A Rare Case of Bronchomediastinal Pulmonary Vein Fistula due to Fibrosing Mediastinitis.

Fibrosing mediastinitis (FM) is a rare condition with extensive proliferation of fibrous tissue in the mediastinum usually happens few years after Histoplasma infection. FM usually occurs years later after presentation of Histoplasma infection, and usually what makes patients seek medical attention are symptoms from compression and occlusion of vital mediastinal structures, such as the central airways, superior vena cava, pulmonary arteries, and veins. Rarely, heart, pericardium, coronaries, and aorta are involved. We report a case of 39-year-old-male who was admitted with fever and cough. The patient's condition worsened despite being on broad-spectrum antibiotics, with worsening encephalopathy and a new onset lower extremity weakness. Brain imaging showed multiple strokes suggestive of embolic event. CT chest/abdomen was suggestive of FM along with cavitary lung nodules and pneumomediastinum. Splenic and renal infarcts were also noted. Infective endocarditis was one of the top differential diagnosis due to multiple embolic infarcts, and hence a transesophageal echocardiography (TEE) was pursued. TEE showed a mass along with air bubbles entering the left atrium from the pulmonary vein. On re-evaluation of CT chest images, a fistula was seen extending from the mediastinum to the left main bronchus and the left upper pulmonary vein. This supported the diagnosis of FM with erosion of lymph node into the left main bronchus and left upper pulmonary artery, leading to fistula formation and subsequent systemic air embolization. The diagnosis of FM requires a multimodality approach, high clinical suspicion, and accurate history taking. Treatment mainly aims at managing the mechanical complications.

Strain rate echocardiography uncovers subclinical left ventricular dysfunction in cystic fibrosis.

BACKGROUND: CFTR is expressed in cardiac myocytes. In mice, lack of CFTR alters cardiomyocyte contraction and Ca2+ signaling, and decreases cardiac reserve. We undertook a pilot study evaluating left ventricular (LV) function in CF patients using strain and strain rate echocardiography. METHODS: Echocardiography with tissue Doppler and strain and strain rate imaging were performed in 8 CF adults following pulmonary function tests. Results were compared to literature values obtained in healthy subjects. RESULTS: All CF individuals had normal LV ejection fractions. In contrast, 50% of men and 100% of women with CF had decreased LV systolic strain. Strain rates were significantly decreased in 100% of CF individuals. RV function was normal and LV function did not correlate with lung function. CONCLUSIONS: Strain and strain rate echocardiography identified LV systolic abnormalities in CF individuals not detected by conventional echocardiography. We propose that this echocardiography modality may identify subclinical cardiac dysfunction in CF.

Correlation of echo-Doppler aortic valve regurgitation index with angiographic aortic regurgitation severity.

We assessed aortic regurgitation (AR) severity by utilizing multiple echo-Doppler variables in comparison with AR severity by aortic root angiography. Patients were divided into 3 groups: mild, moderate, and severe. An AR index (ARI) was developed, comprising 5 echocardiographic parameters: ratio of color AR jet height to left ventricular outlet flow diameter, AR signal density from continuous-wave Doppler, pressure half-time, left ventricular end-diastolic diameter, and aortic root diameter. There was a strong correlation between AR severity by angiography and the calculated echo-Doppler ARI (r = 0.84, p = 0.0001). As validated by aortic angiography, the ARI is an accurate reflection of AR severity.

Superiority of 10% air-10% blood-saline mixture for measuring the velocity of tricuspid regurgitation in patients with severe emphysema.

BACKGROUND: Severe emphysema frequently is associated with elevated pulmonary artery systolic pressure. However, it is often difficult to obtain adequate tricuspid regurgitation (TR) signals for measurement of pulmonary artery systolic pressure in patients with severe emphysema. PURPOSE: This study was conducted to evaluate the usefulness of air-blood-saline mixture in measuring TR velocity in severe emphysema. METHODS: We studied 82 patients with severe emphysema (67.7 +/- 9.2 years, 57 males) who had no or mild TR on color Doppler. Contrast echocardiography studies were performed with agitated 10% air-90% saline and 10% air-10% blood-80% saline mixtures. Tracing quality and peak velocity were assessed on baseline continuous wave signals and contrast continuous wave signals with the 2 mixtures. RESULTS: With the injection of an air-saline mixture, the quality of TR tracing improved in 45 patients (P <.0001) and a higher peak TR velocity was obtained (2.46 +/- 0.37 m/s vs 2.95 +/- 0.40 m/s, P <.0001) compared with baseline echocardiography. Compared with air-saline mixture, the air-blood-saline mixture further enhanced TR tracing quality in 17 patients (P <.0001) and the peak TR velocity increased to 3.13 +/- 0.42 m/s (P <.0001). CONCLUSIONS: In patients with severe emphysema, an air-blood-saline mixture improves the quantifiable TR signals for more accurate estimation of pulmonary artery systolic pressure, even when there is minimal valve TR.

Comparison of transthoracic and intraoperative transesophageal color flow Doppler assessment of mitral and aortic regurgitation.

BACKGROUND: We examined the agreement between transthoracic echocardiography (TTE) and intraoperative prepump transesophageal echocardiography (TEE) in the assessment of left-sided regurgitant lesions and echocardiographic variables associated with grading discrepancies. METHODS: The TTE and prepump TEE studies of 54 patients undergoing aortic-valve replacement for aortic stenosis were reviewed. Agreement and correlation in assessment of aortic (AR) and mitral regurgitation (MR) severity were evaluated. RESULTS: There was no significant difference between mean TTE and prepump TEE grading of MR (0.23 +/- 0.19 vs. 0.21 +/- 0.15 jet area/area of the left atrium, p = 0.49), but the correlation between the two methods was weak (r = 0.40, p = 0.003), with an exact agreement of 54%. Prepump TEE tended to grade AR as more severe (mean grade 1.43 +/- 0.94 vs. 1.24 +/- 0.75, p = 0.058). The correlation between the two methods in AR assessment was fair (r = 0.70, p = 0.0001) with an agreement of 59%. For MR and AR grading, no significant correlations between valvular regurgitation severity and blood pressure differences between preoperative TTE and prepump TEE were found. In 17% of cases, discrepancies in identifying severe mitral or aortic valve regurgitation could have affected patient management. CONCLUSIONS: There is modest agreement in MR and AR assessment between TTE and prepump TEE. Cardiologists, cardiac surgeons, and anesthesiologists must be aware of differences between these methods when using prepump TEE to guide intraoperative decisions.

The usefulness of a 10% air-10% blood-80% saline mixture for contrast echocardiography: Doppler measurement of pulmonary artery systolic pressure.

OBJECTIVES: We assessed an air-blood-saline mixture for Doppler measurement of pulmonary artery systolic pressure (PASP) and the mechanism of enhancement of the Doppler signal by this mixture. BACKGROUND: Underestimation of PASP by Doppler echocardiography occurs with inadequate continuous wave (CW) signals of tricuspid regurgitation (TR). METHODS: We assessed in vitro the diameter and concentration of microbubbles of agitated air-saline mixture, air-blood-saline mixture and 10% air-10% plasma-80% saline mixture immediately, 5, 10 and 20 s after agitation. In 20 patients, PASP was estimated by Swan-Ganz catheter and CW Doppler of TR: 1) without contrast injection; 2) with intravenous injection of 10% air-90% saline; and 3) 10% blood-10% air-80% saline mixture. RESULTS: Compared to air-saline, addition of blood or plasma to the air-saline solution significantly increased the concentration of microbubbles (p < 0.001). The air-blood-saline (26.7 +/- 7.2 microm) and air-plasma-saline mixture (25.3 +/- 7.4 microm) had smaller microbubbles than air-saline mixture (31.6 +/- 8.2 microm) (p < 0.001). The correlation between Doppler- and catheter-measured PASP at baseline (r = 0.64) improved with agitated air-saline (r = 0.86). With the air-blood-saline mixture, the correlation further improved (r = 0.92) and the best limits of agreement were obtained. CONCLUSIONS: The combination of the patient's own blood is a method of making a sterile solution of numerous small microbubbles for injection into the right-sided cardiac chambers. Clinically, the air-blood-saline mixture is easily prepared at bedside and is superior to the air-saline mixture in assessing PASP in patients with inadequate CW Doppler signals.