PNEUMOPERICARDIUM: A CASE REPORT

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pneumopericardium is the presence of air or gas in the pericardial space, usually secondary to blunt or penetrating trauma. Most pneumopericardium are non-tension. The use of positive pressure ventilation (PPV) increases the chances of developing a tension pneumopericardium. We report the case of a 22-year-old male patient admitted for COVID-19 pneumonia who developed pneumopericardium with cardiac tamponade features. CASE PRESENTATION: A 22-year-old male was admitted for acute respiratory distress syndrome due to COVID-19 pneumonia and required intubation on hospital day 10. The next day, he became febrile with new leukocytosis. A chest x-ray showed new extensive pneumomediastinum and pneumopericardium. Vasopressor support and broad-spectrum antibiotics were started for septic shock, however he continued to decompensate rapidly, requiring maximal medical support. His arterial line waveform showed pulsus paradoxus, leading to concern for underlying tension pneumopericardium. Bedside echo was unrevealing as imaging was obstructed by the air in pericardial sac. The patient was too unstable for a CT scan of the chest. After extensive discussion with his family, he was placed on palliative measures only and expired. DISCUSSION: Pneumopericardium is due to an abnormal connection between the pericardial space and a source of air or gas. Levin and Macklin describe three main mechanisms by which this connection can be made. The first: acute rises in alveolar pressure and volume or ventilator associated lung injury leading to rupture of alveoli with gas tracking along perivascular and peri bronchial sheaths to the mediastinum. The second: macro-perforation of the pericardial space leading to communication with respiratory or gastrointestinal tracts. Third: existence of a pneumothorax in the presence of traumatic pericardial tear or congenital pleuro-pericardial connection. Spontaneous pneumopericardium without any anatomic connection is rare and is due to a direct extension of infectious etiologies of the lungs or by an infection of the pericardial space with gas forming bacteria. A tension pneumopericardium causing cardiac tamponade can develop from pneumopericardium with PPV where the pericardial sac acts as a shutter valve letting air in but not out as has been reported sparingly in the literature. Cummings et al described 93 patients who developed tamponade out of 252 patients with pneumopericardium. Our patient possibly developed a pleuro-pericardial tract secondary to his pneumonia. With continued PPV his simple pneumopericardium likely developed into a tension pneumopericardium evidenced by arterial waveforms consistent with pulsus paradoxus, worsening hypotension despite maximal vasopressor support and development of ventricular tachycardia. CONCLUSIONS: Our case highlights the importance of considering pneumopericardium causing cardiac tamponade in the setting of mechanical ventilation. Reference #1: Mindaye ET, Arayia A, Tufa TH, Bekele M. Iatrogenic pneumopericardium after tube thoracostomy: A case report. Vol. 76, International journal of surgery case reports. 2020. p. 259–62. Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984 Jun;37(6):511–8. Reference #3: Levin AI, Visser F, Mattheyse F, Coetzee A. Tension pneumopericardium during positive-pressure ventilation leading to cardiac arrest. J Cardiothorac Vasc Anesth. 2008 Dec;22(6):879–82. MACKLIN CC. TRANSPORT OF AIR ALONG SHEATHS OF PULMONIC BLOOD VESSELS FROM ALVEOLI TO MEDIASTINUM: CLINICAL IMPLICATIONS. Arch Intern Med [Internet]. 1939 Nov 1;64(5):913–26. Available from: https://doi.org/10.1001/archinte.1939.00190050019003 DISCLOSURES: No relevant relationships by Aarti Mittal No relevant relationships by Beenish Naqvi

To drain, or not to drain: Diagnostic and therapeutic challenges associated with cardiac tamponade in Right heart sided heart failure and pulmonary hypertension

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.

Paradoxical thinking and entrepreneurial resilience: a study against the backdrop of COVID-19 disruption

Entrepreneurial resilience' acquires seminal significance especially during a crisis situation. With COVID-19 pandemic rendering unprecedented disruption over the worldwide socio-economic landscape, entrepreneurs and business managers necessitate resilience for mitigating various emerging challenges. Modem enterprises often face competing demands and contradictory expectations from its diverse stakeholder groups. Entrepreneur's ability to relentlessly acclimatise and thrive particularly during adversities, while balancing competing needs is a crucial characteristic that bolsters organisational performance. This investigation examines the potential relation between stakeholder engagement, paradoxical thinking/paradox mind-set and entrepreneurial resilience. The entrepreneurs' propensity to integrate conflicting organisational and normative obligations is likely to improve her/his resilience. Contemporary organisations innately embody many contradictory tensions. Paradoxical thinking embraces these tensions and may also help the entrepreneurs to respond with enhanced resilience. This quantitative study involving social entrepreneurs in India against the backdrop of COVID-19 pandemic indicates that stakeholder engagement is positively associated with resilience. This relation is mediated by the entrepreneur's paradoxical mind-set.

Living with tensions in the workplace: a grounded theory of paradoxical leadership in cultivating subordinates' paradox mindset

Purpose>The purpose of this paper is to investigate the process of how paradoxical leadership cultivates subordinates' paradox mindset.Design/methodology/approach>This study used the grounded theory approach. Data collection included semi-structured interviews and observations from eleven top managers and their six subordinates in five Chinese organizations. Managers and their subordinates were asked how they perceived and dealt with tensions in the workplace.Findings>Paradoxical leadership promotes subordinates' paradox mindset by helping them learn to face, cope, and live with tensions. First, paradoxical leaders acted as role models for their subordinates and directly influenced followers' attitudes, motivation, and positive psychological states towards tensions. Moreover, when managers help their subordinates reduce stress and anxiety and build confidence, followers learn to cope with tensions. Consequently, subordinates' capacity to live with tensions is increased and they develop the paradox mindset.Practical implications>The results imply that reducing subordinates' stress and anxiety and building their confidence can be integrated into work practices and training, which provide insights for managers to cultivate their subordinates' paradox mindset.Originality/value>This paper investigates how paradoxical leadership impacts and cultivates subordinates' paradox mindset in a tension-setting work environment. The findings not only provide fresh insights into the detailed process of developing employees' paradox mindset but also deepen the understanding of the leader–follower relationship.

Post-COVID-19 paradoxical vocal cord movement and dysfunctional dysphonia: A clinical case.

Introduction: Post-COVID persistent dyspnea linked to a paradoxical vocal fold movement has rarely been described, and it has never been described as associated with dysfunctional dysphonia. Case study: We present a case of a 46-year-old patient with severe COVID-19 history who presented to our hospital for persistent cough, dysphonia, and intermittent episodes of dyspnea, getting worse when speaking. A chest computed tomography (CT) scan done was normal. The patient was treated by empiric bronchodilators with inhaled corticosteroids but without any improvement. A bronchoscopy was done and revealed spontaneous paradoxical vocal fold movement and dysfunctional dysphonia. The patient was referred to a speech therapist, and her problem was resolved. Conclusion: Resistant dyspnea to empiric treatment, after COVID-19, should suggest the diagnosis of paradoxical vocal fold movement. Laryngoscopy should be done to confirm the diagnosis, and the patient should be referred to a speech therapist.

The paradoxes of just-in-time system: an abductive analysis of a public food manufacturing and exporting company in Thailand: MRN

Purpose>study aims to investigate the implementation and impact of a just-in-time (JIT) system in a food manufacturing and exporting company in Thailand.Design/methodology/approach>At the company, the authors used an anomaly case study. The authors performed content analysis on the data collected through semi-structured interviews and direct observations to determine operational flows through customer order, production and delivery. The authors constructed a framework that helped in mapping current operations and subsequently assessing JIT’s impacts;the authors reported the best practices to the company’s owner. Based on the follow-up after a year, the authors used an abductive approach to refine the JIT theory using data from case organizations and relevant studies.Findings>The company encountered errors and delays in international delivery owing to inadequate inputs resulting from uncertain agricultural production, delayed contact with freight forwarders, improper documentation and insufficient staffing. Besides the highly centralized system, the limitations of the JIT philosophy contributed to the issues, thereby increasing mental and physical health problems and turnover rate. Owing to these paradoxical effects, the authors extended the JIT theory. Of the study’s several recommendations, the company observed only the following: contacting the freight forwarder after the purchase order confirmation, not production completion. The authors observed increased customer satisfaction, despite the additional cost of booking containers early.Originality/value>This research presents a balanced JIT that can minimize JIT’s impacts and resource shortage, owing to demand-supply uncertainties and sustain competitiveness.

The wandering bullet: An unusual case of paradoxical embolization involving the neck, aortic arch, and iliac artery

Paradoxical intravascular bullet embolism involving the aortic arch (AA) is a rare and highly lethal condition. We describe an unusual case of a civilian gunshot injury to the neck. A bullet entered in the neck, injured the internal jugular vein (IJV), and then continued into the lumen of the common carotid artery (CCA). The bullet traveled under its own momentum and against the flow of blood, along the carotid and brachiocephalic vessels, finally lodging in the wall of the lesser curvature of the AA. The injury tract resulted in an arterial-venous fistula between IJV and CCA and a pseudoaneurysm of the AA. Open surgical repair of the neck and AA was complicated by secondary distal embolization of the bullet, requiring an embolectomy.

The Life of a Myxoma—Transoesophageal Images of the Progressive Growth of a Myxoma Over a 19-month Period

Introduction: A paucity in data exists regarding the expected growth rate of myxomas given the prompt transition to surgical intervention on initial discovery. Most case reports describe an initial normal echocardiogram compared with a subsequent echocardiogram revealing a myxoma at the time of diagnosis [1-3]. Uniquely, our case follows the sequential monitored growth of an atrial myxoma with transoesophageal images over a 19-month period. Case: This case describes a 71-year-old woman with a history of hypertension and hypercholesterolaemia admitted with a provoked deep vein thrombosis. This was complicated by bilateral pulmonary emboli and a presumed paradoxical embolus through a patent foramen ovale (PFO) resulting in a middle cerebral artery stroke. She was thrombolysed, then managed with rivaroxaban. During PFO closure, intraoperative transoesophageal echocardiogram (TOE) revealed a new left-sided atrial mass 1.0cm x 0.6cm in size, resulting in procedure abandonment. Uncertainty around diagnosis in addition to delays related to the COVID-19 pandemic led to serial imaging. The mass was monitored via TOE at 5, 11 and 19 months, revealing an initially stable then unexpected rapid progression to a size of 3.6cm x 2.9cm in the final 8 months. The patient had prompt excision of her myxoma and patch closure of interatrial septum. Discussion: This case exhibits a rare opportunity to appreciate the visual progression of an atrial myxoma and the unpredictable rapid growth over an 8-month period, highlighting the importance of interval monitoring of undifferentiated atrial lesions. [Formula presented]

Dorsal Push and Abdominal Binding Improve Respiratory Compliance and Driving Pressure in Proned Coronavirus Disease 2019 Acute Respiratory Distress Syndrome.

We describe seven proned patients with coronavirus disease 2019-related acute respiratory distress syndrome in whom a paradoxical decrease in driving pressure reversibly occurred during passive, volume-controlled ventilation when compressing the lower back by a sustained "dorsal push." We offer a potential explanation for these unexpected observations and suggest the possible importance of eliciting this response for lung-protective ventilation of similar patients. DESIGN/SETTING: Case series at a single teaching hospital affiliated with the University of Minnesota. Measurements were recorded from continuously monitored airway pressure and flow data. PATIENTS: Nonconsecutive and nonrandomized sample of coronavirus disease 2019 acute respiratory distress syndrome patients who were already prone and paralyzed for optimized lung protective clinical management while inhaling pure oxygen. INTERVENTIONS: Sustained, firm manual pressure applied over the lower back in all patients, followed by abdominal binding in a subset of these. MEASUREMENTS AND MAIN RESULTS: Respiratory system driving pressure declined and respiratory system compliance improved in seven patients with the dorsal push maneuver. In a subset of four of these, abdominal binding sustained those improvements over >3 hours. CONCLUSIONS: Sustained compressive force applied to the dorsum of the passive and prone patient with severe respiratory failure due to coronavirus disease pneumonia may elicit a paradoxical response characterized by improved compliance and for a given tidal volume, lower plateau, and driving pressures. Such findings, which suggest end-tidal overinflation within the aerated part of the diseased lung despite the already compressed anterior chest wall of prone positioning, complement and extend those observations recently described for the supine position in coronavirus disease 2019 acute respiratory distress syndrome.

Medical treatment for paradoxical and saddle pulmonary embolism in a young man with patent foramen ovale and coronavirus disease 2019.

Here, we reported a 32-year-old male presenting to the emergency department with respiratory symptoms and coronavirus disease 2019 (COVID-19) diagnosis. Multiple thrombi were detected in his heart and inferior vena cava, probably due to former deep-vein thrombosis. The presence of patent foramen ovale and high pressure of the right heart caused the clots to enter the heart's left side. He received fibrinolytics, and his condition improved with no need for surgery. Hence, patients with impending paradoxical embolism may take advantage of medical treatment, such as fibrinolytics. Moreover, COVID-19 appears to be associated with a strong thrombotic tendency, and anticoagulants might be helpful.

BASCULE syndrome in a child with prior asymptomatic COVID-19 infection.

BASCULE syndrome, characterized by Bier anemic spots, cyanosis, and an urticaria-like eruption, has been described as a benign vasomotor dermatosis that occurs in the setting of transient tissue hypoxia. It has been postulated that dermal ischemia triggers an exaggerated vasoconstrictive arteriolar reaction, which then causes a paradoxical urticarial rash by an unknown mechanism. In patients with COVID-19, there is evidence of angiocentric inflammation leading to vasoconstriction, endothelial damage, and thrombosis. We present a case of acute-onset BASCULE syndrome appearing after asymptomatic infection with COVID-19. BASCULE syndrome should be considered in the expanding spectrum of dermatologic manifestations associated with COVID-19.

Paradoxical Embolism Causing Myocardial Infarction in a COVID-19 Patient Presenting With Pulmonary Embolism.

The presence of myocardial injury in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection is common. The cardiac complications of SARS-CoV2 infection are varied and distinguishing between them can be complicated.  A 55-year-old man with recent diagnosis of SARS-CoV2 infection presented with chest pain, syncope, and was found to have saddle pulmonary embolism (PE). Marked elevation in cardiac enzymes prompted a coronary angiogram which was normal. Cardiac MRI revealed late gadolinium enhancement (LGE) in the anterolateral wall consistent with myocardial infarction (MI). He was diagnosed with paradoxical embolism causing MI. The differential for elevated cardiac enzymes is wide in patients with SARS-CoV2 infection. This case illustrates that sometimes multiple diagnoses exist, and that a high index of suspicion is required to continue work-up.

The Paradoxical Effects of COVID-19 in Italian Systemic Practice: Clinical and Teaching 'Insights'.

The COVID-19 pandemic has impacted the personal and professional lives of all of us and has laid the bases for a social and cultural change. This article is written as a reflection on the paradoxical effects of the 'viral phenomenon.' We wish to highlight the opportunities and changes that have arisen from the emergency situation, especially through the use of the online setting, both in the clinical work and training activities of systemic therapists. This article is not intended to be a panegyric on the merits of digital sessions, but an appraisal, also through clinical examples, of the contributions that technology may give to our practices. We do not consider technology as a substitute, but as an integration and enrichment of the therapist's and trainer's tools. This tough experience may be transformed into an opportunity for learning new techniques and practices in which the screen becomes a useful support.

COVID-19 and human papillomavirus: Paradoxical immunity.

Coronavirus disease 2019 (COVID-19) is a multisystemic disease that can cause progressive lung failure, organ dysfunction, and coagulation disorder associated with high mortality and morbidity. COVID-19 is known to either primarily cause skin symptoms or increase existing skin diseases. Human papillomavirus (HPV) is a DNA virus that can cause benign and malignant neoplasms. Mucocutaneous verruca vulgaris are common benign lesions of HPV. Here, we report a case of verruca vulgaris regressed after COVID-19.