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M&M CONFERENCE August 11, 2011

M&M CONFERENCE August 11, 2011. Sadi Raza, MD Naveen Seecheran, MD. Case # 1. 60 y/o male patient presents to clinic for evaluation of a chronically “leaky” valve with 2 weeks of shortness of breath Describes dyspnea on exertion, 3 pillow orthopnea, mild non-productive cough

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M&M CONFERENCE August 11, 2011

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  1. M&M CONFERENCEAugust 11, 2011 Sadi Raza, MD Naveen Seecheran, MD

  2. Case # 1 • 60 y/o male patient presents to clinic for evaluation of a chronically “leaky” valve with 2 weeks of shortness of breath • Describes dyspnea on exertion, 3 pillow orthopnea, mild non-productive cough • Furosemide dose increased, echocardiogram obtained but 24 hours later patient reports worsening symptoms, symptoms with minimal activity • Clinic advises patient to present to ER for evaluation and likely admission

  3. Past Medical History • CAD; s/p MI in 1996 with PoBA of distal LCx, s/p MI in 1998 with LAD arthrectomy, s/p CABG in 2004 (LIMA to D2 and LAD, Left radial arterial graft to Ramus, SVG to PDA), s/p MI in 2008 with PCI x 2 to distal LCx • Severe MR, first noted on echo in 2010 • A. fib s/p MAZE w CABG (2004) • A. flutter s/p DCCV (2010) • Cardiomyopathy 2o ischemia and tachycardia • CVA with seizures (2010) • Hx of GI bleed (2010) • Hx of Gastric Bypass (2010) • Hx of pneumonia with intubation (2011)

  4. Medications • Carvedilol • Warfarin • Simvastatin • Furosemide • Spirinolactone • Dofetilide • Lisinopril • ASA • Pantoprazole • Levetiracetam • Colchicine

  5. Family/Social History • Former tobacco user (20 pack year history), quit 12 years ago • Minimal EtOH use, heavy cannabis user presently • Brother with DM II, no FH of early CAD

  6. Initial Assessment • BP 126/71, RR 14, HR 59 94% on 2L • Gen: Middle aged male in NAD Neck: Supple, JVD to below the angle of the mandible CVS: S1, S2, RRR, III/VI murmur at the apex Chest: Right basilar crackles Extremities: 1+ LE edema • Received 40mg IV Furosemide x 1 in the ER

  7. Labs 10.3 7.5 204 31.7 139 105 24 92 4.0 26 0.9 INR: 2.0 Trop: <0.05 BNP: 1040

  8. Initial ECG

  9. Initial Plan • Diuresis with IV Furosemide • Review Echocardiogram • CT Surgery evaluation • Fluid restriction, monitor I/O, daily weights • Diagnostic LHC • Reverse INR with Vitamin K

  10. Echocardiogram • Left ventricle: The estimated ejection fraction was 50-55%. • Moderate to severe regurgitation directed posteriorly and along the left atrial wall • LVED: 57mm • LVES: 42mm • PA Pressure: 60-65mm Hg

  11. Cardiac Cath • LAD: High grade mid LAD disease and an 80% stenosis of the first diagonal branch. • LCx: CTO of distal Cx • Ramus: CTO • RCA: CTO • Grafts: SVG-Ramus & SVG-RCA patent. LIMA to LAD and LIMA to D2 patent

  12. Surgery Right mini thoracotamy to avoid redo sternotomy

  13. Surgery • Intubated with double-lumen ET tube, required neb treatment immediately • Normal mitral leaflets w/o myxoma • Tethering of anterior and posterior leaflet chordae • Successful MVR with TEE confirmation of trace MR • Acute hypoxia when double lumen ET tube switched to single lumen with frothy sputum from ET tube • Constant foaming leg to bag ventilation, unable to be put back onto vent ~ 300cc of ‘foam’ • BP dropped, put on Epinephrine, Levophed w/o improvement • Asystole, no shockable rhythm

  14. Left lung: 670 grams Right lung: 1620 grams Note large disparity between the two lungs, due to severe right lung edema.

  15. Tenacious mucus in trachea and bronchial tree (next slides)

  16. Left lung

  17. Right lung

  18. Heart weight: 742 grams. Note old MI in posterior wall, transmural. Smaller old MI’s in septum and anterior wall

  19. Upper lobe, right lung Note the edema and congestion

  20. Lower lobe, right lung. Similar changes, more severe

  21. Hemosiderin-laden macrophages, secondary to longstanding mitral regurgitation or congestive heart failure (or both)

  22. Upper lobe, right lung

  23. Upper lobe, left lung

  24. Pathology Conclusion • Cause of death: • Severe unilateral pulmonary edema and congestive heart failure following • Valvuloplasty for mitral regurgitation due to Ischemic, dilated cardiomyopathy • Hypertensive and atherosclerotic cardiovascular disease

  25. POPE (Post Obstructive Pulmonary Edema) • First noted in 1927 in dogs, AKA negative pressure pulmonary edema • Life-threatening, immediate onset pulmonary edema after airway obstruction • Type I (more common): Forceful inspiratory effort in the context of an acute obstruction; Type 2: After relief of a chronic obstruction • Forceful inspiration  Increase in venous return and flow to right heart + decrease flow to the left heart  Increased PV pressure  Increased hydrostatic pressure and edema formation

  26. POPE (Post Obstructive Pulmonary Edema) • In a study of ~ 900 patients 100% of patients with unilateral pulmonary edema (UPE) had severe MR (p<0.0001) • Treatment: Maintain airway, PEEP, 100% FiO2, diuretics controversial as they can cause hypovolemia and hypoperfusion

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