A Case of Post-operative Jaundice After Cardiac Surgery.

Hyperbilirubinemia is a common gastrointestinal complication seen post-cardiac surgery. Here, we describe a case of a 72-year-old male with a past medical history of chronic obstructive pulmonary disease, chronic kidney disease (CKD), pulmonary hypertension, and valvular heart disease with severe aortic stenosis, severe mitral and tricuspid regurgitations who underwent elective aortic valve replacement (AVR), mitral valve replacement (MVR), and tricuspid valve (TV) repair; in addition, he required left thoracotomy for the repair of pulmonary artery perforation from a Swan-Ganz catheter that resulted in a large left pleural bleed. Post-operatively, he developed severe jaundice, which was predominantly conjugated that peaked at 24 mg/dL. He also required multiple blood products' transfusion in the perioperative period and was supported temporarily with hemodialysis for acute kidney injury superimposed on his CKD. He underwent extensive evaluation for jaundice, which included ultrasound of the liver, hepatobiliary iminodiacetic (HIDA) scan, and magnetic resonance cholangiopancreatography (MRCP), which were all normal. The patient eventually got better and was discharged from the hospital. The hyperbilirubinemia slowly got better without any specific therapy and on his follow-up visit to the office following discharge, his bilirubin level was found completely normalized. Although most cases of post-cardiac surgery hyperbilirubinemia resolve without any specific therapy, the occurrence is not completely benign since it can increase morbidity and mortality. It is paramount that intensivists and cardiothoracic surgeons caring for these patients are aware of this occurrence to prevent unnecessary diagnostic evaluation. Most early cases of hyperbilirubinemia are transient and do not usually increase morbidity and mortality. In the late cases, infectious etiology resulting in sepsis needs to be entertained early and treated aggressively.

The Heterogeneity of COPD Patients in a Community-Based Practice and the Inadequacy of the Global Initiative for Chronic Obstructive Lung Disease Criteria: A Real-World Experience.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease with differing clinical presentations, which range from an asymptomatic obstructive defect on spirometry to symptomatic normal spirometry. The current standard for diagnosis requires exposure history and the presence of an obstructive ventilatory defect (forced expiratory volume in 1 second [FEV1] to forced vital capacity [FVC] ratio < 70%) on spirometry. In this real-world study, we analyzed patients with physician-diagnosed COPD, described their characteristics, and evaluated the diagnostic sensitivity of Global initiative for chronic Obstructive Lung Disease (GOLD) criteria in this population. METHODS: We retrospectively analyzed the charts of 2115 patients for eligibility. A total of 1224 patients with physician-diagnosed COPD were selected for this study. The average age was 68.4±11.5 years, with 51% being female. Of the 1224 patients, 18% did not have a history of smoking, 73% had bronchodilator testing, and a significant response of ≥12% was noted in 23% of the COPD patients. Moreover, 43% of the patients met the GOLD criteria for the diagnosis of COPD, whereas the Global Lung Function Initiative (GLI) and lower limit of normal (LLN)criteria were only able to identify 26%. DISCUSSION: COPD-related mortality is continuing to rise, and it is currently ranked as the third leading cause of death, globally, after cardiovascular diseases and strokes. Despite this alarming statistic, COPD diagnosis is delayed in most cases and can remain undiagnosed, even in smokers. This is partly due to the restrictive GOLD diagnostic criteria, which requires the presence of FEV1/FVC ratio<70. CONCLUSIONS: The recently proposed COPD Genetic Epidemiology (COPDGene®) 2019 definition for COPD will improve and enhance our ability to diagnose COPD earlier and more accurately.

Pulmonary-esophageal variceal bleeding: a unique presentation of partial cor triatriatum sinistrum.

Cor triatriatum sinistrum is a rare congenital disorder defined as a division of the left atrium by a diaphragmatic membrane resulting in two left atrial chambers. The membranous division of the atrium can be partial or complete and can affect either atrium, with involvement of the right atrium referred to as cor triatriatum dexter. The presence of fenestrations within the membrane allows for communication and forward passage of blood into the true atrium. Absence of fenestrations leads to early symptomatic engorgement of the lungs. We report the case of a young adult male presenting with recurrent hematemesis due to variceal bleeding. On CT imaging the patient was found to have cor triatriatum sinistrum, with a vertical membrane resulting in total obstruction of the pulmonary venous drainage on the right, with normal pulmonary venous drainage on the left. There was extensive pulmonary-systemic arterial collateralization to the right lung suggesting retrograde filling of the right pulmonary artery with effective flow reversal in the right lung.

Uncommon cause of paradoxical embolism in a case of scimitar syndrome.

Scimitar syndrome, a rare congenital cardiopulmonary condition, presents in both pediatric and adult populations as an anomalous pulmonary venous return of most of the right lung to the inferior vena cava. Recently, asymptomatic adult cases have been diagnosed with advances in imaging studies. We report the case of an asymptomatic 43-year-old male, with a complex variant scimitar syndrome diagnosed by computed tomographic angiography.