PA injury is a feared complication after Swan-Ganz catheterization and can be fatal. In patients who develop massive or recurrent hemoptysis after Swan-Ganz catheter use, PA injury must be considered and airway protection should be employed along with appropriate catheter based or surgical interventions.
Background
- The formation of recipient-to donor atrio-atrial connections (AAC) in patients after orthotopic heart transplantation (OHT) is poorly understood. We sought to investigate the mechanisms of atrial tachyarrhythmias after OHT, the role of AACs, and their relationship to the immunological match.
Methods
- In a large series of OHT patients we performed a retrospective review of 42 patients who underwent catheter ablation for atrial arrhythmias. A realistic 3D computer model of human atria was used to study AAC conductivity.
Results
- Patient age was 55±15 years (71% male). 24/42 patients (57%) had bi-atrial anastomosis. An AAC was found in 9/42 patients (21%, right-sided in 5 patients with bi-atrial anastomosis, left-sided in 4 patients). The AAC became apparent at the time of the electrophysiology study 10.1±7.6 years after OHT (range 0.3-22.2 years). Donor-specific antibodies (DSAB) were present in no patient with AAC, but were present in 69% of patients without AAC, p=0.002. In all patients with AAC, a recipient atrial tachycardia propagated via AAC to the donor atrium (4 patients presented with atrial fibrillation). Simulations showed AAC conduction requires an isthmus of ≥2 mm and is cycle length (CL) and location dependent. Patients without AAC (n=13) frequently presented with donor atrial arrhythmias, in 77% cavo-tricuspid isthmus (CTI) flutter was ablated. The procedural success was high, although, 12 patients (29%) required re-ablation.
Conclusions
- AACs are found in 21% of OHT patients with atrial tachyarrhythmias and can manifest very early after OHT. Immune privilege characterized by the absence of DSAB may facilitate AAC formation. Propagation across an AAC is width, CL and location dependent. Patients with AAC present with focal atrial tachycardias or atrial fibrillation originating from the recipient atria; patients without most frequently present with CTI dependent atrial flutter. While multiple arrhythmias frequently require re-ablation, ablative therapy is highly effective.
A 59-year-old male with alcoholic cirrhosis presented to our hospital with an acutely painful umbilical hernia, and 4 mo of exertional dyspnea. He was noted to be tachypneic and hypoxic. He had a massive right sided pleural effusion with leftward mediastinal shift and gross ascites, with a tense, fluid-filled, umbilical hernia. Emergent paracentesis with drain placement and a large volume thoracentesis were performed. Despite improvement in dyspnea and drainage of 15 L of ascitic fluid, the massive transudative pleural effusion remained largely unchanged. He underwent a repeat large volume thoracentesis on hospital day 4. The patient subsequently developed a tension pneumothorax, which resulted in a dramatic reduction in the effusion. A chest tube was placed and serial radiographs demonstrated resolution of the pneumothorax but recurrence of the effusion. The radiographs illustrate the movement of fluid between the peritoneal and pleural cavities. In this case, the mechanism of pleural effusion was confirmed to be a hepatic hydrothorax via an unintended tension pneumothorax. Methods to elucidate a hepatic hydrothorax include Tc99m or indocyanine green injection into the ascitic fluid followed by its demonstration above the diaphragm. The unintended tension pneumothorax in this case additionally demonstrates bi-directional flow across the diaphragm.
Congenital absence of the pericardium is a very rare anomaly which has an incidence of 1 in 14000 cases in autopsy studies. Defects in the pericardium are either partial or complete with complete defects having a much benign course than partial defects. Partial defects are associated with complications like strangulation of a herniated cardiac chamber or coronary artery stenosis from external compression. Absence of the left pericardium is the most frequently encountered type of defect which accounts for 2/3 of the cases. We herein report a case of complete absence of the entire pericardium which is an extremely rare subtype with associated Cardiac magnetic resonance images.
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