An Internist\u27s Approach to a Case of Negative Pressure Pulmonary Edema: A Rare Cause of Noncardiogenic Pulmonary Edema

Negative-pressure pulmonary edema (NPPE) is a rare cause of noncardiogenic pulmonary edema, which usually presents postoperatively. Its pathophysiology is mostly described as a profound negative intrathoracic pressure caused by an airway obstruction such as laryngospasm, which may occur during extubation. But, there are other hypotheses about it, such as catecholamines release causing an elevated hydrostatic pressure in the cardiopulmonary circuit and, consequently, a major capillary leak to the interstitium. Its natural course varies, from prompt recovery to intensive care unit escalation and prolonged mechanical ventilation. Although anesthesiologists often detect this condition, this case\u27s objective is to bring awareness of this condition to internists as a potential differential diagnosis for hypoxia in the postoperative setting

NEUROLOGIC COMPLICATIONS OF TRANSAXILLARY ACCESS IN TAVR - A CASE OF POSTPROCEDURAL ULNAR AND MEDIAN NERVE INJURY

Background: Peripheral nerve injuries secondary to endovascular procedures are relatively rare but cause significant functional impairment. With transaortic valve replacement (TAVR), these injuries more commonly occur during axillary access compared to femoral and radial access (due to its proximity to brachial plexus). While hematoma and pseudoaneurysm formation are the more common complications, nerve injury may occur secondary to compression or direct needle puncture. Case: A 76-year-old male with severe aortic stenosis underwent two failed TAVR attempts due to poor access. Initial attempts at femoral access and transcaval access were aborted due to existing abdominal aortic endograft. Further attempts via carotid access were aborted due to stenosis. An attempt at left axillary access was then performed and TAVR was successful. Postoperatively (day 0), the patient developed left upper extremity (LUE) numbness over the 4th and 5th digits, medial palm, and dorsum of the hand with weakness when holding objects. Our neurological evaluation identified a total ulnar nerve (UN) and partial median nerve (MN) injury. Decision-making: Transaxillary access for TAVR is a disfavored approach due to the better outcomes when performed with other access sites. After out identification of a postprocedural nerve injury, we ordered a LUE arterial duplex ultrasound (US) and CT angiogram which excluded hematoma or pseudoaneurysm formation. US of the left brachial plexus revealed questionable edematous change at the take-off of the left UN and MN. Patient’s symptoms did not improve postoperatively until his discharge from the hospital (day 3) and an outpatient nerve conduction study was scheduled. Conclusion: We report a rare case of proximal UN and MN injury in a patient who underwent transaxillary TAVR due to the lack of alternative access. Prompt evaluation to rule-out vascular mechanism of injury in this patient was critical as early intervention results reduce further morbidity. With symptoms of motor and sensory brachial plexopathy and concerning imaging findings, the patient was scheduled for outpatient follow-up

Hepatitis C Cirrhosis, Hepatitis B Superimposed Infection, and the Emergence of an Acute Portal Vein Thrombosis: A Case Report

Acute portal vein thrombosis (PVT) is a complication of liver cirrhosis. The presence of viral infections such as hepatitis B (HBV) and hepatitis C (HCV) can further increase cirrhotic patients\u27 risk of developing PVT, especially in the rare case when there is superinfection with both HBV and HCV. We present a patient with HCV cirrhosis whose clinical condition was decompensated secondary to the development of superimposed HBV infection, who developed acute PVT during hospitalization. This case offers a unique presentation of acute PVT that developed within several days of hospitalization for decompensated liver disease, as proven by the interval absence of portal venous flow on repeat imaging. Despite the workup on the initial presentation being negative for PVT, reconsideration of differentials after the change in our patient\u27s clinical status led to the diagnosis. Active HBV infection was likely the initial trigger for the patient\u27s cirrhosis decompensation and presentation; the subsequent coagulopathy and alteration in the portal blood flow triggered the development of an acute PVT. The risk for both prothrombotic and antithrombotic complications remains high in patients with cirrhosis, a risk that is vastly increased by the presence of superimposedinfections. The diagnosis of thrombotic complications such as PVT can be challenging, thus stressing the importance of repeat imaging in instances where clinical suspicion remains high despite negative imaging. Anticoagulation should be considered for cirrhotic patients with PVT on an individual basis for both prevention and treatment. Prompt diagnosis, early intervention, and close monitoring of patients with PVT are crucial for improving clinical outcomes. The goal of this report is to illustrate diagnostic challenges that accompany the diagnosis of acute PVT in cirrhosis, as well as discuss therapeutic options for optimal management of this condition

THE COMPLICATION-RIDDEN DESTINY OF THE SYSTEMIC RIGHT VENTRICLE IN L-TRANSPOSITION OF THE GREAT ARTERIES: MANAGEMENT DILEMMAS

Background: Congenitally corrected levo-transposition of the great arteries (L-TGA) is a congenital heart disease in which the ventricles and great arteries are transposed from their typical anatomy. In L-TGA, the double discordance, atrioventricular and ventriculoarterial, create an acyanotic milieu which allows patients to survive their early decades, however, progressive systemic right ventricle (sRV) dysfunction creates complications later on. Case: A 40-year-old male with L-TGA presented with symptoms of acute decompensated heart failure (ADHF). In childhood, he had surgical repair of a ventricular septal defect. In adulthood, he developed sRV dysfunction, systemic tricuspid valve (sTV) regurgitation, and left-bundle branch block for which he underwent cardiac resynchronization therapy. Transthoracic echocardiogram obtained during the admission showed a sRV ejection fraction of 40%, severe sTV regurgitation, and a newly identified sRV apical thrombus; the thrombus was confirmed by ultrasound-enhancing agents and transesophageal echocardiography. Decision-making: Our patient was optimized with guideline-directed medical therapy and diuresis. The presence of a sRV thrombus posed a dilemma given the limited literature. Guidelines for intracardiac thrombus in patients with structurally typical hearts recommend anticoagulation with a vitamin K antagonist (VKA) followed by echocardiography to assess for resolution. However, multiple case reports and small-scale studies support the use of direct oral anticoagulants. It is unknown whether these principles can be extrapolated to patients with congenital heart disease. Review of literature identified no cases of sRV thrombus making this one of the first reports. Our patient was anticoagulated with a VKA and later referred for evaluation by advanced heart failure and heart transplant services. Conclusion: We describe one of the first reported cases of sRV thrombus in L-TGA presenting with ADHF. This case illustrates the natural history of L-TGA and highlights the importance of surveillance and monitoring in these patients with dedicated cardiac imaging including advanced imaging modalities to identify complications

Application of Impella mechanical circulatory support devices in transcatheter aortic valve replacement and balloon aortic valvuloplasty: A single center experience

BACKGROUND/PURPOSE: Percutaneous valve interventions for aortic stenosis (AS) include transcatheter aortic valve replacement (TAVR) and balloon aortic valvuloplasty (BAV). Intraprocedural mechanical circulatory support (MCS) with Impella devices (Abiomed, Danvers, MA) is used in select high-risk patients, although data regarding its efficacy is limited. This study sought to evaluate the clinical outcomes of Impella use in patients with AS who underwent TAVR and BAV at a quaternary-care center. METHODS/MATERIALS: All patients with severe AS who underwent TAVR and BAV with Impella between 2013 and 2020 were included. Patient demographics, outcomes, complications, and 30-day mortality data was analyzed. RESULTS: Over the study period 2680 procedures were performed, 1965 TAVR and 715 BAV. 120 utilized Impella support, 26 TAVR and 94 BAV. Among TAVR Impella cases, justifications for MCS included cardiogenic shock (53.9 %), cardiac arrest (19.2 %), and coronary occlusion (15.4 %). Among BAV Impella cases, justifications for MCS included cardiogenic shock (55.3 %) and protected percutaneous coronary intervention (43.6 %). The 30-day mortality rate in TAVR Impella was 34.6 % and in BAV Impella was 28 %. BAV Impella cases involving cardiogenic shock had a higher rate of 45 %. Impella remained in-use past 24 h from the procedure in 32.2 % cases. Vascular access-related complications occurred in 4.8 % cases and bleeding complications occurred in 1.5 % cases. Conversion to open-heart surgery occurred in 0.7 % cases. CONCLUSIONS: MCS is an option for high-risk patients with severe AS who require TAVR and BAV. Despite hemodynamic support, the 30-day mortality rate remained high especially in cases where support was employed for cardiogenic shock