ABSTRACT
We report a case of a 22-year-old female with antiphospholipid antibody (APLA) syndrome who presented with severe dyspnea. Diagnostic imaging confirmed pulmonary embolism (PE), and treatment comprised unfractionated heparin and apixaban. APLA syndrome was diagnosed based on clinical, serological, and radiological findings. During evaluation, the patient developed cardiogenic shock necessitating catheter-directed thrombolysis, followed by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) due to deteriorating condition and suspected heparin-induced thrombocytopenia (HIT). Surgical embolectomy with bivalirudin use followed, and a hybrid veno-arterial-venous (VAV) ECMO setup was implemented. Postoperatively, the patient improved, transitioning to veno-venous (VV) ECMO and eventually ECMO withdrawal. ECMO is a valuable tool for managing complex cardiorespiratory cases like PE. In the context of HIT and APLA syndrome, prompt anticoagulant transition is vital, and bivalirudin is an effective heparin alternative. Our study highlights the challenges involved in managing patients needing ECMO support with immunothrombotic conditions like HIT and APLA syndrome.
ABSTRACT
Ganglioneuroma is a benign, slow-growing neurogenic tumor arising from neural crest cells. It is extremely rare (1/1,000,000) and is located most commonly in the posterior mediastinum (41.5%), retroperitoneum (37.5%), and adrenal glands (21%). We present a case of a 62-year-old lady who had complaints of shortness of breath on exertion and dyspnea for the past 3 months. She had no other significant history. Computerised tomography (CT) scan of the thorax suggested left-sided loculated subpulmonic pleural effusion, 14 × 12 cm in dimension. She underwent assisted video-assisted thoracoscopic surgery (VATS) exploration of the thorax with debridement and drainage of subpulmonic collection that was abutting the diaphragm, along with release of trapped lung. Histopathological examination showed multiple ruptured cystic masses with nodules; microscopical evidences of Schwann cells, ganglion cells, and spindle cells-all these along with immunohistochemistry-revealed features consistent with ganglioneuroma. Postoperative recovery was uneventful, and the patient did not have any complaints or other limitations to daily life activities at 6 months' follow-up. Ganglioneuroma is essentially benign in nature, asymptomatic, and rare. A systematic review of the literature has shown that giant-sized ganglioneuromas (size more than 10 cm) have rarely been reported. Surgical excision and clearance is the treatment modality of choice. In our case, due to large size and difficulty in access and mobilisation of the mass adherent to the diaphragm, assisted VATS had to be performed. We increased the size of the utility port from 5 to 10 cm and used a rib retractor for better surgical negotiation. This could have been more challenging, as there have been incidences where ganglioneuromas have extended both into the thoracic and abdominal cavities and even involved vital organs and vessels. Regular follow-up is essential, as late recurrence and slow progression potential is a known complication.
ABSTRACT
We report a unique intraoperative finding of an additional double left atrial appendage (LAA) during an arterial switch operation with ventricular septal defect closure in a 4-month-old girl. Immediately after the procedure, a prolapsing mass within the left atrium (LA) on the transesophageal echocardiogram raised concerns of a possible thrombus. The LAA was clearly visible with a pressure monitoring line which was put intraoperatively. To investigate further, cardiopulmonary bypass was resumed, and the heart was arrested and explored. There was an appendage-like structure, separate from the one that had the pressure monitoring line, which was inverted inside. It was pulled out from outside clearly establishing a double LAA. This report illustrates an example of a diagnostic dilemma caused by a double atrial appendage which was invaginated into LA masquerading as a mass or thrombus.
