MM CONFERENCE August 11, 2011

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

9. Initial ECG

10. 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

11. Echocardiogram

12. 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

16. 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

30. 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

31. 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 POPE (Post Obstructive Pulmonary Edema)