Pulmonary Embolism in Donor Lungs-Incidence and Management.

In efforts to decrease the mortality on the waiting list for lung transplantation, alternatives to increase the donor pool have been explored. Caution must be used when accepting donor lungs with pulmonary embolism (PE), as prior evidence has shown mixed results after transplantation of donor lungs with PE. However, the mere diagnosis of PE on imaging should not be the sole reason for the exclusion of these donors for transplant, and they should be reviewed as any other donor. A comprehensive evaluation should be performed for every donor, with a special focus on abnormalities of gas exchange and gross pathologic characteristics during procurement.

Pulmonary Embolism Following Lung Transplantation: Prevention and Management.

Thromboembolic events are the third leading cardiovascular diagnosis following stroke and myocardial infarction. In the United States, 300,000 to 600,000 people per year are diagnosed with venous thromboembolism, either deep venous thrombosis or pulmonary embolism (PE). Of those patients, thousands die from PE despite heightened vigilance and improved therapies. Lung transplant recipients are at increased risk of developing PE due to multiple risk factors unique to this population. Additionally, the transplant recipients are more susceptible to morbid complications from PE. As a result, prevention, timely recognition, and intervention of PE in the lung transplant population are of the utmost importance.

Point-of-Care Ultrasound With Artificial Intelligence-Driven Diagnostics in Giant Cell Arteritis: Blindness Prevention on a Global Scale.

Giant cell arteritis (GCA) is the most common autoimmune systemic vasculitis of older adults.1 Typically, it affects individuals 50 years and older, and more women than men. The lifetime risk of GCA for women is 1% and 0.5% for men.

Caught in the Act: A Recurrent Tamponade After Coronary Artery Bypass Grafting With Culprit Lesion Identified on Computed Tomography Angiogram.

Delayed cardiac tamponade after cardiac surgery is a rare complication with significant diagnostic challenges. The recurrence of cardiac tamponade physiology after initial intervention creates another degree of difficulty in the management of already medically complex patients. We present the case of a 65-year-old male who underwent four-vessel coronary artery bypass grafting that was complicated by the delayed presentation of cardiac tamponade requiring mediastinal exploration. Following this he developed a recurrence of cardiac tamponade with bleeding from a vein graft identified on multiphase spiral computed tomography angiography.

Right Coronary Artery Button Pseudoaneurysm After the Modified Bentall Procedure.

Anastomoses of the coronary buttons are the Achilles' heel of the modified Bentall procedure (MBP) for the repair of the aortic root and ascending aorta. We present a rare case of post-MBP right coronary artery button pseudoaneurysm in a 30-year-old man. The contained leak, attributed to a pseudoknot in the polypropylene suture, was visualized via computed tomography angiography and transesophageal echocardiogram and repaired under deep hypothermic circulatory arrest.

The value of COPE therapy in the perioperative care of heart failure patients receiving left ventricular assist device implantation.

Purpose: This pilot study implemented Creating Opportunities for Personal Empowerment (COPE), a cognitive behavioral therapy (CBT) intervention, in the perioperative care of patients with advanced heart failure awaiting left ventricular assist device (LVAD) implantation. Methods: Using a quasi-experimental study design, the patients were screened for anxiety and depression using the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) screening tools. If patients scored 5 or greater on either tool, they received COPE. Patients were re-evaluated following intervention. Results: Average scores for depression and anxiety symptoms pre-intervention were 10.6 and 10.2, respectively. Post intervention, scores decreased to an average of 5.4 and 3.2, respectively. Qualitative data suggests that they felt the intervention was helpful. Conclusion: Results show that it is possible to implement a multi-session CBT intervention in this population. The improvements in the severity of depression and anxiety symptoms in the five participants with LVAD is interesting and needs to be verified in a study with a larger sample size. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01493-9.

Bilateral Lung Transplantation in Kartagener's Syndrome and Situs Inversus.

Kartagener's syndrome (KS) is a genetic disorder and a subgroup of primary ciliary dyskinesia characterized by situs inversus, chronic sinusitis and bronchiectasis. Patients with KS can develop severe bronchiectasis with end-stage lung disease due to recurrent pulmonary infections. Lung transplantation is a treatment option with good outcomes reported in the literature. Lung transplantation in such patients can be technically challenging given the dextrocardia, bronchial asymmetry and anatomical variation of major vascular structures due to situs inversus. We present a case of a 45-year-old male with KS complicated by recurrent infections and chronic respiratory failure, who successfully underwent a bilateral sequential lung transplant (BSLTx). Because of repeated infections and severe bronchiectasis, the patient's quality of life was impaired, and he was oxygen dependent. As a definitive treatment, successful lung transplantation led to a reversal of hypoxic respiratory failure and the patient's symptoms markedly improved, reinforcing data in the literature to consider lung transplantation in this patient population.

Diffuse Coronary Vasospasm After Mitral Valve Replacement, Maze Procedure, and Tricuspid Valve Repair.

Coronary vasospasm is a known complication after coronary artery bypass grafting surgery but has rarely been described in non-coronary cardiac operations. We report the case of a 51-year-old male with nonischemic cardiomyopathy and paroxysmal atrial fibrillation. He presented with severe mitral and tricuspid regurgitation and was taken for mitral valve replacement, tricuspid valve repair, and Maze procedure. Postoperative emergent coronary angiography demonstrated diffuse coronary vasospasm. Injection of intracoronary nitroglycerin led to clinical and angiographic improvement. This demonstrates the possibility of coronary vasospasm following mitral valve replacement and effective treatment with intracoronary administration of vasodilating agents.

Double Valve Replacement in a Patient With Hunter Syndrome.

Hunter syndrome is a rare disorder in which affected patients have significant airway abnormalities (macroglossia, small mouth opening, and supraglottic narrowing) that complicate their management. Deposition of glycosaminoglycans in the heart leads to cardiomyopathy, and cardiac valve dysplasia that can lead to valvular stenosis or regurgitation or both, necessitating valve replacement. Management of patients with Hunter syndrome is complex and needs a multidisciplinary team approach. Mechanical valve replacement is a suitable treatment option.

Giant ventral hernia following left ventricular assist device bridge to heart transplantation.

Ventral hernias following left ventricular assist device (LVAD) placement are rare. With the improvement in technology, and miniaturization of devices associated with intrapericardial placement, these complications have largely been abolished. The mere presence of a large ventral hernia should not exclude recipients from being candidates for orthotopic heart transplantation.

Extracorporeal Membrane Oxygenation to Facilitate Chemotherapy-Moving the Goalposts!

Extracorporeal membrane oxygenation (ECMO) is a lifesaving intervention in critically ill patients with cardiorespiratory failure. ECMO in patients with cancer is generally contraindicated not only to conserve precious resources and properly direct use but also due to a multitude of associated physiological derangements in these subsets of patients. ECMO in patients with disseminated cancer is an automatic rule-out except for anecdotal reports. Despite this, select patients with metastatic chemotherapy-sensitive cancer may benefit from ECMO as a bridge to therapy. In this report, we describe the use of veno-arterial-venous ECMO (VAV-ECMO) as a bridge to facilitate chemotherapy in a patient with cardiorespiratory failure secondary to a chemotherapy-sensitive metastatic non-seminomatous germ cell tumor.

Classification and Stratification of Pulmonary Embolisms.

Pulmonary embolism remains a leading cause of cardiovascular mortality. Presentation and outcomes are variable among patients and require rapid risk stratification for assessment and prognosis, as well as selection of appropriate treatment. Over the past several decades, several different models and parameters have become available to assess risk and classify pulmonary embolism into different risk categories. Some patients may be candidates for early discharge or complete outpatient treatment, while some may require invasive diagnostics and intensive monitoring. In this review, we summarize contemporary guidelines and methods for classification and risk stratification in an effort to provide tools for physicians to use in their management of patients with acute pulmonary embolisms.

Acute Massive and Submassive Pulmonary Embolism: Historical Considerations/Surgical Techniques of Pulmonary Embolectomy/Novel Applications in Donor Lungs with Pulmonary Emboli.

Pulmonary embolectomy has a chequered history but the quest to surgically treat a patient diagnosed with pulmonary embolism effectively spurred the development of cardiopulmonary bypass and a new dawn for cardiac surgery. The advent of cardiopulmonary bypass, extracorporeal membrane oxygenation, and computed tomography pulmonary angiogram has allowed rapid diagnosis and made surgical pulmonary embolectomy a relatively safe procedure that should be considered when indicated. Pulmonary emboli in donor lungs, often get rejected for transplantation. Ex vivo lung perfusion is among newly available technology with the ability to not only recondition marginal lungs but also treat donor lung pulmonary embolisms, effectively increasing the donor pool.

Management of Thoracic and Cardiac Trauma: A Case Series and Literature Review.

Patients with cardiac and thoracic trauma remain one of the most difficult presentations to diagnose and treat in an emergency room setting. Here, we present our series of four cases of cardiac and thoracic trauma with varied presentations, including lung, vascular, and diaphragmatic injuries that were managed successfully. We further review the manifestations of cardiac trauma, including cardiac contusions, cardiac rupture, pericardial injury, and valvular injuries; thoracic trauma, including lung and diaphragmatic injury. The sheer complexity of the anatomical structures within the thorax makes it of the utmost importance to timely and appropriately manage them.

Caught in a vice.

Esophageal dysmotility and dysphagia are well known in patients with scleroderma. Interstitial lung disease (ILD) in these patients is an indication for lung transplantation but is considered high risk in many centers. This report is an attempt to highlight how anatomical causes can contribute to dysphagia in such patients and complicate the post-operative course after lung transplantation. Such a finding is uncommon in this subset of patients and use of suitable imaging can help in arriving at the diagnosis. We present a patient following lung transplantation for scleroderma related ILD with an aberrant right subclavian artery compressing the esophagus in a vice like grip. Imaging is the key to prompt diagnosis and management.

Hyperammonemia in lung transplant patients and its management: a review.

Objective: To synthesize the evidence for incidence, pathophysiology, etiology, and protocol-based management of hyperammonemia in lung transplant patients. Background: Elevated ammonia levels are toxic to the brain, and hyperammonemia results in a potentially fatal complication for lung transplant recipients. The hallmark of this condition is ammonia production being way out of proportion to the degree of liver derangement. While there are many hypotheses, the cause remains obscure. Methods: A retrospective review of patients with hyperammonemia following lung transplantation was done to understand the pathophysiology, various treatment modalities, and its impact on patient mortality and morbidity. Studies in the English literature were identified through an electronic database search from PubMed/MEDLINE, Ovid Embase, Google Scholar, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, Web of Science, and ClinicalTrials.gov until June 2020. No restriction of dates were used, and the search was up until June 2020. Discussion: Mortality among patients with hyperammonemia following lung transplantation is high. Multi-modal treatment approaches include avoiding nephrotoxic drugs, use of bowel decontamination, nitrogen scavengers, branched-chain amino acids, adjustment of immunosuppression, antibiotics like fluoroquinolones or azithromycin, and renal replacement therapy. However, there remains a scarcity of preoperative screening protocol for patients at risk of hyperammonemia as well evidence-based post-operative management guidelines. Intermittent hemodialysis, compared to continuous venovenous hemodialysis, provides better patient outcomes. Conclusion: Early detection of patients at risk by appropriate screening, along with maintaining a high degree of suspicion for hyperammonemia and multi-modal treatment approach, is the key to successful patient outcomes. Further prospective observational studies would facilitate development of protocol-based treatment of this potentially fatal condition.