Left Lower Lobe Pulmonary Artery Research Articles

Ovarian Cancer Metastasis to Lung Parenchyma without Peritoneal Dissemination: A Rare Case

Ovarian cancer is the most lethal gynecological malignancy worldwide. Despite the advances in treatment for ovary cancer, the 5-year survival rate of advanced ovarian cancer patients with peritoneal metastasis remains as high as 30%. Clinical stage is the most important prognostic factor and most patients are at an advanced stage. There is often no clearly identifiable precursor lesion; therefore, the events which lead to metastatic disease are poorly understood. Solitary lung parenchyma metastasis is extremely rare. We report a case of 39-year-old woman who was admitted with a lung mass. She had a history of high-grade serous carcinoma ovary, which was detected and treated 6 years ago with cytoreductive surgery as well ashyperthermic intraperitoneal and adjuvant chemotherapy. During the routine follow-up, positron emission tomography computed tomography scan showed two nodules of soft-tissue density in the lung parenchyma of the left lower lobe with a dimension of 2.8 × 2.5 cm. Intraoperatively, two conglomerated lung nodules seen in lung parenchyma of the left lower lobe. Deeper nodule was in close proximity to the left lower lobe bronchus and left lower lobe pulmonary artery. Video-assisted thoracoscopic surgery was conducted to perform left lower lobectomy. Postoperatively, the patient was stable. Microscopically, the tumor was classified as a high-grade serous carcinoma, and the patient was diagnosed for having an ovarian cancer metastasis. Ovarian cancer rarely metastasizes to the lung parenchyma in a relapse. However, excision of lesion with further chemotherapy showed excellent results. Surgical excision biopsy and intraoperative frozen sectioning, followed by lobectomy or segmentectomy, are both diagnostic and therapeutic.

Tales of the Unexpected: Donor Lung with CTEPH, a Unique Case Report

<h3>Introduction</h3> Whilst chronic thromboembolic pulmonary hypertension (CTEPH) is a recognised indication for lung transplantation, it is an undesirable finding in a lung donor. We present the case of an individual who underwent a single lung transplant with an allograft that was subsequently identified as having CTEPH. <h3>Case Report</h3> This 65 year old, 167cm, blood group A RhD+ female with fibrotic organising pneumonia was listed for a left single lung transplant on the basis of a hypokinetic right hemi-diaphragm. She received an organ from a 55year old, 159cm, blood group A RhD+, non-smoking female DBD donor, who died from a subarachnoid haemorrhage. The donor had possible asthma (not formally diagnosed) and an unenhanced CT chest demonstrated non-specific mosaic attenuation. A donor echocardiogram showed mild tricuspid regurgitation with normal right ventricular (RV) size but impaired radial systolic function. Donor blood gases on FiO₂ 1.0 demonstrated PaO₂ 35kPA in the left upper lobe and 64kPa in the left lower lobe pulmonary veins. The recipient surgery was uneventful, although she developed primary graft dysfunction with RV impairment. She was stabilised and extubated after 24 hours onto 2L/min supplemental oxygen. Day 10 post-transplant she developed increasing oxygen requirements. CT pulmonary angiography demonstrated patent vascular anastomoses, left lower lobe pulmonary artery occlusion and features of CTEPH, but no lung necrosis. A right heart catheter study confirmed mild pulmonary hypertension with a mean pulmonary artery pressure 25mmHg and pulmonary vascular resistance 6 Wood Units. She underwent pulmonary endarterectomy (PEA) with good clearance of the donor vasculature. She weaned easily from cardiopulmonary bypass and her supplemental oxygen was down-titrated. She was discharged home 6 weeks post-transplant to complete 12 weeks of anticoagulation. 5 months post-transplant she developed fever and hypoxia with imaging features of left lower lobe consolidation, but no new thrombus. In the context of poor physiological reserve, the patient and family requested palliation. <h3>Summary</h3> CTEPH is rare in the general population, with a prevalence 3-30 per million. In this case, the diagnosis of CTEPH only came to light after transplantation and this is the first report of PEA performed in a lung recipient. Transplant teams should be alert for CTEPH in potential lung donors.

PULMONARY EMBOLISM CAUSING INACCURATE READINGS OF CARDIOMEMS

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: The CardioMEMS™ HF System is a wireless pulmonary artery (PA) pressure monitoring system implanted in the left lower lobe (LLL) PA branch; FDA approved in the management of heart failure (HF) patients with New York Heart Association (NYHA) class III symptoms and at least one hospitalization within the last year. This hemodynamic data is useful to reduce HF hospitalizations and mortality (1,2). We present the first reported case of a device-unrelated acute LLL pulmonary embolism (PE) leading to discordant CardioMEMS readings in a breast cancer patient with HF. CASE PRESENTATION: Patient is a 56 year-old female with past medical history of triple negative right breast cancer in 1998 treated with lumpectomy, anthracyclines, and radiation therapy that was complicated by recurrence in 2018 which was treated with bilateral mastectomy followed by adjuvant dose dense chemotherapy with doxorubicin, cyclophosphamide, and paclitaxel that resulted in anthracycline-induced cardiomyopathy with reduced left ventricular ejection fraction (LVEF) of 30%. LVEF eventually recovered to 60% after the initiation of optimal medical therapy for HF. Unfortunately, she remained with persistent NYHA class III symptoms requiring frequent hospitalizations. Thus, a CardioMEMS device was inserted to optimize HF management and reduce recurrent hospitalization by remote monitoring of PA pressure. Eight months later, she developed an acute PE within the LLL PA branch (originating from her left leg). She was eventually treated with anticoagulation therapy with resolution of her dyspnea and was eventually discharged home. On her post-hospitalization appointment, she reported worsening HF symptoms despite being euvolemic on exam. CardioMEMS (2 months after PE) showed persistently elevated PA pressures. Due to concerns for PE into the LLL affecting the CardioMEMS readings, a right heart catheterization was performed which showed marked discrepancy between PA pressure and CardioMEMS readings. DISCUSSION: In the setting of a recent PE to the same PA branch where the CardioMEMS implant was located, it was presumed that the PE caused device malfunction by falsely elevating CardioMEMS readings. It is worthy to mention, however, that the PE spared the actual implant. Despite proper management of the acute PE, PA pressure remained falsely elevated even after 2 months of anticoagulation therapy. Thus, given the discordant PA pressure readings, it was necessary to recalibrate the device. As a result of the recalibration, the patient's HF management was appropriately optimized using data from the recalibrated CardioMEMS device. CONCLUSIONS: In the correct clinical context, discordance between implantable hemodynamic monitoring device readings and physical exam should prompt right heart catheterization, as an acute PE at the sensor site is a rare, but diagnosable and easily treatable cause of CardioMEMS malfunction. REFERENCE #1: CardioMEMS TM HF System. (2014, May). Retrieved from https://www.accessdata.fda.gov/cdrh_docs/pdf10/p100045c.pdf. REFERENCE #2: Abraham, W. T., Stevenson, L. W., Bourge, R. C., Lindenfeld, J. A., Bauman, J. G., & Adamson, P. B. (2016). Sustained efficacy of pulmonary artery pressure to guide adjustment of chronic heart. REFERENCE #3: failure therapy: Complete follow-up results from the CHAMPION randomised trial. The Lancet, 387(10017), 453-461. doi:10.1016/s0140-6736(15)00723-0. DISCLOSURES: No relevant relationships by Rafael Garcia-Cortes, source=Web Response No relevant relationships by Saarik Gupta, source=Web Response no disclosure on file for KATHLEEN MORRIS; No relevant relationships by Amjed Zidan, source=Web Response

Clinical Update of the Latest Evidence for CardioMEMS Pulmonary Artery Pressure Monitoring in Patients with Chronic Heart Failure: A Promising System for Remote Heart Failure Care.

The CardioMEMS pulmonary artery (PA) monitoring system placed in the left lower lobe pulmonary artery is capable of measuring pulmonary artery pressure remotely as a surrogate of intracardiac filling pressures and volume status. The technique is safe and reliable. By using remote PA monitoring for proactive medical interventions, there is a growing body of clinical evidence for a substantial, robust reduction in HF hospitalizations in various populations (clinical trial setting, post-marketing studies and real-world experiences). This review summarizes the clinical evidence, outlines future perspectives, and aims for remote patient care in heart failure using CardioMEMS.

PULMONARY ARTERY INTIMAL SARCOMA MISTAKEN FOR AN ACUTE PULMONARY EMBOLISM

SESSION TITLE: Fellows Lung Pathology Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary artery intimal sarcoma (ISPA) is an exceedingly rare tumor that arises from the vascular lumen of the pulmonary artery (PA). We present a patient who was initially thought to have an acute pulmonary embolism (PE) and later diagnosed with ISPA. CASE PRESENTATION: A 23-year-old woman initially presented to an outside hospital 6 months prior with progressive dyspnea. Imaging reportedly showed an acute PE in the right main PA and the patient was discharged on anticoagulation. Her symptoms worsened. Repeat imaging revealed a large 8.9 cm right hilar mass as well as a large filling defect extending from a stenosed right main PA, across the pulmonary trunk, into left lower lobe PA (Fig 1 A-C). The soft-tissue density and nodular appearance of the defect was more fitting with tumor than recurrent or chronic PE. Positron-emission tomography (PET) showed the right hilar mass was highly FDG avid and the vascular lesion mildly FDG avid, consistent with malignancy (Fig 1 D). The patient underwent percutaneous biopsy of the mass. Histopathology revealed a poorly differentiated sarcoma. FISH studies were positive for MDM2 (murine double minute 2). Together these findings were consistent with ISPA. The patient was started on chemotherapy with doxorubicin, ifosfamide, and mensa. Restage Imaging after 4 of 6 cycles showed a significant response to therapy (Fig 2), with the plan for surgical reconstruction with endarterectomy. DISCUSSION: Pulmonary artery sarcomas are an extremely rare malignancy, with an estimated incidence of 0.001-0.03% and only 200-400 cases described, the majority post-mortem. There appears to be a slight female predominance (1.3:1) with a mean age of diagnosis of 48 years (13-86 years). These tumors arise in the pulmonary trunk, either in the intimal (ISPA) or mural layer, and extend locally along the vasculature into the adjacent structures. The majority of patients present with symptoms of PE or right heart failure and are initially misdiagnosed. Diagnosis requires tissue biopsy. Histopathology often shows poorly differentiated, malignant spindle or epithelioid cells with atypia. Immunohistochemical staining is variable, sometimes with desmin or smooth muscle actin positivity. MDM2 is a proto-oncogene that regulates p53 activity and is highly expressed in the majority of ISPA. Surgical resection with endarterectomy is considered first line and confers a modest survival benefit (10 vs 1.5 months, compared to no surgery). Neoadjuvant chemotherapy improves surgical outcomes and survival, however due to its rarity, there is no consensus treatment and data is extrapolated from extrapulmonary sarcomas, often using doxorubicin-based regimens. CONCLUSIONS: ISPA is an incredibly rare malignancy that is often misdiagnosed a PE and carries an overall grim prognosis. Reference #1: Mussot S, et al. Retrospective institutional study of 31 patients treated for pulmonary artery sarcoma. Eur J Cardiothorac Surg. 2013 Apr;43(4):787-93. PMID 22843511 Reference #2: Assi T, et al. A comprehensive review of the diagnosis and management of intimal sarcoma of the pulmonary artery. Crit Rev Onc. 2020 Jan;147: 1040. Reference #3: Blackmon SH, et al. Management of primary pulmonary artery sarcoma. Ann Thorac Surg. 2009 87(3):977-984. DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: $5001 - $20000 Added 04/07/2020 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: $5001 - $20000 Added 04/07/2020 by Jaime Betancourt, source=Web Response, value=Honoraria No relevant relationships by Richard Watson, source=Web Response

Prenatal sonographic diagnosis of partial left pulmonary artery sling: A rare case report

Pulmonary artery sling is a rare congenital vascular anomaly. Partial anomalous left pulmonary artery is even rarer and no in utero observation has yet been reported. Here, we present the ultrasonographic findings of a 38-year-old woman at 32 weeks of gestation whose fetus showed a normal bifurcation of the pulmonary trunk into the right and left pulmonary arteries, but an anomalous origin of the left lower lobe pulmonary artery from the right pulmonary artery. These findings were confirmed by postnatal echocardiography and thoracic computed tomography.

Pulmonary bullet embolism following cardiac gunshot wound: case report of a bullet that traversed the heart twice

BackgroundCardiac gunshot wounds with bullet embolism (BE) into the pulmonary artery are rare. Most pulmonary BE follow injuries of peripheral veins without concomitant cardiac injury. Herein, we describe a case of cardiac gunshot injury in which the bullet migrated from right atrium through the inferior vena cava down to right internal iliac vein and back to the left pulmonary artery. Such bullet migration is too rare and unusual and to our knowledge not reported before.Case presentationOn March 4, 2019, a man of 39 had a bullet injury during celebratory gunfire. He was clinically stable with entrance on right posterior chest but no exit. Chest CT scan showed a bullet in the right atrium. The next day, the bullet migrated to the right pelvis as shown by plain chest and pelvic radiographs. CT angiography 3 weeks afterwards displayed the bullet in the right internal iliac vein. Meanwhile, the patient was asymptomatic, thus discharged home. However, 3 months later, he was readmitted because of chest pain, dyspnea, and sweating. A repeat chest CT scan showed the bullet in the left lower lobe pulmonary artery. Hence, pulmonary BE was suspected and eventually a 0.36 bullet was removed via left thoracotomy.ConclusionsThis is a case of symptomatic venous BE with typical diagnostic criteria (a small low-velocity bullet with inlet but no exit located away from anticipated trajectory with migration proven by serial radiographs). Endovascular removal was preferred but was not available. BE of the heart is exceedingly rare. Hence, diagnosis requires a high degree of clinical awareness.

Endovascular exclusion and open resection of aberrant pulmonary artery aneurysm associated with intralobar pulmonary sequestration

A 67-year-old man with recurrent left lower lobe pneumonia and abscess was referred for a calcified lesion within the left chest, initially detected on non-contrast-enhanced computed tomography (CT) scan. CT angiography revealed an aneurysmal, aberrant left lower lobe pulmonary artery with scarred lung parenchyma (A). The aneurysm was bilobed with a 3.6-cm maximum diameter in the distal portion. In addition, the artery was aneurysmal at its origin from the descending thoracic aorta (A), just above the diaphragm.

Toward Transpulmonary Chemoembolization with Degradable Starch Microspheres: Systematic Analysis of Local and Systemic Effects in a Porcine Model.

To investigate local and systemic effects of transpulmonary chemoembolization (TPCE) with degradable starch microspheres (DSM) and doxorubicin. The long-term goal is to establish DSM-TPCE as a treatment option for pulmonary malignancies. Nine pigs underwent TPCE of either the right or left lower lobe pulmonary artery (LLPA) and bland embolization (TPE) of the contralateral LLPA. Before the procedures, macroaggregated albumin (MAA) particles were injected into both LLPAs, to exclude systemic shunting. Pulmonary arterial pressure, heart rate and oxygenation were recorded immediately before and at 1, 3, 5 and 10min after treatment. To investigate possible nontarget embolization, animals underwent cerebral MRI (cMRI). We killed the animals after a contrast-enhanced chest computed tomography (CT) and performed a pathologic examination at 12h (3), 24h (3) and 72h (3) after treatment. All experiments were technically successful. Mean injected DSM dose until stasis was similar in TPCE and TPE (4.3 ± 1.4 vs. 4.0 ± 1.4mL). Pulmonary arterial pressure increased significantly 3min after treatment (TPE: 17 ± 5 vs. 27 ± 7mmHg; TPCE: 22 ± 6 vs. 36 ± 8mmHg). No significant changes in heart rate or peripheral oxygenation levels occurred. We observed no evidence of structural lung damage or permanent perfusion disruption on CT. MAA test injection and cMRI revealed no shunting or nontarget embolization. The pathologic assessment revealed nonspecific local inflammation of the lung parenchyma. In this large-animal model, TPCE and TPE appear feasible and safe. We observed a mild increase in pulmonary arterial pressure. Nontarget embolization did not occur. TPCE, as well as TPE, did not cause structural damage to the normal lung parenchyma.

SUN-206 Acute Cardiovascular Complications FromTestosterone Therapy

Background: Some studies have suggested Testosterone (T), especially parenteral administration may increase the short-term risk of thromboembolic events. We report 2 patients who developed acute cardiovascular complications following treatment with intramuscular injection of T. Case 1: A 43-year-old man was evaluated for erectile dysfunction and fatigue. History was significant for hypercholesterolemia treated with atorvastatin. On physical examination, vital signs, heart and lung examinations were normal. Testicular volume was 15 mL bilaterally. Lab revealed normal CBC, liver function, creatinine, and iron studies. A serum T level at 7am was 140 ng/dL; FSH 4.2mIU/mL, LH 3.8 mIU/mL, prolactin and TFT were normal. Pituitary MRI was normal. Patient was started on T enanthate 200 mg IM every 2 weeks. 6 weeks later, serum T level (obtained 7 days after injection) revealed a value of 480 ng/dL. 2 months following treatment the patient noted significant improvement. Four months after T treatment patient developed acute chest pain followed by cardiac arrest. Despite resuscitation, the patient expired after 45 minutes. Autopsy confirmed obstructions of left anterior descending coronary artery and right coronary artery. Case 2: A 48-year-old man was evaluated for erectile dysfunction and generalized muscle weakness. Past history and family history were noncontributory. Physical examination revealed normal vital signs and examination of the heart, lungs and abdomen was normal. Right testis 10 mL and left testis 15 mL in size. Lipid panel showed LDL 110 mg/dL, HDL 48 mg/dL. Serum T level at 8am was 135 ng/dL, FSH 3.1 mIU/mL, LH 2.8 mIU/mL, prolactin and TFT were normal. A pituitary MRI showed an empty sella. Patient was started on T injection 100 mg every 10 days. Six weeks later follow-up serum T (5 days after injection) was 466 ng/dL and serum estradiol was 39 pg/mL. Six months later he developed acute dyspnea and tachycardia. D-dimer value was 3260 ng/mL. CT angiogram revealed a thrombus in one of the left lower lobe pulmonary artery branches. Patient was treated in the intensive care unit with supportive care and anticoagulation. Follow-up evaluation confirmed factor V Leiden mutation. Discussion: T replacement is commonly given for hypogonadism but clinicians need to be aware of the potential rare adverse side effects such as acute cardiac events, as described in these 2 otherwise healthy patients with no known risk factors. In the second patient serum estradiol which may contribute to thrombosis was normal. The mechanism of these CV effects are unknown, but may be due to increased expression of platelet thromboxane A2 receptor and/or via other mechanisms especially in patients with procoagulant predisposition.

Pulmonary Arterial Stenting Complication: A Case Report about the Retrieval of a Stent Lost in a Child with Bilateral Glenn Shunt

Percutaneous stenting of the pulmonary artery is a diffuse procedure, above all in patients with congenital heart disease. The effectiveness of the procedure is associated with potential and feared complications. This case describes the embolization of a premounted stent into the left lower lobe pulmonary artery in a 3-years old patient with univentricular heart and left-side superior vena cava undergone to Norwood procedure modified according to Sano (stage I) and then bilateral cavo-pulmonary anastomosis according to Glenn (stage II). The retrieval procedures were complicated by the severe hypoplasia of the left pulmonary artery and by the complex anatomy of the patient. This case shows how to pull-back an embolized stent in a child with a complex congenital heart disease despite the limitations related to the low weight and the complex vascular anatomy.

IP269. Intraoperative Cone Beam Computed Tomography Pulmonary Angiography: An Effective Adjunct Imaging Tool for Rapid Diagnosis and Safe Catheter-Directed Thrombolysis

Submassive and massive pulmonary embolism (PE) is associated with high mortality, and effective treatment lies within a short window of time. In these instances, rapid diagnosis and treatment are vital for providing fast and efficacious care. We report a novel technique of intraoperative cone beam computed tomography pulmonary angiography (CBCT-PA) for diagnosis and treatment of PE in selected highly morbid cases. Between April 2015 and February 2016, patients who underwent intraoperative CBCT-PA were retrospectively reviewed. In our hybrid operating room equipped with a robotic angiography system (Artis zeego; Siemens Healthcare GmbH, Erlangen, Germany), CBCT-PA images were acquired using a 5-second CBCT protocol (syngo DynaCT; Siemens) after injection of 40 mL of 50% iodinated contrast material at 8 mL/s through a pigtail catheter in the main pulmonary artery. Four patients underwent intraoperative CBCT-PA during the study period. Two of four patients (50%) were hemodynamically unstable in the intensive care unit and deemed unstable for transfer to computed tomography imaging in the radiology suite. These patients were taken directly to the operating room under high suspicion of massive PE and for possible intervention. In one patient, CBCT-PA revealed a large embolus in the left pulmonary artery (Fig 1), prompting an attempt at mechanical thrombectomy. In the other patient, CBCT demonstrated only a small subsegmental embolus in the right lower lobe pulmonary artery (Fig 2), which made PE the unlikely cause for acute decompensation. In the remaining two patients, CBCT imaging was performed for follow-up after placement of thrombolytic catheters the day before. CBCT demonstrated residual clot in subsegmental branches, and thrombolytic catheters were repositioned. Both patients did well after removal of thrombolytic catheters and prescription of systemic anticoagulation. CBCT-PA is an effective adjunct imaging tool for diagnosis of PE in the operating room, especially in hemodynamically unstable patients, for whom transfer to the radiology imaging suite is often unsafe, and during catheter-directed thrombolysis. Until conventional computed tomography imaging becomes routinely available in the operating room, such novel intraoperative imaging options can be a valuable addition to the PE response team algorithm to optimize care in patients with PE.Fig 2Oblique coronal reconstruction of computed tomography image showing small embolus in the left lower lobe pulmonary artery (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Migration of a Nexplanon contraceptive implant to the pulmonary artery

This is a case report of a 17-year-old woman who experienced distant intravascular migration of a radio-opaque Nexplanon contraceptive implant. She presented with an impalpable implant and this was located...

A TWO-YEAR FOLLOW-UP OF A FEMALE PATIENT WITH RECURRENT PULMONARY THROMBOEMBOLISM AFTER SUCCESSFUL COMBINED TREATMENT

Objective: to describe a clinical case of recurrent pulmonary thromboembolism (PTE) with developed chronic thromboembolic pulmonary hypertension (CTEPH) and successful stenting of the pulmonary artery branch after ineffective thrombolysis. Patient Ch. born in 1978 was admitted to a cardiology unit with suspected PTE. The patient complained of obvious resting dyspnea increasing with minimal physical exercise. Blood test revealed leukocytosis, D-dimer just above the normal value. Electrocardiography showed sinus rhythm, right axis deviation, and complete right bundle-branch block. EchoCG indicated right hearth dilatation with an increase in systolic pressure gradient across the tricuspid valve up to 60 mm Hg. Lower extremity venous duplex scanning revealed a muscle vein dilated up to 14 mm with echogenic parietal deposits in the muscle thickness at the middle third of the right leg; compression was virtually complete; the valves were incompetent and a muscle vein irregularly dilated up to 7 mm in the middle third of the left leg; the walls were uneven; compression was complete. Angiopulmonography detected occlusion of the lower and middle lobe branches of the right pulmonary artery and the lower lobe branch of the left pulmonary artery. Results. It was decided to perform local thrombolysis in terms of the patient»s young age, obvious clinical symptoms (New-York Heart Association Functional Class (FC) III–IV dyspnea) and the data of earlier studies on the benefit from thrombolysis in intermediate-risk persons and a council of a vascular surgeon, a cardiologist, and an X-ray endovascular diagnosis and treatment physician, and an invasive specialist. The patient underwent local thrombolysis with purolase 6,000,000 IU. Control angiopulmonography revealed no positive changes in the branches of the pulmonary artery. Because of ineffective thrombolysis and the persistence of significant pulmonary hypertension and FC III–IV dyspnea, the patient underwent conduction recanalization of the area of left lower lobe pulmonary artery occlusion, percutaneous transluminal balloon angioplasty, and endoprosthesis replacement with an 8.0–29-mm holometallic peripheral stent. Control angiopulmonography showed that the arterial lumen was completely restored and blood flow was not distally embolized. Conclusion. This clinical case is an example of the delayed diagnosis of recurrent PTE, which was a reason for ineffective thrombolytic therapy that had been performed 11 days after the onset of an episode. In this situation, percutaneous transluminal balloon angioplasty and pulmonary artery branch stenting can improve the status of a patient and reduce the risk of CTEPH in the future. In spite of its apparent ease, angioplasty can cause problems: impossibility and hazard of enhanced contrasting of the pulmonary artery; extensive injury of its branches; arterial cicatricial process associated with multiple episodes of PTE. After angioplasty, patients may develop reperfusion pulmonary edema, the causes of which are fully unclear. However, the successful intervention makes it possible to lower pulmonary artery pressure, pulmonary vascular resistance, and blood NT-proBNP levels and to increase exercise tolerance. At the present time, a number of centers are performing such procedures in patients with CTEPH. This requires 2–3 balloon inflations per session. Holometallic stent placement can decrease the number of necessary inflations and reinterventions in the future. This clinical case demonstrates that pulmonary artery stenting is successful in the patient with recurrent PTE after ineffective thrombolysis.

Heparin Reduces Overcirculation-Induced Pulmonary Artery Remodeling Through P38 MAPK in Piglet

Artery remodeling is the principal change of pulmonary artery hypertension. Heparin has been shown to inhibit vascular smooth muscle cell proliferation. We hypothesized that heparin may modulate vascular remodeling in pulmonary artery hypertension, and explored the mechanism. A localized overcirculation-induced artery remodeling was created in piglets by anastomosing the left lower lobe pulmonary artery (LLLPA) to the thoracic aortic artery. Piglets were treated with heparin or saline for 4 weeks. Hemodynamic data were collected, and histology of the lung was assessed. We investigated the expressions of several candidate genes in lung and further observed the involvement of P38 mitogen-activated protein kinases (MAPK). The effects of heparin on the growth of cultured pulmonary arterial vascular smooth muscle cell and P38 MAPK expression were further determined under various conditions. Four weeks after the shunt setup, overcirculation caused significant LLLPA remodeling, pressure increase, and pulmonary vascular resistance increase, and LLLPA flow reduction compared with that immediately after the shunt setup. Heparin reduced the LLLPA remodeling, pressure, and pulmonary vascular resistance, and increased the LLLPA flow compared with that not heparin treated. Shunt and heparin treatment did not change the piglet's systemic hemodynamics. Shunt increased the expression of P38 MAPK and heparin decreased its expression in the shunted LLLPA. Both heparin and P38 MAPK inhibitor suppressed VSMC growth and P38 MAPK expression in the cultured VSMC, but they did not present additive effects when the two treatments were combined. Heparin reduces overcirculation-induced pulmonary artery remodeling through a P38 MAPK-dependent pathway.

Catheter-Directed Reperfusion Therapy after Unsuccessful Systemic Thrombolysis in a Patient with Evolving Sub-massive Pulmonary Embolism

Thrombolysis in sub-massive pulmonary embolism remains controversial. We present a case of a 52 year old obese male admitted for a 2-week history of dyspnea and swelling of the right leg. On admission, the patient was dyspneic and tachycardic. Venous duplex study showed acute partially occlusive thrombosis of the right femoral vein and totally occlusive thrombosis of the right popliteal vein. Echocardiography revealed a dilated right ventricle with severe pulmonary hypertension (95 mmHg). B-type natriuretic peptide and D-dimer levels were elevated. Computerized tomography (CT) angiogram showed a saddle thrombus in the main pulmonary artery with almost complete obstruction of the proximal left lower lobe segmental artery. Systemic thrombolysis with 100 mg of recombinant tissue plasminogen activator (r-TPA) was given, followed by low molecular weight heparin. Approximately 30 hours after thrombolysis, the patient had recurrence of dyspnea, and became hypoxemic. A repeat CT angiogram of the pulmonary arteries revealed an interval thinning of pulmonary embolus of the main pulmonary artery, interlobar arteries and proximal branches, but the obstruction of the proximal left lower lobe segmental artery was unchanged. Right heart catheterization revealed a pulmonary artery pressure (PAP) of 68/30 mmHg. Pulmonary angiogram showed a large thrombus at the right main pulmonary artery, and total occlusion of the left lower lobe pulmonary artery. Catheter-directed thrombolysis to the pulmonary artery was done with 50 mg of r-TPA, given over 2 hours. An inferior vena cava filter was also inserted. PAP decreased to 50 mmHg after catheter-directed thrombolysis. There was relief of dyspnea, and his heart rate normalized. This case demonstrated the safety and feasibility of systemic thrombolysis followed by catheter-directed thrombolysis in sub-massive pulmonary embolism and deep venous thrombosis done in the local setting.

Contraceptive Implant Embolism Into the Pulmonary Artery

A 36-year-old woman with a subdermal contraceptive implant Implanon (etonogestrel) (Merck Inc, Whitehouse Station, NJ), placed 7 months previously, requested device removal because of unwanted side effects from unopposed progesterone. The device could not be palpated in the arm. Upper arm ultrasonography and roentgenography were unsuccessful in locating the device. After an episode of chest pain, a chest roentgenogram revealed a foreign body projected over the left lower lobe pulmonary artery (Fig 1, arrow).

Assessment of ventriculo-arterial interaction in pulmonary arterial hypertension using wave intensity analysis

To the Editor: Wave intensity analysis (WIA) is a recently described haemodynamic analysis methodology which enables assessment of ventriculo-arterial interactions via time-domain analysis of pressure and flow waveforms [1]. It enables quantification of wave energy, separation of waves into forward and backward components, and estimation of wave speed [2]. To date, WIA has not been applied to the pulmonary arterial circulation in humans. As WIA offers a potential novel approach for the study of pulmonary haemodynamics, the present study sought to evaluate the feasibility of invasive WIA of the pulmonary circulation during right heart catheterisation (RHC). The study was approved by the institutional review board (Sydney Local Health District Ethics Review Committee (RPA Zone)) and consent was obtained from seven controls (mean±sd age 69±9 years, three females) and six patients (age 56±13 years, four females) with pulmonary arterial hypertension (PAH). Control subjects presented to the cardiac catheterisation laboratory for investigation of possible coronary artery disease. Following standard pulmonary haemodynamic measurements (including thermodilution cardiac output), a combined dual-tipped pressure and Doppler wire (ComboWire; Volcano, Rancho Cordova, CA, USA) was positioned distal to the origin of the right or left lower lobe pulmonary artery via a 6 Fr multipurpose catheter (Mach 1; Boston Scientific, Natick, MA, USA) under angiographic guidance. Pressure and flow measurements were acquired simultaneously at a sampling frequency of 1000 Hz, once stable signals were obtained. Data were processed offline using customised MatLab software (MathWorks, Natick, MA, USA). Signals were ensemble-averaged with timing gated to the ECG R-wave and smoothed using a Savitzky–Golay filter [3]. Intrinsic hardware processing delays (between pressure and flow signals) were corrected by shifting signals to achieve a linear pressure–flow (P–U) relationship in early systole [4]. Wave speed (c) was derived from the P-U loop method …

Migrating bullet: A case of a bullet embolism to the pulmonary artery with secondary pulmonary infarction after gunshot wound to the left globe

Bullet embolism is a rare phenomenon following gunshot injuries. We present a case of a 25-year-old male who sustained a gunshot wound to his left globe with the bullet initially lodged in his right transverse sinus. The bullet ultimately embolized to a left lower lobe pulmonary artery resulting in a pulmonary infarct. A discussion of select prior cases, pathophysiology, and management strategies follows.

Isolated absence of right pulmonary artery: Radiographic and multi-detector CT demonstration

Isolated absence of right pulmonary artery: Radiographic and multi-detector CT demonstration