VENTRICULAR COMPRESSION OF LEFT LOWER LOBE BRONCHUS MASQUERADING AS LOWER LOBE COLLAPSE

Abstract

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: There have been reports of tracheobronchial compression from vascular enlargements such as that seen in pulmonary hypertension of the pulmonary artery. Severe aortic aneurysms or congenital abnormalities of the pulmonary artery and descending aorta have been reported to cause compression of the left main stem bronchus. We present a rare case of compression of the left main and lower lobe bronchus from an enlarged left ventricle (LV). CASE PRESENTATION: 61 year old man with history of non-ischemic cardiomyopathy who presented with a ST elevation myocardial infarction (MI) to an outside hospital. He underwent percutaneous intervention and was noted to have a thrombus in the left anterior descending artery (LAD). Balloon dilation, thrombectomy and TPA instillation were performed, however, given severe cardiogenic shock, patient required mechanical circulatory support with an impella device and was intubated for respiratory failure. His stay was complicated by ventricular tachyarrhythmia cardiac arrest. After return of circulation was achieved, patient was transferred to our facility for further management. On arrival, he was alert, had decreased breath sounds at the left lung base with rhonchi throughout, soft abdomen, pulses present throughout all extremities, with pitting edema of the lower extremities, and appropriate flows at 3.5L on the impella. He developed fevers soon after arrival, concerning for sepsis. On chest x-ray, patient was noted to have left lower lobe collapse, with thick foul smelling sputum. Hence we performed bronchoscopy which showed minimal secretions and extrinsic compression at the level of the left secondary carina. No significant mucous plugging was noted. On echo, patient had a severely dilated left ventricle with impella in appropriate position and a mildly dilated right ventricle. DISCUSSION: Vascular enlargements in the mediastinum causing tracheobronchial compression have been reported in case reports and case series, however LV enlargement leading to compression of left main stem bronchus is rare. After ruling out usual causes of white out of the left lower lobe on chest xray including obstruction (often mucous plugging), consolidation, pleural effusion, atelectasis, in patients with severe LV dilation and dysfunction, enough to warrant mechanical circulatory support, LV compression of the left lower lobe should be considered as well. CONCLUSIONS: Left lower lobe collapse in a patient with cardiogenic shock and severe LV dysfunction may be secondary to LV dilation causing compression of the left main-stem or left lower lobe bronchus. Further studies are needed to determine whether decompression of the LV relieves this bronchial compression. Reference #1: Jaijee SK, Ariff B, Howard L, et al. Left main bronchus compression due to main pulmonary artery dilatation in pulmonary hypertension: two case reports. Pulm Circ. 2015;5(4):723-5. Reference #2: Park SH, Park SY, Kim NK, et al. Bronchial compression in an infant with isolated secundum atrial septal defect associated with severe pulmonary arterial hypertension. Korean J Pediatr. 2012;55(8):297-300. DISCLOSURES: No relevant relationships by Bindu Akkanti, source=Web Response No relevant relationships by Maryam Kaous, source=Web Response