Lower Lobe Pulmonary Artery Research Articles

Life Story of a Mycotic Pulmonary Artery Aneurysm

A 29-year-old woman with a history of IV heroin use presented to the emergency department with hemoptysis. Prior to admission, she had a large tricuspid valve vegetation with embolism to the left lower lobe (Figure 1A). At that time, she had an embolic event to the right lower lobe pulmonary artery (Figure 1B) and underwent tricuspid valvuloplasty. Intraoperative microbiology confirmed Candida albicans.

ОЦЕНКА БЛИЖАЙШИХ И ОТДАЛЕННЫХ РЕЗУЛЬТАТОВ АКУШЕРСКОГО КРОВОТЕЧЕНИЯ С ЭМБОЛИЗАЦИЕЙ МАТОЧНЫХ АРТЕРИЙ И ПЕРЕНЕСЕННОЙ КОРОНАВИРУСНОЙ ИНФЕКЦИЕЙ (КЛИНИЧЕСКИЙ СЛУЧАЙ)

The study aims to present a complicated clinical case of a woman who almost died due to comorbid obstetric pathology associated with a coronavirus infection. The term “near miss” refers to the detailed analysis of each clinical case classified as a critical obstetric condition, as well as the registration of patients with such conditions in the Russian register established in 2021 to prevent maternal mortality and make management decisions. A severe clinical near miss case of a female patient included the following serious obstetric syndromes: postpartum obstetric hemorrhage followed by uterine artery embolization, endomyometritis by the third day, partial thrombosis of the branches of the right lower lobe pulmonary artery by the seventh day, thrombosis of parametrial vessels, partial necrosis of the uterus by the eighth day, and a new coronavirus infection COVID-19 by the thirteenth day after delivery. The complexity of diagnosis and treatment is demonstrated in the results of the study in the acute period and in the outcome of the disease.

Clinical and Predictive Value of Computed Tomography Angiography in High-Altitude Pulmonary Hypertension.

High-altitude pulmonary hypertension (HAPH), as the group 3 pulmonary hypertension, has been less studied so far. The limited medical conditions in the high-altitude plateau are responsible for the delay of the clinical management of HAPH. This study aims to identify the imaging characteristics of HAPH and explore noninvasive assessment of mean pulmonary arterial pressure (mPAP) based on computed tomography angiography (CTA). Twenty-five patients with suspected HAPH were enrolled. Right heart catheterization (RHC) and pulmonary angiography were performed. Echocardiography and CTA image data were collected for analysis. A multivariable linear regression model was fit to estimate mPAP (mPAPpredicted). A Bland-Altman plot and pathological analysis were performed to assess the diagnostic accuracy of this model. Patients with HAPH showed slow blood flow and coral signs in lower lobe pulmonary artery in pulmonary arteriography, and presented trend for dilated pulmonary vessels, enlarged right atrium, and compressed left atrium in CTA (P for trend<0.05). The left lower pulmonary artery-bronchus ratio (odds ratio: 1.13) and the ratio of right to left atrial diameter (odds ratio: 1.09) were significantly associated with HAPH, and showed strong correlation with mPAPRHC, respectively (r=0.821 and r=0.649, respectively; all P< 0.0001). The mPAPpredicted model using left lower artery-bronchus ratio and ratio of right to left atrial diameter as covariates showed high correlation with mPAPRHC (r=0.907; P< 0.0001). Patients with predicted HAPH also had the typical pathological changes of pulmonary hypertension. Noninvasive mPAP estimation model based on CTA image data can accurately fit mPAPRHC and is beneficial for the early diagnosis of HAPH.

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.

ACUTE PULMONARY EMBOLISM IN A PATIENT WITH A NORMAL D-DIMER

ACUTE PULMONARY EMBOLISM IN A PATIENT WITH A NORMAL D-DIMER

Using barium as an internal radioprotective shield for pregnant patients undergoing CT pulmonary angiography: A retrospective study

PurposeThe purpose of our retrospective study was to assess the effect of barium sulfate contrast medium on radiation dose and diagnostic quality of CT Pulmonary Angiography (CTPA) in an in-vivo study of pregnant patients. MethodsOur retrospective study included 33 pregnant patients who underwent CTPA to exclude pulmonary embolism. The patients received oral 40% w/v barium solution just prior to the acquisition of their planning radiograph. All CTPA were performed on 64-slice, single-source CT scanners with AEC with noise index = 28.62–31.64 and the allowed mA range of 100–450. However, only 5/33 patients had mA modulation (AEC 100–450 mA range), while 28/33 patients had mA maxed out at the set maximum mA of 450 over the entire scan range. We recorded CTDIvol (mGy), DLP (mGy.cm) and scan length. The same information was recorded in weight-and scanner-matched, non-pregnant patients. Statistical tests included descriptive data (median and interquartile range) and Mann-Whitney test. ResultsThere were no significant differences in CTDIvol and DLP between the barium and control group patients (p > 0.1). The median mA below the diaphragm was significantly higher in each patient with barium compared to the weight and scanner-matched patient without barium. Evaluation of lung and subsegmental lower lobe pulmonary arteries was limited in 85% barium group. Due to thin prospective section thickness (1.25 mm), most patients were scanned at maximum allowed mA for AEC. ConclusionUse of AEC with thick barium in pregnant patients undergoing CTPA as an internal radioprotective shield produces counterproductive artifacts and tube current increments.

A Case Report of Sagittal Sinus Thrombosis and Pulmonary Embolism in an Asymptomatic SARS-CoV-2 Infection

Background: Vascular thrombotic events such as pulmonary embolisms have been frequently reported in the course of SARS-Cov-2 infection. However, sagittal sinus thrombus is extremely rare, and patients may lack other appealing Covid-19 infection symptoms. Case report: 46-year-old female with past medical history of Hyperlipidemia, Hypertension presented to Emergency room with headache, chest pain, vomiting. SARS-CoV-2 IgG Antibodies were reactive. Except for elevated PTT-Lupus Anticoagulant at 50 Sec, Hypercoagulable workup was negative. The MRI venogram findings were consistent with the Dural thrombus of superior sagittal sinus. Patient subsequently developed chest pain, and Computed tomography angiography found pulmonary emboli within segmental branches of the right lower lobe pulmonary artery. Patient was managed in the ICU with Heparin and switched to Coumadin for discharged. Conclusion: The incidence of Cerebral Venous Sinus thrombus (CVST) among Covid-19 patients is inferior to 0.02%. And most of the patients lack typical Covid-19 presentations such as pneumonia. The lack of symptoms may promote the insidious course of pre-thrombotic events that lead to CVST. However more Retrospective studies are necessary to established consistent odd ratios. Due to the higher mortality associated with CVST and the ongoing of Covid-19 pandemic, we recommend a higher level of clinical suspicion.

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.

Stent Migration: Dangerous Flight but Safe Landing

A 59-year-old woman with a brachiocephalic fistula underwent balloon dilation of a stenosis to 5-mm diameter (Fig 1) and subsequent 5-mm × 5-cm stent graft placement (VIABAHN, Gore, Flagstaff, Arizona) (Fig 1). An attempt was made to postdilate the stent graft to 6 mm. Three months later, fistulography for recurrent dysfunction revealed disappearance of the stent graft. Fluoroscopy and contrast-enhanced computed tomography scan showed that the stent graft had migrated to a right lower lobe pulmonary artery branch and remained patent (Fig 2a, b).

Subacute Cardiac Tamponade in a Patient with Malignancy

We hereby present a 57-year-old woman with a history of asthma and hypertension who presented to the emergency department with shortness of breath, syncope and loss of consciousness. Patient complained of decreased appetite, constipation and 20lbs weight loss over one month. Patient denied fever, chills, chest pain, nausea, vomiting, headache, pain or swelling in lower extremity, trauma, hemoptysis. Vitals at presentation: temperature 99.8 F, pulse 124 bpm, BP 135/93 mm Hg, respiratory rate 18 pm, oxygen saturation 96% on room air. Non-contrast CT scan of the brain was unremarkable. Cervical spine CT did not show any acute bony fracture or subluxation or central canal stenosis. Chest xray showed right upper lung infiltrate and very small right pleural effusion. Chest CT showed: small pulmonary emboli involving right lower lobe and left upper lobe sub segmental pulmonary arteries, large pericardial effusion, right upper lobe ground glass pulmonary infiltrates, right upper lobe pulmonary mass with multiple bilateral pulmonary nodules concerning for metastatic process, small right-sided pleural effusion, bilateral hilar and mediastinal lymphadenopathy concerning for metastatic disease, multiple ill-defined hepatic lesions. EKG showed sinus tachycardia without electrical alternans. Echocardiogram showed: left ventricular ejection fraction 50- 55%, grade 1 diastolic dysfunction consistent with impaired relaxation and normal filling pressures. There is a large circumferential pericardial effusion and right ventricular diastolic collapse suggesting tamponade physiology evident on echocardiogram. Pericardiocentesis was done, about 700 cc of fluid was removed and the patient’s symptoms improved. This patient had pericardial effusion most likely due to malignancy. Pericardial fluid buildup and subsequent tamponade in a malignancy is usually subacute. In malignancy, fluid accumulates slowly, pericardium stretches with time allowing ample fluid to be accumulated vs in an acute tamponade as there is very rapid, large pericardial effusion, pericardium does not have time to stretch and may present with more alarming signs and symptoms. Sub-acute tamponade as is seen in malignancy presents with less alarming signs and symptoms and might be missed. Patients with subacute tamponade may be asymptomatic or complain of fatigability, chest discomfort, dyspnea caused by decreased cardiac output and increased filling pressures.

Mycotic aneurysms of pulmonary artery secondary to pulmonary valve endocarditis in a child

We present the case of a 7-year-old child with mycotic aneurysms of bilateral lower lobe pulmonary arteries secondary to pulmonary valve endocarditis. The child underwent pulmonary vegetectomy with ventricular septal defect closure and left lower lobe pulmonary lobectomy via midline sternotomy.

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 PSEUDOANEURYSM DISGUISED AS MALIGNANT LESION

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary artery pseudoaneurysms (PAPs) are rare, associated with cardiovascular disease, and have potentially life-threatening complications such as exsanguination. They may be iatrogenic, or related to trauma, infection, neoplasm, pulmonary hypertension, or vasculitis. Patients with PAPs may be asymptomatic or present with hemoptysis. CASE PRESENTATION: Patient is a 67-year-old female with a significant medical history of PAF, HFrEF, DM, HTN, breast cancer s/p lumpectomy, & colon cancer s/p partial colectomy was admitted for generalized weakness & shortness of breath on exertion. She was admitted about two weeks prior for pneumonia and streptococcus agalactiae bacteremia, developed new onset atrial fibrillation, and was discharged home on Eliquis and Augmentin. Vitals were: T 98 F, BP 110/50, HR 80, RR 16, O2 sat 98 % on RA. Physical exam was unremarkable except trace pitting edema bilaterally. Lab studies including metabolic panel, cell counts, & troponins were unremarkable. BNP was elevated at 290. Echocardiogram showed EF 35%, moderate LVH paradoxical septal motion, posterior mitral valve leaflet prolapse, & moderate circumferential pericardial effusion. Chest x-ray was negative for any infiltrate & CT scan of the chest without contrast showed a right lower lung lobe opacity suspicious for malignancy Her symptoms were thought to be as a result of multifactorial etiologies including possible underlying pneumonia & exacerbation of CHF. Patient was started on broad spectrum antibiotics. Patient was scheduled for CT chest angiogram with IV contrast before proceeding with a biopsy of the right lower lobe mass, which in turn showed a 3 cm pseudoaneurysm with connection to the branch of right lower lobe pulmonary artery. Following this discovery on imaging studies, patient underwent IR-guided ablation & coiling. The first attempt at embolization was aborted after hemodynamically significant extravasation from the right lung was noted after angiographic runs. Patient was intubated for airway protection. While intubated, patient underwent a second successful attempt of IR-guided procedure. Eventually she was extubated and discharged home. DISCUSSION: Pulmonary Pseudoaneurysm (PA) is rare and potentially life threatening. It may be idiopathic or traumatic, infection, primary or metastatic lung neoplasm, Pulmonary HTN, or vasculitis. Most cases are asymptomatic, but may present with dry cough & hemoptysis. MDCT angiogram of the chest remains the investigation of choice in the diagnosis of PA. These cases are managed with Urgent endovascular procedure (Coil Embolization) or Surgery [ Open thoracotomy and aneurysm resection with lobectomy for involved lobes] CONCLUSIONS: Pulmonary artery pseudoaneurysms should be on the differential diagnosis for any lung mass or nodule. Prior to obtaining a biopsy of a suspected lung mass or nodule, patients should always undergo a CT chest with IV contrast. Reference #1: Pulmonary Artery Pseudoaneurysms: Clinical Features and CT Findings Ying Chen1, Matthew D. Gilman1, Kathryn L. Humphrey2, Gloria M. Salazar1, Amita Sharma1, Ashok Muniappan3, Jo-Anne O. Shepard1 and Carol C. Wu1 Reference #2: E. Jean-Baptiste, “Clinical assessment and management of massive hemoptysis,” Critical Care Medicine, vol. 28, no. 5, pp. 1642–1647, 2000. View at: Publisher Site | Google Scholar Reference #3: Lafita V, Borge MA, Demos TC. Pulmonary artery pseudoaneurysm: etiology, presentation, diagnosis, and treatment. Semin Intervent Radiol. 2007;24(1):119-123. DISCLOSURES: No relevant relationships by Sharath Bellary, source=Web Response No relevant relationships by Sudipa Chowdhury, source=Web Response No relevant relationships by William Meng, source=Web Response No relevant relationships by Richard Miller, source=Web Response No relevant relationships by SUMITANAND MISHRA, source=Web Response No relevant relationships by Rutwik Patel, source=Web Response No relevant relationships by Hari Sharma, source=Web Response

A CASE OF PULMONARY VEIN THROMBOSIS WITH EXTENSION INTO THE LEFT ATRIUM

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary vein thrombosis (PVT) is a rare and often misdiagnosed condition due to nonspecific symptoms at presentation. PVT is most commonly associated with lung malignancy, recent major pulmonary surgery, or atrial fibrillation. Symptoms generally include cough, dyspnea, nonspecific chest pain, and hemoptysis, similar to pulmonary embolism. Delay in diagnosis can be lethal. CASE PRESENTATION: A 76-year-old female with hyperthyroidism, history of DVT in 2018 previously on rivaroxaban, venous insufficiency and hypertension presented with cough, congestion, and progressive fatigue for 3 days. She was increasingly dyspneic at rest and with activity the day prior to admission. She required supplemental oxygenation with 2 L/minute via nasal cannula on evaluation at our emergency center. She additionally tested positive for influenza A and B. She denied chest pain, palpitations, or orthopnea, but did have associated worsening right lower extremity edema. Bilateral lower extremity venous duplex showed evidence of an acute thrombus in the right common femoral, superficial femoral, deep femoral, and popliteal veins; the left leg had no thromboses. Given evidence of acute DVT and acute hypoxemic respiratory failure on presentation, a CT PE protocol was done, noting a thrombus in the left lower pulmonary vein that extended into the left atrium (figures 1-3), with chronic occlusion of the left lower lobe pulmonary arteries as well as enlarged pulmonary arteries. She was initially treated with a heparin drip from 1/23/2020 to 1/27/2020, then she was transitioned to oral anticoagulation with rivaroxaban 20 mg PO daily. She maintained resting oxygen saturations on room air for three days prior to discharge on 1/28/2020 and her respiratory symptoms improved significantly. She had no evidence of underlying malignancy at the time. She has followed up twice with her primary care physician, remains on oral anticoagulation, and has had no respiratory complaints since discharge. Pending outpatient hypercoagulable workup and repeat chest imaging, which was recommended in 6 months. DISCUSSION: PVT is a rare yet life threatening condition if undiagnosed. It can lead to pulmonary hypertension, cor pulmonale, TIA or stroke, and even pulmonary infarction or gangrene. Though there is no present gold standard for diagnosis of PVT, CT pulmonary angiography led to the diagnosis in this case. CONCLUSIONS: Chronic anticoagulation is the mainstay of therapy for PVT. Though some cases may be idiopathic, it is prudent to investigate further for hypercoagulable states, including malignancy. Reference #1: Chaaya, G., & Vishnubhotla, P. (2017). Pulmonary Vein Thrombosis: A Recent Systematic Review. Cureus, 9(1), e993. https://doi.org/10.7759/cureus.993 Reference #2: Rana, M. A., Tilbury, N., & Kumar, Y. (2016). Idiopathic pulmonary vein thrombus extending into left atrium: a case report and review of the literature. Hindawi Publishing Corporation: Case Reports in Medicine, 2016, (article ID 3528393), 1-3. https://www.hindawi.com/journals/crim/2016/3528393/ Reference #3: Sahay, S., & Lodato, R. (2013). Pulmonary vein thrombosis: a rare entity. CHEST Journal, 144 (4_MeetingAbstracts). https://journal.chestnet.org/article/S0012-3692(16)42762-5/fulltext DISCLOSURES: No relevant relationships by Kendall Creed, source=Web Response No relevant relationships by Peter Khalil, source=Web Response No relevant relationships by Victor Test, source=Web Response No relevant relationships by Alexandra Wichmann, source=Web Response

O05 Active Bechet's with life threatening arterial disease, complicated by concurrent COVID-19 infection at the peak of the COVID-19 pandemic: did immunosuppression help or hinder?

O05 Active Bechet's with life threatening arterial disease, complicated by concurrent COVID-19 infection at the peak of the COVID-19 pandemic: did immunosuppression help or hinder?

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.

Methylene Blue/Collagen Mixture for CT-Guided Presurgical Lung Nodule Marking: High Efficacy and Safety

PurposeTo assess outcomes of computed tomography (CT)-guided methylene blue/collagen marking of preoperative lung nodules before video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS). Materials and MethodsA retrospective cohort study assessing 25 methylene blue/collagen solution CT-guided lung nodule localization procedures on 26 nodules in 25 patients was performed. The procedures were performed by a fellowship-trained radiologist 1–2 hours before scheduled surgery under local anesthesia. Approximately 4–6 ml of methylene blue/collagen solution was injected in a perinodular location under CT guidance with a 19-gauge trocar needle and along the track to the visceral pleural surface. Post-procedural CT images confirmed appropriate lung nodule location marking. ResultsPerinodular CT-guided trocar needle placement was achieved in all marking procedures (n = 26/26). Increased consolidation near the target nodule was also demonstrated in all patients on the post-procedural localized CT scans. One patient with moderate emphysema developed a small to moderate-sized pneumothorax (∼20%–30%), and an 8-Fr thoracentesis catheter was placed under CT guidance before surgery. There was no bleeding or hemoptysis in any patient. Methylene blue/collagen solution was readily visible by the thoracic surgeon in association with all target nodules. One patient required conversion to open procedure due to the proximal portion of the right lower lobe pulmonary artery segmental branch. Of the 26 identified nodules, pathology specimens confirmed the adequacy of nodule resection in all cases. ConclusionsPreoperative CT-guided methylene blue/collagen solution injection offers a safe and highly effective technique for marking subpleural lung nodules undergoing VATS or RATS.

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.

P885 Pulmonary artery stent implantation in an adult with chronic thromboembolic pulmonary stenosis

Abstract Introduction Pulmonary artery stenosis presenting in adults is rare. Chronic thromboembolic pulmonary hypertension (CTEPH) is by far the most common cause of pulmonary artery stenosis. Stenosis in these patients are not caused by an abnormality of the arterial wall itself, but by intraluminal narrowing as a result of the only partially resolved and organized thromboembolism. In contrast to paediatric patients, in adults with pulmonary artery stenosis, pulmonary stenting is not routinely performed. Case report A 51-year male, smoker, diabetic, hypertensive, and with chronic kidney disease. He was diagnosed two years earlier with bilateral multiple pulmonary emboli and was maintained on oral anticoagulation therapy. Recently, he presented with gradually progressive shortness of breath and signs of right ventricular failure. Diagnostic imaging: 1-Transthoracic and transesophageal echocardiography showed normal global systolic left ventricular function with no regional wall motion abnormalities, dilated right ventricle (RV) with moderately impaired function, severe pulmonic valve incompetence, mild tricuspid incompetence and a severely elevated right ventricular systolic pressure (RVSP) of 82 mmHg. In addition, a small rounded mass (6 x 11 mm) was visualized attached to the posterior wall of the RV outflow tract (RVOT) about 15mm proximal to the pulmonary valve annulus, (figure A). 2- Computed tomography pulmonary angiography showed a right main pulmonary artery (RPA) with circumferential narrowing, which was highly suggestive of chronic thrombosis. There was an abrupt tapering noted in the segmental branches of the right lower lobar pulmonary artery, with non-opacification of the distal arteries. No contrast opacification was noted in the right upper lobe pulmonary arteries. The left main pulmonary artery showed thickening of its bifurcation, again suggestive of chronic thrombosis, with narrowing of its left upper lobar branch, (figures B&amp;C). 3-Cardiac magnetic resonance (CMR) showed a non enhancing RVOT mass protruding through the incompetent pulmonary valve during systole with features suggestive of a thrombus. Management In view of the clinical history, CTEPH was considered to be the most likely aetiology of the pulmonary hypertension. The decision was to perform balloon angioplasty and stent implantation in the RPA. Immediately after the procedure, RVSP was reduced from 80 to 50 mmHg. The clinical course after this procedure was uncomplicated and the patient showed significant clinical improvement. Follow up CMR showed patent stent with improvement of RV function ( fig D) Abstract P885 Figure.

1357. Mycobacterium abscessus Native Tricuspid Valve Endocarditis. Is a 6-Week Course of Combination Antibiotic Therapy Enough?

BackgroundInfective endocarditis of the native heart valves due to M. abscessus has been reported in individuals who inject drugs. Only one case thus far has been reported with survival beyond 4 months after completion of antibiotic therapy. 24-year-old Caucasian woman with a history of intravenous drug use presented with intermittent fevers for 3–4 months. She was having chills, night sweats, and productive cough. She acknowledged using intravenous cocaine and heroin every few days after being discharged from our hospital 6 months previously when she was treated for tricuspid valve endocarditis. Chest radiograph demonstrated right lower lobe airspace disease suggestive of pneumonia. Three days later her blood cultures grew acid-fast bacilli, later identified as M. abscessus.MethodsShe was empirically treated with azithromycin, amikacin, and imipenem. Transthoracic and transesophageal echocardiograms were suggestive of tricuspid valve endocarditis. CT angiogram of the chest showed filling defects within several large right lower lobe pulmonary arteries and dense right lower lobe consolidation with pleural effusion. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and therapeutic thoracoscopy with drainage and thoracostomy tube placement. BAL cultures also grew AFB. Multiple sets of blood cultures drawn after commencement of antibiotic therapy during the hospital course were negative. Drug susceptibilities were available 3 weeks later. The isolate was susceptible to amikacin. Linezolid, imipenem, and cefoxitin exhibited intermediate activity, and TMP/SMX, ciprofloxacin, moxifloxacin, doxycycline, minocycline, and clarithromycin were reported resistant. Inducible erm gene was present. Azithromycin and linezolid were discontinued and tigecycline was added.ResultsPatient completed 6 weeks of antibiotics from the day of the first negative blood culture. Repeat TTE 1 month after completion of therapy revealed a decrease in tricuspid valve vegetation. Blood culture done 3 months later was sterile. AFB blood cultures done a year later did not report any growth.ConclusionThis case opens a debate, if in a selected group of patients, a short course of combination antibiotic therapy is enough to obtain cure. This will require further analysis. Disclosures All authors: No reported disclosures.