Post-Cardiac Surgery Localized Alveolar Hemorrhage: A Diagnostic Challenge

Abstract

SESSION TITLE: Fellow Case Report Poster - Cardiac and Transplant Surgery SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Alveolar hemorrhage is associated with syndromes causing capillaritis, diffuse alveolar damage or bland pulmonary hemorrhage. We present a case of localized alveolar hemorrhage following cardiac surgery. CASE PRESENTATION: A 23-year old woman with a history of primum type atrial septal defect repair and mitral cleft closure presents as an adult with left bronchial stenosis associated with a vascular ring and RVOT obstruction. She underwent ductus arteriosus ligation, RVOT augmentation and stenting of left bronchus. She returned with severe mitral regurgitation associated with hemoptysis and chest pain. She underwent mitral valve repair and uproofing of the coronary sinus which had been previously baffled to the left atrium during repair of her primum ASD. Post operatively, she had persistent hypoxemia and hemoptysis. Chest X-ray and non-contrast computerized CT scan revealed infiltrates worse on the right. Bronchoscopy with serial lavages showed bloody fluid consistent with alveolar hemorrhage. A trans esophageal echocardiogram was technically difficult but appeared to show patent right sided pulmonary veins. However, subsequent CT scan with contrast demonstrated no flow in the right-sided pulmonary veins. Urgent repeat surgery revealed a single, right-sided pulmonary vein orifice with possible narrowing near the left atriotomy. We removed extensive clot within the pulmonary venous system and reconstructed the junction between the pulmonary vein and left atrium. During this time she developed thrombocytopenia suggesting the possibility of heparin induced thrombocytopenia and thrombosis. However the serotonin release assay was negative. DISCUSSION: Alveolar hemorrhage is an infrequently reported complication following cardiac surgery. It is usually diffuse and considered to be the result of inflammation or drug reaction. This patient presented with localized alveolar hemorrhage secondary to unilateral pulmonary venous thrombosis. The etiology of her clot development was likely mechanical from low flow through a narrowed orifice. The process improved following surgical clot removal and post-operative anticoagulation. CONCLUSIONS: The differential diagnosis of alveolar hemorrhage in patients who have recently undergone cardiac surgery should include pulmonary venous thrombosis, particularly when hemorrhage is localized Reference #1: A case of diffuse alveolar hemorrhage developing after open heart surgery. Nakamura Y, Shimokawa S, Watanabe S, Sakasegawa K, Sakata R, Higashi M, Miyahara K. Kyobu Geka. 2001;54:892-4 DISCLOSURE: The following authors have nothing to disclose: Yashaswini Yeragunta, Luke Wiggins, Kriti Lonial, David Kelley, Craig Baker No Product/Research Disclosure Information