Inferior Pulmonary Artery Research Articles

Cardiac involvement in Behcet's syndrome: a case series of 32 patients

Abstract Background and Aims Behçet syndrome (BS) is a complex multisystemic vasculitis of unknown exact etiology. Cardiac involvement (CI) is rarely described, yet associated with high morbidity and mortality rates. Our work aims to depict the profile and outcomes of BS patients presenting with cardiac lesions. Methods This descriptive and monocentric study was retrospectively carried out between 2000 and 2022, among 531 patients admitted to our department for BS. Results 32 cases of CI were enrolled (6%). The sex ratio (M/F) was 3:1 and the mean age was 30 ± 7 years (21-48). Cardiovascular risk factors comprised smoking (21%), high blood pressure (15%), and diabetes mellitus (11%). CI was mostly asymptomatic (71%), discovered during systematic screening. Otherwise, patients presented with chest pain (21%), dyspnea (19%), dry cough (18%), and hemoptysis (17%). Inflammatory parameters were elevated in 71% of the cases, with a median ESR of 46 mm/h and CRP of 55 mg/l. Hemostasis parameters were within the normal ranges for all patients. The lesions visualized were right intracardiac thrombosis (79%), pericarditis (34%), coronary thrombosis (12.5%), myocarditis (6%), and endomyocardial fibrosis (3%). Concomitant vascular involvement was frequent (72%), especially thrombotic lesions in the inferior vena cava (23%), pulmonary arteries (21%), lower extremities (15%), cerebral veins (18%), and superior vena cava (9.5%). Arterial aneurysms were also common, mostly located in the pulmonary arteries (25%). Noncardiovascular involvements were mucocutaneous (78%), articular (28%), ocular (43%), neurological (18%), and digestive (3.6%). Patients were treated with colchicine (96%), glucocorticoids (96%), curative anticoagulation (54%), cyclophosphamide (57%), azathioprine (46%), and TNF-a inhibitor (3%). No patient underwent an endovascular procedure. Surgery was performed in 6.3% of the cases. One relapse of intracardiac thrombosis was recorded. Death was documented in five cases. Conclusions CI is a serious manifestation of BS. Although rare, it is also fairly underdiagnosed due to its nonspecific features and discrete evolution. Hence, better knowledge of the disease is crucial for early diagnosis and prompt initiation of immunosuppressive therapy.

A rare case of pulmonary artery to left atrium fistula

BackgroundThe first description of right pulmonary artery-to left atrium communication was done by Friedlich and coauthors in 1950. The right pulmonary artery and left atrium are directly connected by the right pulmonary artery to left atrial fistula through a thin-walled aneurysm. Here, we describe a female adult patient who underwent investigation for dyspnea and had Type 1 right pulmonary artery to left atrium connection.Case presentationTwenty-two-year-old female presented with history of breathlessness (New York Heart association classification grade III) for 3 years. On initial examination, her saturation was 60% with no clinical evidence of cyanosis. Initial radiographic examination and CT pulmonary angiogram revealed a dilated communication between the right inferior pulmonary artery and left atrium. The patient was then referred for cardiac MRI. The MR imaging showed the following findings: Dilated right ventricle and atrium with Ostium secundum type of atrial septal defect. Large focal outpouching was noted arising from the right inferior pulmonary artery whose inferomedial portion appeared to communicate with left atrium. The final diagnosis was right pulmonary artery to left atrial fistula-Type I with ostium secundum type atrial septal defect. Midline sternotomy was performed for ligation of this fistula with septal correction. Post surgery, patient began to improve clinically and her saturation in room air increased to 92%ConclusionsRight pulmonary artery to left atrial fistula is different from the pulmonary AV fistula and its rarity directs the need for imaging to diagnose the condition and for management selection. The fistulous connection, which most frequently originates from the posterior wall of the descending branch of RPA and inserts into the LA, is readily seen on CT/catheter angiography. Due to the rarity of this entity and much fewer evidences in imaging, we have reported a type 1 right pulmonary artery to left atrium connection.

Coupled waveform patterns in the arterial and venous fontan circulation are related to parameters of pulmonary, lymphatic and cardiac function

The lack of a sub-pulmonary ventricle in patients with a Fontan circulation contributes to circulatory decline, largely related to increased central venous pressure. Our group has determined that single-site waveform analysis correlates with clinical features of Fontan patients. The goal of this study was to determine if multi-site waveform analysis yielded additional associations with functional status or cardiac performance. Patients with a Fontan circulation (N = 95) that underwent free-breathing cardiac MRI were included in this study. Volumetric flow rate curves were sampled in the ascending aorta, superior vena cava, inferior vena cava and left pulmonary artery. Flow curves were interpolated to equal temporal phases and were then used to create three data matrices of arterial and venous waveforms. Principal component analysis was performed on each matrix and principal components that accounted for >10% variance were correlated to traditional clinical indices. Results indicate correlation of inferior and superior vena cava waveform patterns to parameters of pulmonary (RV/TLC %, lowest SaO2%), lymphatic (cystatin-c, BUN, alkaline phosphatase) and to ventricular function (CI, EF, EDVi, ESVi and VVCR). This study demonstrates that coupled waveform analysis of arterial and venous vessels relays additional information about Fontan patient status.

Virtual Reality Cardiac Surgical Planning Software (CorFix) for Designing Patient-Specific Vascular Grafts: Development and Pilot Usability Study.

BackgroundPatients with single ventricle heart defects receive 3 stages of operations culminating in the Fontan procedure. During the Fontan procedure, a vascular graft is sutured between the inferior vena cava and pulmonary artery to divert deoxygenated blood flow to the lungs via passive flow. Customizing the graft configuration can maximize the long-term benefits. However, planning patient-specific procedures has several challenges, including the ability for physicians to customize grafts and evaluate their hemodynamic performance.ObjectiveThe aim of this study was to develop a virtual reality (VR) Fontan graft modeling and evaluation software for physicians. A user study was performed to achieve 2 additional goals: (1) to evaluate the software when used by medical doctors and engineers, and (2) to explore the impact of viewing hemodynamic simulation results in numerical and graphical formats.MethodsA total of 5 medical professionals including 4 physicians (1 fourth-year resident, 1 third-year cardiac fellow, 1 pediatric intensivist, and 1 pediatric cardiac surgeon) and 1 biomedical engineer voluntarily participated in the study. The study was pre-scripted to minimize the variability of the interactions between the experimenter and the participants. All participants were trained to use the VR gear and our software, CorFix. Each participant designed 1 bifurcated and 1 tube-shaped Fontan graft for a single patient. A hemodynamic performance evaluation was then completed, allowing the participants to further modify their tube-shaped design. The design time and hemodynamic performance for each graft design were recorded. At the end of the study, all participants were provided surveys to evaluate the usability and learnability of the software and rate the intensity of VR sickness.ResultsThe average times for creating 1 bifurcated and 1 tube-shaped graft after a single 10-minute training session were 13.40 and 5.49 minutes, respectively, with 3 out 5 bifurcated and 1 out of 5 tube-shaped graft designs being in the benchmark range of hepatic flow distribution. Reviewing hemodynamic performance results and modifying the tube-shaped design took an average time of 2.92 minutes. Participants who modified their tube-shaped graft designs were able to improve the nonphysiologic wall shear stress (WSS) percentage by 7.02%. All tube-shaped graft designs improved the WSS percentage compared to the native surgical case of the patient. None of the designs met the benchmark indexed power loss.ConclusionsVR graft design software can quickly be taught to physicians with no engineering background or VR experience. Improving the CorFix system could improve performance of the users in customizing and optimizing grafts for patients. With graphical visualization, physicians were able to improve WSS percentage of a tube-shaped graft, lowering the chance of thrombosis. Bifurcated graft designs showed potential strength in better flow split to the lungs, reducing the risk for pulmonary arteriovenous malformations.

Management and prognosis comparison between incidental and nonincidental intravenous leiomyomatosis: a retrospective single-center real-life experience.

BackgroundIntravenous leiomyomatosis (IVL) is a rare, difficult-to-treat type of smooth muscle tumor that originates from the uterine myoma. However, its clinical characteristics, management, and prognosis are not clearly understood. Moreover, the 2 different methods used to diagnose IVL—incidental and nonincidental—result in completely different treatments.MethodsWe conducted a single-center, retrospective study. Our real-life case series included patients pathologically diagnosed with IVL between July 2011 and December 2020. All patients with IVL were divided into 2 groups: an incidental group and a nonincidental group. Medical records of patients, including clinical characteristics, primary treatment, treatment after recurrence, and prognosis, were reviewed.ResultsA total of 39 patients were included in the study, with a median patient age of 47 years. Of the 39 cases, 15 (38.5%) were incidentally diagnosed with only intrapelvic tumors. Among the 24 patients with IVL in the nonincidental group, tumor spread in the inferior vena cava, right heart, and pulmonary artery was identified in 4, 17, and 3 patients, respectively. The most common symptoms were abnormal uterine bleeding in the incidental group and chest distress and dyspnea in the nonincidental group. Among the 15 patients in the incidental group, ovary-preserving surgery was performed in 6 young women (≤40 years old), of whom 3 underwent myomectomy. All 24 patients with IVL in the nonincidental group underwent thrombectomy without uterine or ovary preservation by multidisciplinary surgical treatment. Only 1 patient in each group underwent postoperative adjuvant therapy. During the median follow-up of 36.0 months, recurrence was recorded in 5 (12.8%) cases in the incidental group, with no deaths recorded. Only 1 patient was lost to follow-up. No recurrence was noted in the cases in the nonincidental group. Among the 5 patients who experienced recurrence, 4 received secondary surgical treatment and 1 received hormone therapy. All patients were alive as of this report.ConclusionsPatients with IVL who are diagnosed incidentally have a higher recurrence risk than those who are diagnosed nonincidentally and undergo complete tumor resection. However, patients incidentally diagnosed with IVL can still experience long disease-free survival rates following secondary surgical treatment after recurrence.

Syntopy of Pulmonary Vein Orifices in the Left Atrium of the Human Heart

INTRODUCTION: The syntopy of the left atrial (LA) structures is the least studied aspect of the normal heart anatomy. The morphometric data on the position of orifices of the pulmonary veins in the LA walls relative to the adjacent heart structures and heart vessels are important as reference parameters of heart morphology and are needed in the endovascular treatment of atrial fibrillations.
 AIM: To establish the general patterns and topospecific peculiarities of the location of the pulmonary vein orifices relative to the oval fossa and orifices of the venae cavae using morphometric methods of anatomical preparations of conventionally normal adult human heart.
 MATERIALS AND METHODS: Fiftyfour wet anatomical preparations of the heart without macroscopic signs of hemodynamically significant cardiac pathology were studied. The preparations were obtained from patients aged 3589 years who died from diseases not related to heart pathology. LA diastole was modeled by filling its cavity with silicone; after it hardened, the distances from the oval fossa and orifices of the venae cavae to the orifices of the pulmonary veins were measured using sliding calipers.
 RESULTS: The article presents variation, medians, and extreme values of distances from the oval fossa and orifices of the venae cavae to the orifices of the pulmonary veins at the site of their opening to LA. The significance of differences of morphometric parameters of the topography was evaluated, and their correlation and oneway regression analyses were implemented. The strongest regression dependence was found for LA width and distance from the orifice of the superior vena cava to the orifice of the left inferior pulmonary vein (Y) r2 = 0.45; Х = 19.94 + 0.545Y). The heart dimensions and LA length were not significant predictors for the studied parameters.
 CONCLUSION: The right pulmonary veins were located expectedly closer to the orifices of the venae cavae and the oval fossa than the left pulmonary veins. The narrowest was the space between the orifices of the superior vena cava and the right superior pulmonary vein. The farthest from the orifices of both venae cavae was the orifice of the left inferior pulmonary artery. The strongest correlation relationships were characteristic of the distances from the orifices of both venae cavae to the orifices of the homolateral pulmonary veins, which we propose to consider as one of the criteria of the harmoniousness of the structure of the atrial complex.

Inferior vena cava and pulmonary artery diameters for prognosis of Coronavirus disease

Inferior vena cava and pulmonary artery diameters for prognosis of Coronavirus disease

Abstract 12379: Distal Waveform Patterns in the Fontan Circulation Are Related to Pulmonary, Liver and Cardiac Function

Introduction: The lack of a sub-pulmonary ventricle in patients with a Fontan circulation leads to irreversible circulatory decline. Our group has determined that single-site waveform analysis correlates to clinical features of Fontan patients. The goal of this study was to determine if multi-site waveform analysis contributes to detecting early cardiovascular decline. Methods: Patients with a Fontan circulation that underwent cardiac MRI were included in this retrospective study. Hemodynamic flow curves were measured in the ascending aorta (AAo N=94), superior vena cava (SVC N=82), inferior vena cava (IVC N=91) and left pulmonary artery (LPA N=85). Flow curves were interpolated to equal temporal phases and were used to create three data matrices of proximal and distal waveforms. Principal component analysis (PCA), a data transformation method used to obtain a wieldy number of ranked components (the PCs) representing the variance of the input data, was performed on each matrix. PCs were correlated to clinical measures of current patient status. Results: PCs that accounted for more than 20% of the variance in a data matrix are reported (Pearson’s r, p ) in Table 1. Conclusions: These results indicate that increased liver enzyme levels, with a possible link to Fontan associated liver disease, are related to increased diastolic SVC flow and increased volume in the SVC and IVC throughout the cardiac cycle. An increased diastolic SVC flow profile relates to worsening pulmonary function and oxygen consumption during exercise. A decreased ventricular-vascular coupling ratio is related to increased IVC volume and low oxygen saturations may be indicative of increased LPA volume. Little variations were apparent in the AAo waveforms, suggesting cardiovascular decline may appear distally prior to proximal presentation. We have, for the first time, evaluated multi-site flow patterns and correlated them to functional status in one of the largest Fontan patient cohorts to date.

Asymptomatic cement leakage into inferior vena cava.

Abstract Although percutaneous vertebroplasty (PVP) is a minimally invasive treatment procedure for the painful osteoporotic vertebral compression fracture, cement leakage into the venous system can occur and early detection and immediate management should be initiated despite the absence of clinical symptoms. We experienced a case of accidental finding of cement fragment extending from paravertebral vein into inferior vena cava and pulmonary artery. We have to be aware of cement leakage through the paravertebral venous drain system under fluorescence. It provided a classic image for cement leakage through the venous circulatory system.

Echocardiographic, Biochemical, and Electrocardiographic Correlates Associated With Progressive Pulmonary Arterial Hypertension.

Background: Pulmonary arterial hypertension (PAH) is a progressive proliferative vasculopathy associated with mechanical and electrical changes, culminating in increased vascular resistance, right ventricular (RV) failure, and death. With a main focus on invasive tools, there has been an underutilization of echocardiography, electrocardiography, and biomarkers to non-invasively assess the changes in myocardial and pulmonary vascular structure and function during the course of PAH.Methods: A SU5416-hypoxia rat model was used for inducing PAH. Biventricular functions were measured using transthoracic two-dimensional (2D) echocardiography/Doppler (echo/Doppler) at disease onset (0 week), during progression (3 weeks), and establishment (5 weeks). Similarly, electrocardiography was performed at 0, 3, and 5 weeks. Invasive hemodynamic measurements and markers of cardiac injury in plasma were assessed at 0, 3, and 5 weeks.Results: Increased RV systolic pressure (RVSP) and rate of isovolumic pressure rise and decline were observed at 0, 3, and 5 weeks in PAH animals. EKG showed a steady increase in QT-interval with progression of PAH, whereas P-wave height and RS width were increased only during the initial stages of PAH progression. Echocardiographic markers of PAH progression and severity were also identified. Three echocardiographic patterns were observed: a steady pattern (0–5 weeks) in which echo parameter changed progressively with severity [inferior vena cava (IVC) expiratory diameter and pulmonary artery acceleration time (PAAT)], an early pattern (0–3 weeks) where there is an early change in parameters [RV fractional area change (RV-FAC), transmitral flow, left ventricle (LV) output, estimated mean PA pressure, RV performance index, and LV systolic eccentricity index], and a late pattern (3–5 weeks) in which there is only a late rise at advanced stages of PAH (LV diastolic eccentricity index). RVSP correlated with PAAT, PAAT/PA ejection times, IVC diameters, RV-FAC, tricuspid systolic excursion, LV systolic eccentricity and output, and transmitral flow. Plasma myosin light chain (Myl-3) and cardiac troponin I (cTnI) increased progressively across the three time points. Cardiac troponin T (cTnT) and fatty acid-binding protein-3 (FABP-3) were significantly elevated only at the 5-week time point.Conclusion: Distinct electrocardiographic and echocardiographic patterns along with plasma biomarkers were identified as useful non-invasive tools for monitoring PAH progression.

Declarations: management of a pulmonary arteriovenous fistulae by uniportal video\u2010assisted thoracoscopic surgery: a case report

BackgroundA pulmonary arteriovenous fistula (PAVF) is arare condition that is associated with pulmonary arteriovenous malformation(PAVM). Few reports have described managing PAVMs using uniportalvideo-assisted thoracoscopic surgery (VATS).Case presentationA 13-year-old child with PAVF in the left inferior pulmonary artery was treated by uniportal VATS with left lower lobectomy. After surgery, hemoptysis did not recur and there were no postoperative complications. Six months after the operation, postoperative review of computerized tomography showed no recrudescence of PAVF.ConclusionsPAVF is a rare case that should be diagnosed and treated early. 3D- computerized tomography (CT) reconstruction is useful for diagnosis and preoperative assessment. The case shows that PAVF can be managed with uniportal VATS.

Multidisciplinary surgical approach to renal cancer with vena cava invasion and pulmonary embolism

Renal cancer is unique for many reasons. One reason is that renal cell carcinoma can grow directly into the drainage veins of the kidney, which enter the inferior vena cava leading to the heart. This growth of tumor cells into the veins is called atumor thrombus and is alocally aggressive renal cancer. The present article informs about the experience of our cardiac surgery department together with the transplant surgery department in successful surgical removal of akidney with tumor, with invasion into the inferior vena cava, right atrium of the heart and pulmonary artery in two case reports. A32 years old female without significant history, with suddenly evolving dyspnea was urgently admitted to hospital. Her condition was suspected to be caused by pulmonary artery embolisation. The diagnosis was confirmed by CT scan which revealed unknown tumor mass of the right kidney and tumor embolisation in inferior vena cava and pulmonary artery. The patient was urgently operated by avascular surgeon and cardiothoracic surgeon. They successfully performed left radical nephrectomy and total thromboembolectomy of the tumorous masses from vena cava inferior and pulmonary artery. The postoperative course was without complications, postoperative CT revealed no residual masses, and the patient was discharged in agood condition from the hospital. A58 years old male with arterial hypertension suffered from orchiepididymitis. CT scan showed atumor of the left kidney with propagation of tumorous masses to inferior vena cava and pulmonary artery. In elective surgery the vascular surgeon and cardiothoracic surgeon successfully performed left radical nephrectomy with total thromboembolectomy of the tumorous masses from inferior vena cava and pulmonary artery. After surgery atemporary paralytic ileus and an episode of atrial fibrillation occurred. Both are common postoperative complications related to the given surgical procedure. Follow-up CT scan showed no residual tumor or thrombus in inferior vena cava and pulmonary artery. Echocardiography revealed persistent dilation of right compartments of the heart with good systolic functions of both ventricles. The patient was discharged from hospital in agood condition. Surgical removal of renal tumor and tumor thrombus - radical nephrectomy with tumor thrombectomy - can be acurative treatment and can ensure long-term survival of the patient. Depending on the extent of the tumor thrombus, these operations can be performed in different ways - mini-invasive, robotic or open. When open surgery is used, it is possible to perform the procedure with or without extracorporeal circulation (cardiopulmonary bypass - CPB) depending on the extent of the disease.

IMMOBILE TRAVELLER SYNDROME: A CASE REPORT

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Apart from Economic class syndrome which is a well established entity in air travel, Pulmonary embolism can also occur due to other modes of long travel (1). We present a case of pulmonary embolism resulted from continuous car travel. CASE PRESENTATION: A 45-year-old male came with minimal productive cough ,breathlessness of modified medical research council (MMRC) grade 2 and mild fever for five days. He was a normotensive and non diabetic. On examination he had fine crackles over right infra scapular region. Laboratory investigations showed mild leucocytosis with polymorph predominance. Metabolic panel was normal. His chest x ray showed right lower zone ill defined airspace opacity. HRCT Chest revealed right lower lobe sub pleural consolidation with reverse halo sign. Sputum gram stain and modified Ziehl Neelsen stain were not contributory. Based on the clinical scenario ,lab parameters and radiological findings, community acquired pneumonia of right lower lobe was diagnosed and Patient was started on oral antibiotics. After three days patient returned with history of an episode of minimal hemoptysis. He was admitted for further evaluation. On detailed history evaluation he accepted he himself drove his car to a city for five hours without break and after finishing his work he drove back continuously for five more hours to his hometown two days before the illness. Pulmonary thromboembolism was suspected and d-dimer was found to be elevated(690 ng/ml). Echocardiogram was normal. CT Pulmonary angiogram(CTPA) confirmed multiple emboli (polo mint sign) in branches of right inferior pulmonary artery with infarction and pleural effusion. Patient was successfully treated with low molecular weight heparin for five days and discharged with warfarin. The etiological work up found out that he was having homocyteinemia and anti platelet drug with vitamin supplements were given. After nine months patient himself discontinued dabigatran for two weeks and came with right sided pleurisy and right thigh swelling. Venous Doppler study confirmed deep vein thrombosis(DVT) of right femoral vein and CTPA confirmed recurrent thromboembolism in right inferior pulmonary artery. Patient was subjected to IVC filter and treated again with low molecular weight heparin. Now he is on warfarin. DISCUSSION: Travel history is essential when suspecting pulmonary embolism.Immobilisation during long travel is a definite risk factor for deep vein thrombosis and pulmonary thromboembolism.Like Economic class syndrome of air travel ,Pulmonary embolism due to other modes of long travel can be called as ‘Immobile Traveller’s Syndrome’(2). When sub pleural consolidation with reverse halo sign is noted in CT chest, Pulmonary infarction must be considered in differential diagnosis. CONCLUSIONS: High index of suspicion is the key for diagnosis pulmonary embolism in peripheral branches because it may mimic pneumonia or pleural effusion. Reference #1: 1.Paolo Feltracco;Stefania Barbieri;Francesca Bertamini;Elisa Michieletto;Carlo Ori; Economy class syndrome: still a recurrent complication of long journeys.European Journal of Emergency Medicine. 14(2):100-103, APR 2007 Reference #2: 2. Gispert P1, Drobnic ME, Vidal R. Economy-class syndrome or Immobile Traveler's syndrome? Arch Bronconeumol. 2006 Jul;42(7):373-5. DISCLOSURES: No relevant relationships by Nagarajan Appusamy, source=Web Response No relevant relationships by Mathanraj Sinnassamy, source=Web Response No relevant relationships by Sivaraja Subramaniam, source=Admin input

Ruptured Bullae: A Rare Cause of No-flow Alarms In Ventricular Assist Devices

Introduction Bleeding is a potentially deadly complication of anticoagulation in patients with ventricular assist devices. Management of anticoagulation in this population requires a multidisciplinary approach, especially in the setting of life-threatening bleeding. Case Report A 60-year-old female with emphysema and a HeartMate 3 presented with progressive hemoptysis, dyspnea, and right chest pain. Her hemoglobin was 11.1 g/dL (baseline) and her INR was 2.9. Chest CT showed enlargement of a right lung bullae with intra-bullae hemorrhage (Figure 1). Anticoagulation was held. She had symptomatic hypotension that the thoracic surgeons attributed to recent diuretics. On hospital day two, her hemoglobin decreased to 6.1 g/dL, she had low-flow and no-flow alarms, and hypoxic respiratory failure. She required intubation, blood transfusion, and four inotropes/vasopressors. A chest tube drained 2.7 L of blood with hemodynamic improvement. Angiography showed no active contrast extravasation. Her hemothorax persisted and angiography was repeated the third day; failing again to yield a culprit. However, the interventional radiologists empirically plugged the right inferior pulmonary artery and the bloody chest tube output decreased to 200 mL the following day. She underwent surgical washout with removal of 1 L of clot. Anticoagulation was restarted. She had an ischemic stroke without residual neurologic deficit and a ventilator-associated pneumonia and was discharged on the 32nd day. Discussion This patient had a strong indication for anticoagulation but developed a life-threatening bleed. Her initial hemoglobin was at baseline and she had received diuretics prior to arrival which confounded the severity of her condition. Although angiography was nondiagnostic, holding anticoagulation and empiric plugging of the suspected vessel were lifesaving, at the expense of developing a stroke; fortunately, without permanent neurologic deficit. Conclusion/Teaching point This case highlights the importance of coordinated and intensive multidisciplinary management to achieve early bleeding-source control in patients with mechanical circulatory support; especially when that entails challenging hemorrhagic and thromboembolic complications.

Echocardiographic indices and hospital stay among patients with acute heart failure at the Hospital Guillermo Almenara Irigoyen, 2015

Objective: To know the association between the length of hospital stay for acute heart failure and four echocardiographic indices among inpatients in the Coronary Care Unit of the Hospital Guillermo Almenara Irigoyen. The study indices were the ratio of mitral valve inflow velocity of pulsed-wave Doppler E and mitral annular tissue velocity of pulsed-wave Doppler e' (E/e'), inferior vena cava diameter, inferior vena cava collapse rate and pulmonary artery systolic pressure. Materials and methods: A quantitative, descriptive, retrospective and correlational study was conducted with all patients hospitalized for acute heart failure during 2015. The association that the length of hospital stay has with the E/e' ratio, inferior vena cava diameter and pulmonary artery systolic pressure was analyzed using Pearson's correlation coefficient. The relationship between the length of hospital stay and the inferior vena cava collapse rate was determined using the OR. Results: The study population consisted of 65 patients whose mean age was 67.8 years and who were mainly males (61.5 %). The mean hospital stay was 5.83 days. The diagnosis of heart failure was associated with a hospital stay greater than 5 days (chi-square test). There was no association between left ventricular ejection fraction and hospital stay (OR = 1.016; 95 % CI = 0.380 - 2.717). A significant association was found between a longer hospital stay and the increase in the E/e' ratio (p = 0.002), larger inferior vena cava diameters (p = 0.006) and inferior vena cava collapse rates less than 50 % (p < 0.0000). Conclusions: The increase in the E/e' ratio, the larger inferior vena cava diameter and the inferior vena cava collapse rate less than 50 % are associated with a long hospital stay among inpatients with acute heart failure in a coronary care unit.

P232 A cardiac thrombus... or maybe not

Abstract A 61 years old female with history of rheumatic arthritis and Sjogren Syndrom resorted to the emergency room in December of 2017 for pleuritic chest pain and dyspnea. An angioCT showed a luminal filling defect at the left inferior pulmonary artery with extension to the segmentar vessels. A pulmonary embolism (PE) was diagnosed and the patient was admitted. The study performed, including transthoracic echocardiogram (TTE) was unremarkable. Patient was discharged after 15 days treated with a direct oral anticoagulant. Six months later she returned to the emergency room with the same complaints. A new angioCT showed reduction of the previous luminal filling defects, but a focal defect in the filling of the right atrium (RA) was visualized. A TTE showed a mass (17 mm) at the RA with apparent origin at the superior vena cava. A presumptive diagnostic of atrial thrombus was done and patient started therapy with vitamin K antagonist. Three months later, TTE was repeated and the mass was still present (19 mm). Five months later, the mass was still visualized at TTE (17 mm). A transesophagic echocardiogram confirmed the presence of a RA mass with 30x22 mm of major dimensions, with close relation with the interatrial septum suggestive of a tumor. A cardiac magnetic resonance revealed a RA mass without vascularization. A cardiac gated CT showed at the RA a low density nodular image of 26x22 mm at the axial plan, with an extension of 28 mm, adjacent to the posterior wall of the RA. After contrast administration, some areas did not had significant captation while some did, aspects compatible with a "pseudoenhancement" aspect. A positron tomography showed mild to moderate FDG captation at the RA. Meanwhile, patient was under anticoagulation for 2 years with no regression of the mass. For this reason, patient was oriented to cardiac surgery. The mass was resected and the histology revealed a RA myxoma. Cardiac masses can be due to tumour, thrombus or vegetation. In this case, the mass was highly considered to be a thrombus due to the presence of multiple risk factors: prothrombotic disease and pulmonary embolism. However, the fact that the mass did not reduce with therapy raised suspicion of other diagnosis. Although rare, myxomas can be found in the RA, and should be included in the differential diagnosis of right-sided intracardiac masses. Although myxomas are histologically benign, potential for embolization and sudden death make surgical resection a priority. Its diagnosis has now increased with the use of echocardiogradiography, and has made it the main modality for the evaluation of myxomas. PE is the most dreaded and devastating complication of right-sided myxoma. In cases of RA myxomas, clinically evident PE events are uncommon. Nevertheless, there have been reports of embolization of thrombi or tumor fragments into the pulmonary vessels in cases of right in approximately 3.2% of myxoma patients.

Transcatheter Revision of Fontan Circulation by Connecting the Classical Glenn Circulation With the Inferior Vena Cava and Pulmonary Artery Circulation

Transcatheter Revision of Fontan Circulation by Connecting the Classical Glenn Circulation With the Inferior Vena Cava and Pulmonary Artery Circulation

33: Intrauterine ureaplasma parvum and its treatment alter fetal hemodynamic status in a nonhuman primate model

Exposure to intrauterine inflammation (IUI) is associated with adverse perinatal outcomes. IUI by Ureaplasma parvum is a predominant infectious cause of preterm birth and fetal inflammatory response syndrome (FIRS). The objective of this study was to assess whether proinflammatory mediators induced by the infection are associated with fetal hemodynamic and cardiovascular dysfunction. At preterm gestational age 127-132 days (term 165 days), long-term catheterized rhesus monkeys were assigned to the following groups: (1) control (C) (n=6); (2) infection group (IG), intra-amniotic inoculation with Ureaplasma parvum (107 CFU/ml) (n=17); and (3) treatment group (IG+A), Azithromycin (12.5 mg/kg, every 12 h, intravenous for 10 days after ) after intra-amniotic inoculation with Ureaplasma parvum (n=8). TNFα, IL1β, IL6, PGE2, and PGF2a were analyzed in the amniotic fluid by ELISA. Image-directed pulsed and color Doppler ultrasonography was utilized to obtain serial fetal hemodynamic measurements [cardiac output, EA ratio, Tei index, cerebro-placental ratio, p ulsatility index (PI)/peak systolic velocity (PSV) of umbilical artery (UA) & vein, ductus venosus, hepatic vein, inferior vena cava, aorta, ductus arteriosus, pulmonary artery (PA), and middle cerebral artery] and maternal uterine artery in utero. UA PI was significantly increased in IG comparing to C or IG+A (p = 0.005). Cardiac output in the left ventricle (LCO) was significantly decreased in IG comparing to C (p = 0.004). When the ratio of bilateral cardiac output (RCO/LCO) was obtained, there were significantly more rates of abnormal RCO/LCO (>1.6) cases in IG than C or IG+A (p = 0.020). PA PSV was significantly increased in IG comparing to C or IG+A. PGF2a levels were significantly higher in cases with abnormal UA PI (>1.1) than normal cases (p = 0.002). The value of IL6 in cases of abnormal RCO/LCO was significantly higher than in normal cases (p = 0.030). The correlation coefficient (Spearman, r) between UA PI and PGF2a was 0.6 (p = 0.015). Increase in UA PI, PA PSV and increase in RCO/LCO were observed in IG, which decreased with treatment. These hemodynamic alterations were associated with an increase in amniotic proinflammatory mediators. Ultrasound Doppler measurements should be investigated as a diagnostic tool to identify women who may have IUI and a potential fetal compromise, as cases with preterm labor and/or preterm premature rupture of membranes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

An affordable approach for the extraction of migrated foreign devices into pulmonary arteries

Percutaneous embolization of the hypogastric and gonadal veins represents an effective treatment of pelvic venous congestion syndrome. In rare cases, coil migration may occur. We are presenting the case of a 57-year-old female patient diagnosed in 2013 with pelvic congestion syndrome, treated by a transcatheter coil embolization technique of the gonadal and hypogastric veins. During the procedure, one coil migrated to the right inferior pulmonary lobe artery leading to localized thromboembolism. Four years after the intervention, the patient addressed our Cardiology Department for an attempt of coil extraction. A minimally invasive percutaneous endovascular technique through the right subclavian vein was performed. The reason for the few cases reported regarding the percutaneous extraction and the limited experience in this field is assumed to be due to the absence of clinical expression induced by the migrated coils, most patients being asymptomatic. The management of coil migration in asymptomatic cases is a controversial issue. In the presented case, our patient had two thrombotic events induced by the migrated coil. So, a percutaneous attempt was performed for its extraction since our patient needed long-term oral anticoagulation therapy. The procedure didn’t succeed but showed the fact that percutaneous extraction of pulmonary artery migrated coil could be feasible in those symptomatic cases with recent occurred migration using affordable devices.

Simultaneous pulmonary and inferior vena cava tumor thromboembolism secondary to retroperitoneal pleomorphic liposarcoma.

Retroperitoneal pleomorphic liposarcoma (RPLS) is the least common but the most aggressive subtype of liposarcoma. We herein report a case of tumor embolism (TE) to the inferior vena cava (IVC) and pulmonary arteries in a 54 years old woman with RPLS. The case suggests that fusion fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) can accurately detect occult TE. It also illustrates the usefulness of computed tomography (CT) and high 18F-FDG uptake by PET/CT imaging for diagnosing such findings as filling defect in the veins and beaded pulmonary arteries as TE. To our knowledge, this is the first reported case of simultaneous pulmonary and inferior vena cava thromboembolism secondary to RPLS. And occult TE from RPLS has not been reported previously by 18F-FDG PET/CT.