Obstructive Shock Research Articles

Pediatric pleuropulmonary blastoma: analysis of four cases

BackgroundPleuropulmonary Blastoma (PPB) is an extremely uncommon, highly aggressive tumor that arises from either the lungs or pleura. According to Dehner, PPB was classified into three groups: type I (cystic), type II (mixed), and type III (solid). Type I tends to occur more commonly in infants and has a more favorable prognosis compared to types II and III. This tumor is very rare in pediatric age group; hence, there is no consensus on the optimal treatment regimen for it to date. Type I tumors, which resemble congenital lung cysts, can eventually progress to more aggressive type II and type III tumors. This article aims to increase general awareness of this pathology, clinical presentation, and differential diagnosis in order to identify this rare entity early in its course. By presenting 4 such cases, we highlight that PPB can be missed early in diagnosis and it is important to be alert when putting this rare tumor in differential diagnosis of cystic lung lesions.MethodsA retrospective study was conducted between 2015 and 2020 involving patients who had a definitive diagnosis of PPB with emphasis on clinical presentation, preoperative imaging studies, intra-operative findings, pathological reports, ancillary treatment, and outcomes. All patients were followed up every 6 months to monitor local recurrence and distant metastasis by undergoing physical exam and non-contrast enhanced CT of the chest. The primary outcome is to identify the mortality and morbidity (recurrence and distant metastasis) of PPB for cases admitted in our institute.ResultsFour children were diagnosed with PPB during the study period. Clinically, patients presented with manifestations ranging from respiratory distress, fever to obstructive shock and radiologically, 2 cases were presented with mediastinal mass and the other 2 presented with pneumothorax. Regrettably, none of the cases were diagnosed pre-operatively. One lesion proved to be type I, 2 were type II and one was type III. All cases underwent chemotherapy using the combination of vincristine, Adriamycin and cyclophosphamide (VAC regimen). Recurrence was detected in a type II case, around 2 years after operation, and the other type II case developed brain metastasis that was discovered 3 years after operation. Type I case showed no local or distant metastasis.ConclusionA prompt preoperative diagnosis and workup of cases of PPB is crucial to enable optimal intervention intraoperatively and early postoperative treatment. Though it is uncommon, PPB should be considered in the differential diagnosis of cystic lung lesions.

Historical Left Atrial Myxoma Causing an Obstructive Shock

Learning Objectives: - Explore the clinical presentation and diagnosis of cardiac myxoma. -Find out the potential complications of cardiac myxoma, such as embolic events and heart failure. -Understanding the role of echocardiography in the diagnosis and management of cardiac myxoma. Background: Cardiac myxoma, an uncommon tumor forming in the heart, tends to occur in the left atrium and is generally non-cancerous in nature. The composition, size, and position of the tumor can lead to a range of varied signs and symptoms. These symptoms can range from barely noticeable to severe and may include heart ailments, pulmonary hypertension, and even strokes. The usual course of treatment involves surgical removal of the tumor to resolve the issue. Case Presentation: This manuscript presents a case report of a 33-year-old male patient who presented with sudden dyspnea and was diagnosed with an extraordinarily large left atrial myxoma causing cardiogenic shock. Despite plans for surgery, the patient's condition rapidly deteriorated and he eventually died due to persistent intracardiac obstruction. The article discusses the rarity of primary tumors in the heart, with myxoma being the most prevalent, and the non-specific symptoms that can manifest in a variety of ways, including cardiac, embolic, and systemic symptoms. The importance of echocardiography in diagnosing cardiac tumors and the potential complications of atrial myxomas, including mitral valve obstruction, congestive heart failure, and sudden death, are also discussed. Conclusion: The presence of a giant left atrial myxoma, although benign, can cause severe symptoms and even be life-threatening. Diagnosis is made through echocardiography, and surgical removal of the tumor is the recommended treatment, which should be performed promptly upon diagnosis.

A Rare Case of Obstructive Shock: Right Atrial Hematoma Secondary to Aortic Dissection.

A Rare Case of Obstructive Shock: Right Atrial Hematoma Secondary to Aortic Dissection.

Diagnostic confusion caused by tension gastrothorax – Case series

Abstract The presence of the stomach in the thorax is called gastrothorax. If excessive dilatation occurs due to a valve mechanism in the stomach which then is herniated into the thorax, it is called tension gastrothorax and the situation can be life-threatening. In late presentation, congenital diaphragmatic hernias or traumatic diaphragmatic hernias, if the stomach located in the thorax is severely distended, it can be confused with tension pneumothorax or pleural effusion/empyema. We presented tension gastrothorax in two patients with distended stomach in the thorax, in which tension pneumothorax and pleural effusion/empyema-like images were created, based on plain X-rays taken at the first admission in the emergency department, which may cause diagnostic confusion. The tension gastrothorax can cause mediastinal shift, which can lead to respiratory distress and eventually cardiac arrest secondary to obstructive shock. In case of mediastinal shift, it should reduce the tension of the stomach located in the thorax by inserting a nasogastric catheter, and if this fails, by aspiration with a needle.

Ultrasonographic Effectiveness in Hypotensive Patients

Objective: This study aimed to investigate the efficacy of sonography in reducing morbidity and mortality among patients with shock, particularly in the emergency department (ED). By employing the “Rapid Ultrasound for Shock and Hypotension” (RUSH) protocol with ED patients, the aim was to assess its contribution to patient outcomes. Materials and Methods: This prospective, cross-sectional study spanned 2 years and was conducted in a university-based emergency department. Overall, 100 adult patients with blood pressure ≤90/60 mmHg and shock index >1 were enrolled. The RUSH protocol was followed for each patient. Results: The study comprised 35 females and 65 males, with a mean age of 57.12 ± 17.1 years. The RUSH assessment indicated that 50 patients had fluid volume indices below 1.5 cm, predominantly presenting with hypovolemic shock (55%). Extended Focused Assessment with Sonography in Trauma (E-FAST) examination revealed free abdominal fluid in 18% of the patients. Cardiogenic shock, including arrhythmia and heart failure, was diagnosed in 9 patients each. Nine patients experienced obstructive shock. Initial RUSH protocol diagnoses included hypovolemic shock ( n = 55), distributional shock ( n = 19), cardiogenic shock ( n = 8), obstructive shock ( n = 6), and complex shock ( n = 12). Conclusion: The RUSH protocol has emerged as an early, systematic, and practical method for assessing patients with hypotension and shock in the ED. It may also offer the potential to enhance patient management and outcomes.

New risk classification adapting SCAI shock stages to patients with pulmonary embolism (RISA-PE).

Pulmonary embolism (PE) treatment is based on risk stratification according to European Society of Cardiology (ESC) guidelines. However, emerging therapies in acute PE may require a more granular risk classification. Therefore, the objective of the present study was to propose a new RIsk claSsification Adapting the SCAI shock stages to right ventricular failure due to acute PE (RISA-PE). This registry included consecutive intermediate-high risk (IHR) or high-risk (HR)-PE patients selected for catheter-directed interventions (CDI) from 2018 to 2023 in 15 Spanish centers (NCT06348459). Patients were grouped according to RISA-PE classification as A (right ventricular dysfunction and troponin elevation); B (A + serum lactate >2 mmol/L OR shock index ≥1); C (persistent hypotension); D (obstructive shock); and E (cardiac arrest). In-hospital adverse events were assessed to evaluate RISA-PE performance. A total of 334 patients were included (age 62.1±15.2 years, 55.7% males). The incidence of in-hospital all-cause death was progressively higher with increasing RISA-PE stage (1.2%, 6.4%, 19.0%, 25.6%, and 57.7% for stages A, B, C, D, and E, respectively, P value for linear trend<0.001). However, using the ESC classification, there was an abrupt difference between IHR- and HR-PE patients regarding mortality (4.3% vs. 29.3%, P<0.001). The incidence of in-hospital major bleeding and acute kidney injury followed a similar pattern. The user-friendly RISA-PE classification may improve the granularity in stratifying PE patients' risk and warrants evaluation in larger studies with different therapeutic approaches in order to detect its utility as a decision-making scale.

Obstructive Shock in Acute Vena Cava Filter Thrombosis: A Rare Presentation.

Inferior vena cava (IVC) filters are commonly placed to prevent the development or worsening of pulmonary emboli. They are also inherently thrombogenic. Here we discuss a case of acute IVC filter thrombosis with the unusual presentation of obstructive shock resulting in death. A man, age 70 years, underwent laminectomy for multilevel spinal stenosis. An IVC filter was placed preoperatively for acute calf deep vein thrombosis (DVT). On postoperative day 4 he developed tachycardia, hypotension, and signs of lower extremity arterial insufficiency. No lower extremity swelling was noted. Imaging showed complete IVC occlusion caudal to the IVC filter with extension to bilateral iliofemoral veins. Arterial flow was preserved. Therapeutic heparinization was initiated and urgent percutaneous thrombectomy was performed. However, the patient developed multi-organ failure and died shortly thereafter. This report describes an uncommon etiology of obstructive shock and highlights a potentially life-threatening thrombotic complication associated with IVC filters that clinicians should be vigilant about.

Nursing Patient With Central Airway Stenosis Complicated by Tracheo-mediastinal Fistula

The purpose of this paper is to summarize the nursing experience of a patient who developed a tracheo-mediastinal fistula following bronchoscopic balloon dilation for severe central airway stenosis due to tuberculosis. Key nursing points include: early recognition of complications; enhanced monitoring of the patient's condition to watch for recurrence of the fistula; dynamic monitoring of the circulatory system to prevent obstructive shock; evidence-based and standardized care for indwelling catheters; meticulous management throughout the course of treatment to eliminate mediastinal and subcutaneous emphysema; monitoring thrombus detachment and appropriate anticoagulant therapy; improving discharge guidance and continuous nursing. After effective treatment and careful nursing, the patient made a full recovery and was discharged smoothly.

Management of Post-cardiotomy Shock.

Patients undergoing cardiac surgery experience significant physiologic derangements that place them at risk for multiple shock phenotypes. Any combination of cardiogenic, obstructive, hemorrhagic, or vasoplegic shock occurs commonly in post-cardiotomy patients. The approach to the diagnosis and management of these shock states has many facets that are distinct compared to non-surgical cardiac intensive care unit patients. Additionally, the approach to and associated outcomes of cardiac arrest in the post-cardiotomy population are uniquely characterized by emergent bedside resternotomy if the circulation is not immediately restored. This review focuses on the unique aspects of the diagnosis and management of post-cardiotomy shock.

Primary Cardiac Intimal Sarcoma: Multi-Layered Strategy and Core Role of MDM2 Amplification/Co-Amplification and MDM2 Immunostaining.

Primary cardiac tumours are relatively uncommon (75% are benign). Across the other 25%, representing malignant neoplasia, sarcomas account for 75-95%, and primary cardiac intimal sarcoma (PCIS) is one of the rarest findings. We aimed to present a comprehensive review and practical considerations from a multidisciplinary perspective with regard to the most recent published data in the specific domain of PCIS. We covered the issues of awareness amid daily practice clinical presentation to ultra-qualified management in order to achieve an adequate diagnosis and prompt intervention, also emphasizing the core role of MDM2 immunostaining and MDM2 genetic analysis. An additional base for practical points was provided by a novel on-point clinical vignette with MDM2-positive status. According to our methods (PubMed database search of full-length, English publications from January 2021 to March 2023), we identified three studies and 23 single case reports represented by 22 adults (male-to-female ratio of 1.2; male population with an average age of 53.75 years, range: 35-81; woman mean age of 55.5 years, range: 34-70) and a 4-year-old child. The tumour-related clinical picture was recognized in a matter of one day to ten months on first admission. These non-specific data (with a very low index of suspicion) included heart failure at least NYHA class II, mitral regurgitation and pulmonary hypertension, acute myocardial infarction, ischemic stroke, obstructive shock, and paroxysmal atrial fibrillation. Awareness might come from other complaints such as (most common) dyspnoea, palpitation, chest pressure, cough, asthenia, sudden fatigue, weakness, malaise, anorexia, weight loss, headache, hyperhidrosis, night sweats, and epigastric pain. Two individuals were initially misdiagnosed as having endocarditis. A history of prior treated non-cardiac malignancy was registered in 3/23 subjects. Distant metastasis as the first step of detection (n = 2/23; specifically, brain and intestinal) or during follow-up (n = 6/23; namely, intestinal, brain and bone, in two cases for each, and adrenal) required additional imagery tools (26% of the patients had distant metastasis). Transoesophageal echocardiography, computed tomography (CT), magnetic resonance imagery, and even 18F-FDG positronic emission tomography-CT (which shows hypermetabolic lesions in PCIS) represent the basis of multimodal tools of investigation. Tumour size varied from 3 cm to ≥9 cm (average largest diameter of 5.5 cm). The most frequent sites were the left atrium followed by the right ventricle and the right atrium. Post-operatory histological confirmation was provided in 20/23 cases and, upon tumour biopsy, in 3/23 of them. The post-surgery maximum free-disease interval was 8 years, the fatal outcome was at the earliest two weeks since initial admission. MDM2 analysis was provided in 7/23 subjects in terms of MDM2-positive status (two out of three subjects) at immunohistochemistry and MDM2 amplification (four out of five subjects) at genetic analysis. Additionally, another three studies addressed PCISs, and two of them offered specific MDM2/MDM2 assays (n = 35 patients with PCISs); among the provided data, we mention that one cohort (n = 20) identified a rate of 55% with regard to MDM2 amplification in intimal sarcomas, and this correlated with a myxoid pattern; another cohort (n = 15) showed that MDM2-positive had a better prognostic than MDM2-negative immunostaining. To summarize, MDM2 amplification and co-amplification, for example, with MDM4, CDK4, HMGA3, CCND3, PDGFRA, TERT, KIT, CCND3, and HDAC9, might improve the diagnosis of PCIS in addition to MDM2 immunostaining since 10-20% of these tumours are MDM2-negative. Further studies are necessary to highlight MDM2 applicability as a prognostic factor and as an element to be taken into account amid multi-layered management in an otherwise very aggressive malignancy.

Healthcare and economic cost burden of emergency medical services treated non-traumatic shock using a population-based cohort in Victoria, Australia

ObjectivesWe aimed to assess the healthcare costs and impact on the economy at large arising from emergency medical services (EMS) treated non-traumatic shock.DesignWe conducted a population-based cohort study, where EMS-treated...

Echocardiography as a Vital Tool in Assessing Shock: A Comprehensive Review.

Shock is a critical condition characterized by inadequate tissue perfusion, leading to cellular hypoxia and organ dysfunction. Early and accurate assessment is crucial for timely intervention and improved patient outcomes. Echocardiography has emerged as a vital tool in the assessment of shock, offering real-time visualization of cardiac anatomy, function, and hemodynamics. This comprehensive review aims to elucidate the role of echocardiography in shock assessment by providing an overview of its principles, techniques, and clinical applications. We discuss the importance of early diagnosis, identification of underlying pathology, monitoring response to therapy, and prognostic value offered by echocardiography in managing shock. Furthermore, we explore its utility in different types of shock, including hypovolemic, cardiogenic, distributive, and obstructive shock. Challenges and limitations of echocardiography, as well as future directions and innovations, are also discussed. Through a synthesis of current evidence and clinical insights, this review underscores the significance of echocardiography in optimizing shock management and highlights areas for further research and development.

Intensive Care Treatment of Pulmonary Embolism: An Update Based on the Revised AWMF S2k Guideline.

Acute pulmonary embolism (PE) remains a significant cause of morbidity and requires prompt diagnosis and management. The prognosis of affected patients depends on the clinical severity. Therefore, risk stratification is imperative for therapeutic decision-making. Patients with high-risk PE need intensive care. These include patients who have successfully survived resuscitation, with obstructive shock or persistent haemodynamic instability. Bedside diagnostics by means of sonographic procedures are of outstanding importance in this high-risk population. In addition to the treatment of hypoxaemia with noninvasive and invasive techniques, the focus is on drug-based haemodynamic stabilisation and usually requires the elimination or reduction of pulmonary vascular thrombotic obstruction by thrombolysis. In the event of a contraindication to thrombolysis or failure of thrombolysis, various catheter-based procedures for thrombus extraction and local thrombolysis are available today and represent an increasing alternative to surgical embolectomy. Mechanical circulatory support systems can bridge the gap between circulatory arrest or refractory shock and definitive stabilisation but are reserved for centres with the appropriate expertise. Therapeutic strategies for patients with intermediate- to high-risk PE in terms of reduced-dose thrombolytic therapy or catheter-based procedures need to be further evaluated in prospective clinical trials.

A Clinical Review of Vasopressors in Emergency Medicine

BackgroundVasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access. Objectives of the ReviewThis review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock. DiscussionCriteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause. ConclusionAcross the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states.

Cardiac tamponade complicating esophagectomy and retrosternal gastric tube reconstitution in a patient with an abnormal ascending aorta position: a case report

BackgroundCardiac tamponade is a rare postoperative complication of esophageal cancer surgery, which leads to rapid hemodynamic changes and can be fatal if not treated properly and promptly. Herein, we report a case of cardiac tamponade after thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution for esophageal cancer that was successfully treated with surgical drainage.Case presentationAn 86-year-old man with lower thoracic esophageal cancer underwent thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution. No intra-operative complications were observed. On the first postoperative day, tachycardia and hypotension were observed, and pericardial effusion was identified on computed tomography images. The patient was diagnosed with obstructive shock secondary to cardiac tamponade. As percutaneous puncture drainage was not possible due to the presence of a retrosternal gastric tube, pericardiotomy with a small left anterior thoracotomy was performed, and a large amount of hematogenous fluid was drained, which instantly improved circulation. On the second postoperative day, the patient showed decreased pulse pressure, and computed tomography revealed a residual and enlarged hematoma around the right ventricle. The patient underwent surgical drainage and another pericardiotomy with a small right anterior thoracotomy was performed to drain the hematoma. At this time, multiple injuries to the fatty tissue, epicardium, and myocardium with active bleeding were observed on the anterior surface of the right ventricle near the root of the pulmonary artery. In this patient, the ascending aorta ran further to the right and dorsal sides than usual, causing the anterior wall of the right ventricle near the root of the pulmonary artery to be closer to the back of the sternum. This abnormality may have contributed to injury during the creation of the retrosternal pathway, leading to cardiac tamponade.ConclusionsCardiac tamponade after esophagectomy can occur because of manipulation during creation of the retrosternal route, with an anomaly in the aortic position being present in this case. Gentle manipulation and selection of the reconstruction route according to the patient’s condition are necessary in cases with such anatomical abnormalities.

A Saddle Pulmonary Embolism at Transthoracic Echocardiography: A Case Report

Acute Pulmonary embolism (PE) is a life-threatening disease and is considered the third major cause of cardiovascular death with higher incidence and mortality rates. Identifying a saddle PE between the left and the right pulmonary trunk in transthoracic echocardiography (TTE) is rare, and helps to make a rapid diagnosis to avoid complications. Clinical presentation, electrocardiogram, and X-ray guide the diagnosis but are not specific. TTE is helpful and confirms the diagnosis especially when the CT is not available or in other situations when it is not realizable. Visualizing a pulmonary artery thrombus in TTE is unusual. It can be identified in the right cardiac chambers in less than 5% of patients with PE. The severity of acute PE is determined by its hemodynamics, the sudden pulmonary hypertension, and the development of obstructive shock. Anticoagulation therapy is the cornerstone of PE management and should be initiated as soon as possible.

Acute caval thrombosis leading to obstructive shock in the early post insertion period of an inferior vena cava filter: a case report and literature review

BackgroundObstructive shock is extremely rare in clinical practice and is caused by acute blood flow obstruction in the central vessels of either the systemic or pulmonary circulation. Utilizing inferior vena cava filters (IVCFs) to prevent pulmonary embolism (PE) is associated with some potential complications, such as inferior vena cava thrombosis (IVCT). Shock as a direct result of IVCT is rare. We present a case of obstructive shock secondary to extensive IVCT caused by inadequate anticoagulant therapy after the placement of an IVCF.Case presentationA 63-year-old male patient with a traffic accident injury presented orthopaedic trauma and lower limb deep vein thrombosis (DVT). He experienced sudden and severe abdominal pain with hypotension, tachycardia, tachypnea, oliguria and peripheral oedema 5 days after IVCF placement and 3 days after cessation of anticoagulant therapy. Considering that empirical anti-shock treatment lasted for a while and the curative effect was poor, we finally recognized the affected vessels and focused on the reason for obstructive shock through imaging findings—inferior vena cava thrombosis and occlusion. The shock state immediately resolved after thrombus aspiration. The same type of shock occurred again 6 days later during transfer from the ICU to general wards and the same treatment was administered. The patient recovered smoothly in the later stage, and the postoperative follow-up at 1, 3, and 12 months showed good results.ConclusionThis case alerts clinicians that it is crucial to ensure adequate anticoagulation therapy after IVCF placement, and when a patient presents with symptoms such as hypotension, tachycardia, and lower limb and scrotal oedema postoperatively, immediate consideration should be given to the possibility of obstructive shock, and prompt intervention should be based on the underlying cause.

A Brazilian Neonatal Unit's Experience with Functional Echocardiography and Diagnostic Findings in Congenital Heart Disease

Introduction: The diagnosis of congenital heart diseases is a challenge for pediatricians due to the diversity of clinical presentations and symptoms, just like several other diseases prevalent in the neonatal period. Often the diagnosis is established during the gestation period, sometimes the hypothesis is formulated by neonatal screening. However, several cases will require clinical suspicion from the pediatrician. Given the possibility of this diagnosis, the evaluation of the infant cardiologist is essential. Unfortunately, this professional is not always readily available. In the intensive care units, health professionals use heart rate, blood pressure, capillary refill, urinary output and acid-base balance for hemodynamic analysis. These data are significant, but nonspecific. Thus, functional echocardiography can improve hemodynamic evaluation with positive impact on diagnosis. Our objective was to conduct a retrospective analysis of hospitalizations in a Brazilian neonatal unit, with the goal of identifying the diagnoses of congenital heart diseases made by a researcher using functional echocardiography, from July 2015 to September 2017, having as inclusion criteria; clinical manifestations of distress or respiratory failure, characterized by tachypnea, signs of dyspnea, need for oxygen therapy or ventilatory support and/or hemodynamic instability, characterized by tachycardia, cyanosis, cold extremities, prolonged capillary filling time, fine pulses and/or hypotension, low urinary output. Results: During the 26 months of the study, 362 neonates were hospitalized. Of these, 223 were included in the research for presenting cardiorespiratory manifestations. We observed three cases of obstructive shock related to cardiac tamponade, 18 cases of congenital heart disease, five cases of hypertrophic myocardiopathy, seven cases of myocardial dysfunction not related to structural heart disease, 46 cases of neonatal persistent pulmonary hypertension and 27 cases of patent ductus arteriosus (six with hemodynamics repercussion). Conclusions: The results showed functional and/or anatomical changes in 105 patients analyzed (46.7%), identified a diversity of structural cardiopathies, improved hemodynamic evaluation with impact on the therapeutic approach. While using functional echocardiography in neonates, clinicians should be aware that undiagnosed critical congenital heart defects can present during this period. They should acknowledge the limitations of skills, and it should not be used as a screening tool for diagnosing or excluding congenital heart defects. A patient with a suspected critical congenital heart defect should be quickly referred to a pediatric cardiologist, even if this implies out-of-hospital patient’s transportation. We assume that the systematic implementation of this technology by the medical team can improve diagnostic accuracy, which can positively impact the therapy used. Keywords: Critical care, neonatology, ultrasonography, echocardiography, point-of-care systems, cardiac tamponade, hypertension pulmonary, heart defectal congenits.

Abstract 18212: The Fat Embolism Enigma: Unveiling the Intricate Complications of Breast Reconstructive Surgery

Background: Fat embolism can occur after plastic surgery, especially when injecting fat into subcutaneous tissue. It can be asymptomatic or can have hypoxia, mental status changes, and petechiae rash. Diagnosis is challenging but the workup includes imaging to exclude other differentials including pulmonary thromboembolism. Echocardiography assists in identifying fat emboli. Case Presentation: A middle-aged female with no prior cardiac history was undergoing right-sided breast reconstructive surgery with liposuction from the abdomen and fat grafting. Intraoperatively, the patient became hypoxic and hypotensive. The patient was started on vasopressors. A CT-Angiogram Chest revealed multiple bilateral pulmonary emboli, with some emboli having negative Hounsfield units (HU). Anticoagulation was started. Fat emboli could not be excluded. The patient was ultimately transitioned to venoarterial extracorporeal membrane oxygenation. Transthoracic echocardiogram showed right ventricular (RV) hypokinesis with preserved apical function and multiple, mobile, irregular masses in the RV. Figure 1 With the patient’s history, this was concerning for fat emboli. A transesophageal echocardiogram (TEE) showed multiple (4 visualized) masses seen in the RV, caught into the subvalvular tricuspid apparatus on the chordae and the RV trabeculation. (Largest mass: 1 cm in diameter). Figure 2 A bilateral lower extremity venous duplex was negative. The patient was diagnosed with obstructive shock secondary to fat embolism. She was eventually weaned off of mechanical support and discharged in stable condition. Discussion: Autologous fat grafting (AFG) has gained popularity in reconstructive and aesthetic surgery. It is important to remain vigilant about fat embolism as a complication that presents as sudden hypoxia and obstructive shock in the appropriate setting. DVT should be ruled out. Echocardiography can assist in diagnosis. Treatment is supportive.

Abstract 16826: A Rare Case of an Emergent Third Valve in Valve Intervention

Introduction: Bioprosthetic valves are prone to structural degeneration due to an average lifetime of 10-15 years. Valve in Valve (VIV) TAVR has become an alternative to the high-risk surgical patients as the growing number of successful bioprosthetic valve placements and the deteriorations over time. Emergent VIV intervention effectiveness with prior multiple artificial valves is less studied. Hypothesis: We report a case of a 54-year-old male presenting with obstructive shock with history of substance abuse and bicuspid aortic valve status post bioprosthetic aortic valve with aortic root repair at age of 15(1983), aortic stenosis requiring repeat surgical bioprosthetic Aortic Valve Replacement (SAVR) (25 mm) at age 42(2011). Recalcitrant cardiogenic shock despite vasopressor. Emergent Heart catheterization showed mild coronary artery disease (CAD) and severe cardiomyopathy, Left Ventricle ejection Fraction 15-20%. Aortic valve Gradient was 80 mmHg. Transesophageal Echocardiography (TEE) ruled out endocarditis. Impella CP and Swan-Ganz catheter were placed for hemodynamic support and monitoring. Methods: The Heart Team approach was followed. Patient was at high risk of mortality and operative complications with redo sternotomy. He subsequently underwent valve in valve TAVR with self-expanding 26 mm valve. Prior surgical valve did not require fracturing post implantation. Results: Post Trans Aortic Valve Replacement (TAVR) the mean gradient on echocardiogram decreased to 10 mmHg and LVEF recovered to 55-60%. The patient was successfully weaned off Vaso-pressors and eventually discharged home. Conclusion: Most common cause of transcatheter bioprosthetic valve failure is stenosis from calcification and thrombosis. VIV TAVR in recent studies has proven to be safe with favorable outcomes. Our patient had already undergone two surgical valve interventions, presented with critical bioprosthetic valve stenosis requiring salvage TAVR for cardiogenic shock. After the Heart team approach, TAVR was opted as a more favorable option for the patient. Although, the life of a bioprosthetic valve results in multiple interventions but overall valve in Valve technique has been proven to provide expected results in emergent high-risk patients.