Therapeutic pulmonary artery stenting for metastatic bronchial carcinoid.

We present a case of a middle-aged man with a 3-month history of progressive shortness of breath and peripheral oedema. Ten years prior to this, he had undergone a left pneumonectomy for metastatic bronchial carcinoid. Clinical examination revealed significant right heart failure, supported by transthoracic echocardiography. CT pulmonary angiogram revealed the cause to be marked progression of the bronchial carcinoid causing severe external compression of right pulmonary artery (RPA). In view of the distressing symptoms, a palliative endovascular intervention to the RPA was attempted to relieve obstruction, improve blood flow through the right lung and offload the right ventricle. This was performed under general anaesthesia involving interventional cardiology and radiology specialists together with a specialist anaesthetic team with extensive experience of managing carcinoid patients. The result was a marked improvement in symptoms and right heart function and the patient was discharged 2 days later.

Infective endocarditis with co-existent acalculous cholecystitis: a rare but important association.

The authors present the case of an otherwise healthy retired male who presented with a history of fevers, rigors and right upper quadrant abdominal pain. Although haematological, biochemical and radiological investigations supported a diagnosis of acalculous cholecystitis, the underlying cause was not obviously apparent and the patient's clinical condition deteriorated rapidly over the course of a few hours despite appropriate medical treatment. Repeat clinical examination was consistent with acute pulmonary oedema in association with a new murmur throughout the whole of the cardiac cycle. Transthoracic echocardiography revealed the presence of severe aortic regurgitation, a presumptive diagnosis of infective endocarditis was made and medical therapy adjusted. Shortly after, the patient suffered a cardiac arrest and an attempt at resuscitation was unsuccessful. Postmortem examination revealed the presence of aortic valve cusp rupture secondary to bacterial endocarditis in addition to gallbladder appearances consistent with acute acalculous cholecystitis.