1. M&M CONFERENCE August 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 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 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 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 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 2 o 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 Carvedilol Warfarin Warfarin Simvastatin Simvastatin Furosemide Furosemide Spirinolactone Spirinolactone Dofetilide Dofetilide Lisinopril Lisinopril ASA ASA Pantoprazole Pantoprazole Levetiracetam Levetiracetam Colchicine Colchicine

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

6. Initial Assessment BP 126/71, RR 14, HR 59 94% on 2L BP 126/71, RR 14, HR 59 94% on 2L Gen: Middle aged male in NAD 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 Received 40mg IV Furosemide x 1 in the ER

7. Labs 7.5204 10.3 31.7 139 4.0 105 26 24 0.9 92 INR: 2.0 Trop: <0.05 BNP: 1040

9. Initial ECG

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

11. 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

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

15. Surgery Right mini thoracotamy to avoid redo sternotomy

16. Surgery Intubated with double-lumen ET tube, required neb treatment immediately Intubated with double-lumen ET tube, required neb treatment immediately Normal mitral leaflets w/o myxoma Normal mitral leaflets w/o myxoma Tethering of anterior and posterior leaflet chordae Tethering of anterior and posterior leaflet chordae Successful MVR with TEE confirmation of trace MR 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 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’ 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 BP dropped, put on Epinephrine, Levophed w/o improvement Asystole, no shockable rhythm Asystole, no shockable rhythm

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

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

21. Left lung

22. Right lung

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

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

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

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

27. Upper lobe, right lung

28. Upper lobe, left lung

29. 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 Conclusion

30. POPE (Post Obstructive Pulmonary Edema) First noted in 1927 in dogs, AKA negative pressure pulmonary edema First noted in 1927 in dogs, AKA negative pressure pulmonary edema Life-threatening, immediate onset pulmonary edema after airway obstruction 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 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 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) 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 Treatment: Maintain airway, PEEP, 100% FiO2, diuretics controversial as they can cause hypovolemia and hypoperfusion POPE (Post Obstructive Pulmonary Edema)