M&M CONFERENCE August 11, 2011 Sadi Raza, MD Naveen Seecheran, MD.

M&M M&M CONFERENCECONFERENCE

August 11, 2011August 11, 2011

Sadi Raza, MDSadi Raza, MD

Naveen Seecheran, Naveen Seecheran, MDMD

Case # 1Case # 1 60 y/o male patient presents to clinic for 60 y/o male patient presents to clinic for

evaluation of a chronically “leaky” valve evaluation of a chronically “leaky” valve with 2 weeks of shortness of breathwith 2 weeks of shortness of breath

Describes dyspnea on exertion, 3 pillow Describes dyspnea on exertion, 3 pillow orthopnea, mild non-productive coughorthopnea, mild non-productive cough

Furosemide dose increased, Furosemide dose increased, echocardiogram obtained but 24 hours echocardiogram obtained but 24 hours later patient reports worsening later patient reports worsening symptoms, symptoms with minimal symptoms, symptoms with minimal activityactivity

Clinic advises patient to present to ER Clinic advises patient to present to ER for evaluation and likely admissionfor evaluation and likely admission

Past Medical HistoryPast 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)

MedicationsMedications CarvedilolCarvedilol WarfarinWarfarin SimvastatinSimvastatin FurosemideFurosemide SpirinolactoneSpirinolactone DofetilideDofetilide LisinoprilLisinopril ASAASA PantoprazolePantoprazole LevetiracetamLevetiracetam ColchicineColchicine

Family/Social HistoryFamily/Social History

Former tobacco user (20 pack year Former tobacco user (20 pack year history), quit 12 years agohistory), quit 12 years ago

Minimal EtOH use, heavy cannabis Minimal EtOH use, heavy cannabis user presentlyuser presently

Brother with DM II, no FH of early Brother with DM II, no FH of early CADCAD

Initial AssessmentInitial Assessment BP 126/71, RR 14, HR 59 94% on 2LBP 126/71, RR 14, HR 59 94% on 2L

Gen: Middle aged male in NADGen: Middle aged male in NAD

Neck: Supple, JVD to below the angle of the Neck: Supple, JVD to below the angle of the mandiblemandible

CVS: S1, S2, RRR, III/VI murmur at the apexCVS: S1, S2, RRR, III/VI murmur at the apex

Chest: Right basilar cracklesChest: Right basilar crackles

Extremities: 1+ LE edemaExtremities: 1+ LE edema

Received 40mg IV Furosemide x 1 in the ERReceived 40mg IV Furosemide x 1 in the ER

LabsLabs

7.5 204

10.3

31.7

1394.0

10526

24

0.992

INR: 2.0 Trop: <0.05 BNP: 1040

Initial ECGInitial ECG

Initial PlanInitial Plan

Diuresis with IV FurosemideDiuresis with IV Furosemide Review EchocardiogramReview Echocardiogram CT Surgery evaluationCT Surgery evaluation Fluid restriction, monitor I/O, daily Fluid restriction, monitor I/O, daily

weightsweights Diagnostic LHCDiagnostic LHC Reverse INR with Vitamin KReverse INR with Vitamin K

EchocardiogramEchocardiogram• 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

Cardiac CathCardiac 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

SurgerySurgeryRight mini thoracotamy to avoid redo sternotomy

SurgerySurgery Intubated with double-lumen ET tube, required Intubated with double-lumen ET tube, required

neb treatment immediatelyneb treatment immediately Normal mitral leaflets w/o myxomaNormal mitral leaflets w/o myxoma Tethering of anterior and posterior leaflet Tethering of anterior and posterior leaflet

chordaechordae Successful MVR with TEE confirmation of trace Successful MVR with TEE confirmation of trace

MRMR Acute hypoxia when double lumen ET tube Acute hypoxia when double lumen ET tube

switched to single lumen with frothy sputum switched to single lumen with frothy sputum from ET tubefrom ET tube

Constant foaming leg to bag ventilation, unable Constant foaming leg to bag ventilation, unable to be put back onto vent ~ 300cc of ‘foam’to be put back onto vent ~ 300cc of ‘foam’

BP dropped, put on Epinephrine, Levophed w/o BP dropped, put on Epinephrine, Levophed w/o improvementimprovement

Asystole, no shockable rhythmAsystole, no shockable rhythm

Left lung: 670 grams Right lung: 1620 grams

Note large disparity between the two lungs, due to severe right lung edema.

Tenacious mucus in trachea and bronchial tree (next slides)

Left lung

Right lung

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

Upper lobe, right lung Note the edema and congestion

Lower lobe, right lung. Similar changes, more severe

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

Upper lobe, right lung

Upper lobe, left lung

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

Pathology ConclusionPathology Conclusion

POPE (Post Obstructive POPE (Post Obstructive Pulmonary Edema)Pulmonary Edema)

First noted in 1927 in dogs, AKA negative First noted in 1927 in dogs, AKA negative pressure pulmonary edemapressure pulmonary edema

Life-threatening, immediate onset Life-threatening, immediate onset pulmonary edema after airway obstructionpulmonary edema after airway obstruction

Type I (more common): Forceful Type I (more common): Forceful inspiratory effort in the context of an acute inspiratory effort in the context of an acute obstruction; Type 2: After relief of a obstruction; Type 2: After relief of a chronic obstructionchronic obstruction

Forceful inspiration Forceful inspiration Increase in venous Increase in venous return and flow to right heart + decrease return and flow to right heart + decrease flow to the left heart flow to the left heart Increased PV Increased PV pressure pressure Increased hydrostatic pressure Increased hydrostatic pressure and edema formationand edema formation

In a study of ~ 900 patients 100% of In a study of ~ 900 patients 100% of patients with unilateral pulmonary patients with unilateral pulmonary edema (UPE) had severe MR edema (UPE) had severe MR (p<0.0001)(p<0.0001)

Treatment: Maintain airway, PEEP, Treatment: Maintain airway, PEEP, 100% FiO2, diuretics controversial 100% FiO2, diuretics controversial as they can cause hypovolemia and as they can cause hypovolemia and hypoperfusionhypoperfusion

POPE (Post Obstructive POPE (Post Obstructive Pulmonary Edema)Pulmonary Edema)