Prospective validation of the SCAI shock classification: Single center analysis.

BACKGROUND: The Society for Cardiac Angiography and Interventions (SCAI) Shock Classification has been retrospectively validated by several groups. We sought to prospectively study outcomes of consecutive patients with reference to initial SCAI Shock Stage and therapeutic strategy as well as 24 hr SCAI Shock Stage reassessment. METHODS: Kaplan Meier method was used to describe survival and Cox Proportional hazards modeling used to assess predictors of survival. RESULTS: Over an 18-month period, 166 patients were referred for evaluation. Demographics, hemodynamics, and most laboratory findings were similar between SCAI stages, which were assigned by the team. Initial SCAI Stage was a strong predictor of survival. Thirty-day survival was 100, 65.4, 44.2, and 60% for patients with initial SCAI shock stage B, C, D, and E respectively (p = .0004). Age and initial SCAI Shock Stage were shown to be the strongest predictors of survival by Cox proportional hazards. Mode of mechanical circulatory support (MCS) or lack of such was not a predictor of outcome. Shock stage at 24 hr was also examined. Thirty-day survival was 100, 96.7, 66.9, 21.6, and 6.2% for patients with 3-4 SCAI stage improvement, 2 stage improvement, 1 stage improvement, no change in SCAI stage and worsening of SCAI stage respectively (p < .0001). CONCLUSIONS: Initial SCAI Shock stage predicts the survival of unselected patients with a variety of MCS interventions and medical therapy alone. The 24-hr reassessment of shock stage further refines the prognosis.

The Stages of CS: Clinical and Translational Update.

PURPOSE OF REVIEW: With improvements in cardiovascular care, and routine percutaneous coronary intervention for ST elevation myocardial infarction, more patients are surviving following acute coronary syndromes. However, a minority of patients develop cardiogenic shock which results in approximately 50% 30-day mortality. There are various ways to classify cardiogenic shock, and much has been written about this topic in recent years. This review will examine recent developments and put them in context. RECENT FINDINGS: The large randomized trials of cardiogenic shock treatments such as the IABP-SHOCK II trial used a clinical definition of shock including hypotension (systolic blood pressure of 90 mmHg or less, or requirement of vasopressors to maintain such a blood pressure), as well as hypoperfusion. However, while this defines a minimum standard to define cardiogenic shock, it does not distinguish between a patient on a single vasoconstrictor and one who is on multiple high dose infusions or one on extracorporeal membrane oxygenation. The Society for Cardiac Angiography and Intervention recently published an expert consensus statement defining stages of cardiogenic shock, from at risk to beginning, classic, deteriorating, and extremis cardiogenic shock stages. The simple framework has been validated rapidly in multiple populations including the intensive care unit, a post-myocardial infarction population, an out of hospital cardiac arrest population, and most recently in a multicenter shock collaborative, Classification is fundamental to understanding a disease state, and crafting solutions to improve outcomes. The last 20 years has witnessed an explosion of percutaneous mechanical circulatory support devices of increasing sophistication and capability, and yet there has been little progress in improving outcomes of cardiogenic shock. Hopefully, the next 20 years will see massive advances in understanding of the complexities of the various stages of cardiogenic shock. With such knowledge, it is likely that targeted treatments will be developed and the mortality of this disease will finally plummet.

Kabuki syndrome as a cause of non-immune fetal hydrops/ascites.

Kabuki syndrome (MIM 147920) is a well-described, multiple congenital anomaly syndrome characterized by growth and developmental delay, cardiac, renal, and vertebral anomalies, as well as persistent fetal finger pads and distinct facial features. Facies are characterized by long palpebral fissures with eversion of lateral third of the lower eyelid, resembling the "Kabuki make-up" theatre genre after which the syndrome is named. Kabuki syndrome is estimated to affect 1/32,000 births, with 55-80% of patients showing nonsense or frameshift mutations in the KMT2D (MLL2) gene, which encodes a histone transferase located on chromosome 12q. Additionally, owing to the heterogeneous nature of Kabuki syndrome, a smaller number of diagnosed patients have been identified with mutations or deletions in KDM6A (a component of the same transcriptional complex as KMT2D) with no mutations in KMT2D, or as those diagnosed with Kabuki syndrome and without alterations in either KMT2D or KDM6A. Diagnosis of the syndrome in newborns and infants is difficult, as the facial features are not as evident as in toddler- or childhood. There are no known "tell-tale" signs of Kabuki syndrome prenatally, and there are no reports of common, specific findings in fetuses that might suggest the diagnosis. We present here two infants who presented with prenatal hydrops/ascites, who were subsequently diagnosed with Kabuki syndrome. Although relatively non-specific, we suggest that Kabuki syndrome be added to the list of genetic syndromes that are suspected in cases of prenatal hydrops, review the molecular etiology of Kabuki syndrome, and broaden the phenotype of this well-described disorder. © 2016 Wiley Periodicals, Inc.

Serial ultrasonographic evaluation of ovarian abnormalities with a morphology index.

OBJECTIVE: Transvaginal ultrasonography with tumor morphology index (MI) has been used to predict the risk of ovarian malignancy. Our objective was to analyze changes in serial MI scores for malignant and non-malignant ovarian tumors in a large and asymptomatic population. METHODS: Eligible subjects participated in the University of Kentucky Ovarian Cancer Screening Program and had abnormalities that included cysts, cysts with septations, complex cysts with solid areas, and solid masses. Analysis included: MI, change in MI (delta MI), delta MI per scan and per month, number and duration of scans. RESULTS: From 1987 to 2012, 38,983 women received 218,445 scans. Of the 7104 eligible subjects, 6758 tumors were observed without surgery and 472 were surgically removed. Eighty-six percent (5811) of observed tumors were resolved. There were 74 malignant and 272 non-malignant tumors. Eighty-five percent of malignancies had MI ≥5 at decision for surgery. The risk of malignancy based on MI was: MI=5 (3%), MI=6 (3.7%), MI=7 (12.6%), MI=8 (26.7%), MI=9 (27.8%), MI=10 (33.3%). The mean delta MI per month decreased for tumors that resolved (delta MI -1.0, p<0.001) or persisted without surgery (delta MI -0.7, p<0.001). For abnormalities surgically removed, the mean delta MI per month increased significantly more for malignancies than for benign tumors (delta MI +1.6 vs. +0.3, p<0.001). CONCLUSIONS: The mean MI for malignant ovarian tumors increases over time, while non-malignant tumors have a decreasing or stable MI. Serial MI analysis can improve the prediction of ovarian malignancy by reducing false-positive results, thereby decreasing the number of operations performed for benign abnormalities.

Donor Utilization in the Recent Era: Effect of Sex, Drugs, and Increased Risk.

BACKGROUND: Heart transplantation volumes have increased in recent years, yet less than a third of donors are typically accepted for transplantation. Whether donor sex, donor drug use, or perception of increased risk affects utilization for transplantation is unclear. METHODS: The United Network for Organ Sharing database was queried for donors from January 1, 2007, to December 31, 2017. Donor toxicology was collected when available. Multivariate analysis was conducted to examine correlations with donor utilization. RESULTS: Between January 1, 2007, and December 31, 2017, there were 87 816 heart donors aged ≥15 years. The mean age was 42.7±15.8 years, and 24 831 donors (28.3%) were utilized for heart transplantation. Subsequent analyses focused on donors between 15 and 39 years old. The strongest associations with donor acceptance were for male donor sex, blood type, hepatitis C antibody, donor age, left ventricular hypertrophy, and history of donor drug use. After removing hepatitis C, Public Health Service Increased Risk was identified as a strong negative predictor. Most positive drug toxicology results were associated with donor nonuse except for donors between 15 and 19 years of age. Exceptions included alcohol, marijuana, and cocaine. Opiates were associated with less utilization at all donor ages. The Public Health Service Increased Risk status was associated with significantly less utilization in all age groups except 15- to 19-year-old donors. CONCLUSIONS: While male donors were preferentially utilized, donors with drug use or those deemed Public Health Service Increased Risk were significantly less utilized for heart transplantation. Further consideration of such donors would be appropriate particularly as the demand for transplantation continues to increase.

Lingua Franca of Cardiogenic Shock: Speaking the Same Language.

Cardiogenic shock has remained a vexing clinical problem over the last 20 years despite progressive development of increasingly capable percutaneous mechanical circulatory support devices. It is increasingly clear that the published trials of various percutaneous mechanical circulatory support devices have compared heterogenous populations of cardiogenic shock patients, and therefore have not yielded a single result where one approach improved survival. To classify patients, various risk scores such as the CARDSHOCK and IABP-Shock-II scores have been developed and validated but they have not been broadly applied. The Society for Cardiac Angiography and Intervention Expert Consensus on Classification of Cardiogenic Shock has been widely studied since its publication in 2019, and is reviewed at length. In particular, there have been numerous validation studies done and these are reviewed. Finally, the directions for future research are reviewed.

Percutaneous Closure of a Large Postinfarct Ventricular Septal Defect With an Atrial Septal Defect Closure Device in a High Surgical Risk Patient.

We report here the transcatheter closure of a large and complex post-myocardial infarction ventricular septal defect (VSD) involving the papillary muscle, measuring 38 mm in its greatest extent, too large to utilize a VSD occluder device (the largest VSD occluder is 24 mm). This necessitated the novel, off-label use of an atrial septal defect occluder instead.

Pop the balloon: rapid switch from Intra-aortic balloon pump to alternate device.

When a patient with an intra-aortic balloon pump needs different support, it is simple to use a stiff 0.018-inch interventional wire (360 cm) to exchange the balloon for a new sheath. This allows the team to start with a balloon and then switch if the support is not sufficient.

Intoxicated Donors and Heart Transplant Outcomes: Long-Term Safety.

BACKGROUND: The opioid crisis has led to an increase in available donor hearts, although questions remain about the long-term outcomes associated with the use of these organs. Prior studies have relied on historical information without examining the toxicology results at the time of organ offer. The objectives of this study were to examine the long-term survival of heart transplants in the recent era, stratified by results of toxicological testing at the time of organ offer as well as comparing the toxicology at the time of donation with variables based on reported history. METHODS: The United Network for Organ Sharing database was requested as well as the donor toxicology field. Between 2007 and 2017, 23 748 adult heart transplants were performed. United Network for Organ Sharing historical variables formed a United Network for Organ Sharing Toxicology Score and the measured toxicology results formed a Measured Toxicology Score. Survival was examined by the United Network for Organ Sharing Toxicology Score and Measured Toxicology Score, as well as Cox proportional hazards models incorporating a variety of risk factors. RESULTS: The number and percent of donors with drug use has significantly increased over the study period (P<0.0001). Cox proportional hazards modeling of survival including toxicological and historical data did not demonstrate differences in post-transplant mortality. Combinations of drugs identified by toxicology were not associated with differences in survival. Lower donor age and ischemic time were significantly positively associated with survival (P<0.0001). CONCLUSIONS: Among donors accepted for transplantation, neither history nor toxicological evidence of drug use was associated with significant differences in survival. Increasing use of such donors may help alleviate the chronic donor shortage.

Comparative Intermediate-Term Outcomes of Subclavian and Transcaval Access for Transcatheter Aortic Valve Replacement.

BACKGROUND: Multiple alternative access routes have been employed for patients with contraindications to standard transfemoral transcatheter aortic valve replacement (TAVR); however, the optimal route for alternative access approaches is not established. In order to better understand possible differences in alternative access routes, we compared the procedural efficacy and outcomes at 30 days and 1 year in patients who underwent TAVR via subclavian (SC) or transcaval (TC) access route at a single, tertiary-care center. METHODS: This retrospective analysis included all TAVR procedures performed via SC or TC approaches between December 2011 to January 2020, with outcomes reported to 1 year post procedure. Additional safety and feasibility studies, including successful device deployment, procedural time, blood loss, and total hospitalization length, are included as part of this study. RESULTS: A total of 41 patients underwent SC access and 22 patients underwent TC access for TAVR. Between both cohorts, SC patients were older at the time of TAVR (83.2 ± 3.7 years for SC vs 80.7 ± 3.9 years for TC; P=.03) and all patients were previously deemed high or prohibitive surgical risk (Society of Thoracic Surgeons score, aortic valve replacement only: 10.4 ± 2.6% for SC vs 9.0 ± 1.9% for TC; P=.12), with similar preoperative hemodynamic profiles. PROCEDURAL SAFETY: Device deployment was successful in all patients in both groups, with longer procedural times noted in the SC cohort (62.1 ± 12.1 minutes for SC vs 39.8 ± 12.5 minutes for TC; P<.05). There were no in-hospital deaths in the SC group and 1 intraoperative death in the TC group that was unrelated to access route. Average length of hospital stay was consistent between the two groups (3.8 ± 1.4 days for SC vs 3.4 ± 1.1 days for TC; P=.06). More cerebrovascular accidents were noted in the SC group at 30 days (6 for SC vs 1 for TC), 6 months (3 for SC vs 0 for TC), and 1 year (2 for SC vs 0 for TC), with more postprocedural permanent pacemakers implanted in the SC group at 30 days (9 for SC vs 3 for TC; P<.05, but with fewer at 6 months (2 for SC vs 3 for TC) and 1 year (1 for SC vs 2 for TC). Mortality rate was not statistically different between the two groups at 30 days, 6 months, and 1 year (P>.05 for all). CONCLUSION: Both SC and TC access routes can be safe and feasible options for TAVR in patients at increased or prohibitive surgical risk with contraindications to standard transfemoral access.

Use of MitraClip to Target Obstructive SAM in Severe Diffuse-Type Hypertrophic Cardiomyopathy: Case Report and Review of Literature.

Hypertrophic cardiomyopathy (HCM) is frequently associated with abnormalities of the mitral valve; these commonly include systolic anterior motion (SAM) of anterior mitral leaflets that contribute to dynamic left ventricular outflow tract (LVOT) obstruction and secondary mitral regurgitation (MR). In patients with severe HCM, LVOT obstruction due to SAM, and debilitating symptoms refractory to medical therapy, the current standard of care involves a surgical approach. This involves targeting the ventricular septum through resection or ablation, combined at times with mitral valve replacement or plication of the valve leaflet to relieve LVOT obstruction. In patients with symptoms refractory to medical management who are at prohibitive surgical risk, additional options for less-invasive approaches for the management of HCM are needed. We describe here the successful non-surgical catheter-based management of a 72-year-old woman at high surgical risk, debilitating symptoms refractory to maximal medical management, and severe, diffuse-type HCM. Edge-to-edge repair with MitraClip (Abbott Vascular) was used to target SAM causing dynamic LVOT obstruction, with resulting significant reduction in LVOT gradient and dramatic clinical improvement. Her postprocedure outcomes to 2 years are reported herein. Additionally, we review the current management strategies for HCM management, and include a discussion of minimally invasive options.

Poorly Differentiated Breast Adenocarcinoma as a Rare Cause of Right Ventricular Outflow Tract Compression: Case Report and Review of the Literature.

Metastatic cancer that involves the structures of the heart is a rare complication and most commonly diagnosed during postmortem examination. Classically, the development of secondary tumors involves invasion of the pericardium or the myocardium and may disrupt the cardiac conduction system, causing new arrhythmias and heart failure. In this article, we present the case of a 58-year-old female with new diagnosis of ventricular bigeminy, and evidence of cardiac tamponade physiology from direct compression of the right ventricular outflow tract from high-grade carcinoma of the left breast. As oncologic therapies advance and provide more life-prolonging options to patients, recognition of the mass effect of large tumors should be recognized.

Bioprosthetic Valve Fracture for Early Severe Prosthesis Mismatch After SAVR.

BACKGROUND: Patient prosthesis mismatch (PPM) is an iatrogenic complication that occurs in patients who undergo surgical aortic valve replacement (SAVR). PPM occurs when the implanted surgical valve has an effective orifice area (EOA) that is too small for the patient, resulting in a gradient across the valve despite an otherwise normally functioning prosthesis. PPM has been associated with mid- and long-term increased morbidity and mortality. When this occurs, repeat SAVR with root enlargement and implantation of a larger prosthesis is traditionally employed; however, this approach involves the risks of morbidity and mortality of redo surgery, which may be prohibitive in critically ill or medically complex patients. Bioprosthetic valve fracture (BVF), where high-pressure balloon inflation is employed to fracture the surgical valve sewing ring to increase the EOA, has been used as an adjunct for valve-in-valve (transcatheter aortic valve in surgical aortic valve [TAV in SAV]) procedures for degenerated surgical valves to increase EOA, but has not yet been reported as standalone therapy for early PPM after SAVR. CASE PRESENTATION: We present a case of a 41-year-old male (body surface area, 2.3 m²) who presented 4 months after SAVR with a 21 mm surgical valve (Magna Ease, true inner diameter, 19 mm) with severe PPM (mean gradient, 43 mm Hg) despite normal functioning valvular prosthetic leaflets, associated with debilitating symptoms. This patient was deemed high risk by the heart team, and was successfully treated with TAV in SAV (26 mm Evolut R) and concomitant high-pressure bioprosthetic valve fracture (BVF) with a 22 mm high-pressure balloon. The patient tolerated the procedure well; mean gradient was 5 mm Hg post BVF and prompt resolution of symptoms was seen. His postprocedure recovery was uneventful and his symptoms resolved, allowing him to return to work within a week of his hospital discharge. BVF associated with TAV in SAV appears to be a feasible approach for treatment of severe symptomatic PPM even in the early postoperative period with otherwise normally functioning prosthesis.

Sequential Use of Alcohol Septal Ablation and Electrosurgical Leaflet Resection Prior to Transcatheter Mitral Valve Replacement.

In patients with increased surgical risk and hemodynamically significant mitral disease, a transcatheter strategy for mitral valve replacement (TMVR) may be suitable; however, is also not without procedure risk. Obstruction of the left ventricular outflow tract (LVOT) is one of the most dreaded complications of TMVR, requiring careful consideration of potential candidates with preprocedural imaging and ex vivo valvular fit simulation as part of risk assessment for postprocedure obstruction. In patients at high risk of LVOT obstruction, early studies have shown that alcohol septal ablation or electrosurgical laceration of the anterior mitral leaflet (LAMPOON) procedure prior to TMVR may mitigate the risk of LVOT obstruction. We describe the recent successful management of a patient with severe mitral valve disease, mitral annular calcification (MAC), and high risk of post-TMVR LVOT obstruction, who underwent a sequential strategy of ASA followed by electrosurgical leaflet resection with the LAMPOON procedure prior to TMVR to successfully prevent LVOT obstruction. To our knowledge, this is the first time this dual strategy has been reported, and it may allow more patients with severe mitral valve disease to undergo TMVR in the future.

Fulminant Presentation of a Failed TAVR Valve: Successful Revision with a Transcatheter Approach - Case Report and Review of the Literature.

Transcatheter Aortic Valve Replacement (TAVR) has evolved as a strategy for managing aortic stenosis in a growing proportion of patients considered at high or intermediate surgical risk. Though early data has demonstrated excellent durability and life span of transcatheter valves up to five years, there is an absence of case based studies in the literature regarding transcatheter valve failure after TAVR, and outcomes of subsequent redo TAVR Valve-in-Valve (VIV) procedures. We report here a successful case of emergent, catheter-based treatment for severe, highly symptomatic valve in valve restenosis of a 5 year old Sapien valve.

Increased Rate of Intermediate-Term Valve Failure After TAVR in End-Stage Renal Disease Patients Requiring Maintenance Dialysis.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has been widely adopted, but outcomes in end-stage renal disease (ESRD) patients on hemodialysis (HD) have not been extensively studied. METHODS: A total of 1260 TAVRs were performed at our center between December 2011 and October 2018, including 86 patients (6.82%) with ESRD on HD. Comparisons were made between baseline demographics, preoperative risk, hemodynamics, and reintervention, as well as survival at 30 days, 1 year, and 2 years. RESULTS: Age at TAVR was 62.7 ± 12.1 years in the ESRD-HD group vs 72.3 ± 5.9 years in the non-ESRD group (P<.01). STS scores were 10.2 ± 1.3% in the ESRD-HD group vs 8.1 ± 1.1% in the non-ESRD group (P<.01). Mortality rates were different between the ESRD-HD group and the non-ESRD group (30-day mortality, 5.8% vs 3.1%, respectively [P=.05]; 1-year mortality, 25.1% vs 13.6%, respectively [P<.01]; 2-year mortality, 51.6% vs 23.0%, respectively [P<.01]). Baseline aortic valve areas (AVAs) were comparable; however, ESRD-HD patients had higher gradients than non-ESRD patients at every postprocedural interval assessed (30-day AVA, 1.47 ± 0.2 cm² vs 1.32 ± 0.1 cm², respectively [P<.001]; 1-year AVA, 1.39 ± 0.1 cm² vs 1.05 ± 0.1 cm², respectively [P<.01]; 2-year AVA, 1.28 ± 0.1 cm² vs 0.77 ± 0.05 cm² , respectively [P<.01]). Repeat TAVR was needed within 2 years in 5 ESRD-HD patients (6.8%) and 1 non-ESRD patient (0.01%). CONCLUSIONS: In our single-center cohort, the ESRD-HD TAVR group demonstrated significantly higher rates of need for valvular reintervention (6.8% vs 0.01%) at 2 years, as well as higher mortality rates at 30 days, 1 year, and 2 years.

TAVR Complicated by Thoracic Aortic Perforation and Intussusception of the Right Iliac: Report of Successful Emergent Management With Endovascular Techniques.

Percutaneous approaches have become routine in transcatheter aortic valve replacement (TAVR). Despite numerous advantages, vascular complications associated with percutaneous access can occur during and after TAVR, and increase morbidity and mortality significantly. Effective management of potentially catastrophic vascular complications often requires prompt recognition, diagnosis, and management by multidisciplinary teams.

Transcatheter Mitral Valve-in-Valve and Valve-in-Ring Replacement in High-Risk Surgical Patients: Feasibility, Safety, and Longitudinal Outcomes in a Single-Center Experience.

BACKGROUND: Transcatheter mitral valve-in-valve (TMVIV) or valve-in-ring (TMVIR) replacement has shown early promise in patients deemed poor surgical candidates as a less invasive alternative to conventional reoperative mitral valve (MV) replacement. OBJECTIVE: This retrospective, single-center study reviewed the procedural outcomes of all TMVIV and TMVIR procedures between 2013-2018 at a large tertiary referral center serving the southeastern United States. An analysis of patient safety measures was also performed, with a retrospective assessment of relative procedural safety that included preoperative risk stratification and postoperative mortality predictors, operative time, average blood loss, length of hospital stay, and readmission rates. METHODS: This study included 24 patients with severe MV disease and medical comorbidities who were considered too high risk for conventional MV replacement. All patients underwent TMVIV or TMVIR with Edwards Sapien XT or S3 transcatheter valves (Edwards Lifesciences). A secure database of patient demographics, preoperative risk assessment, and procedural data was created and included technical success rates, blood loss, operative time, and intraoperative and immediate postoperative complications. Subsequent follow-up of patient outcomes reported here include those collected at 30 days, 180 days, and 1 year. RESULTS: Of the 24 patients in our study, 16 received TMVIV and 8 received TMVIR implantation. Each procedure was performed successfully under general anesthesia via transseptal approach (n = 17) or transapical approach (n = 7), with only 1 patient (8.2%) requiring late operative reintervention 252 days post op. Average procedural time was 76 min and average blood loss was <75 mL, with 20/24 patients (83%) successfully extubated on postoperative day 0. Length of Intensive Care Unit stay was 1.7 ± 1.4 days and length of total inpatient stay was 2.8 ± 1.8 days. Echocardiograms were collected immediately post op, at 30 days, at 180 days, and subsequently at yearly intervals; follow-up demonstrated excellent prosthetic valve function with low transvalvular gradients, and no evidence of valve embolization or thrombosis. In patients with follow-up data available at 1 year (n = 13), there were no readmissions at 30 days or 180 days, and only 1 admission (8.3%) during the first postoperative year for symptoms related to congestive heart failure (CHF). CONCLUSION: TMVIV and TMVIR can be safe and effective in a patient population considered at prohibitive risk for conventional surgery. These procedures can be performed efficiently in a hybrid operating room, with relatively short procedural times and high rates of early extubation. Procedural complications, mortality, and readmission rates for CHF at 30 days, 180 days, and 1 year were very low in this high-risk cohort.

ARDS complicating pustular psoriasis: treatment with low-dose corticosteroids, vitamin C and thiamine.

We report the case of a 45-year-old Caucasian woman with a history of psoriasis, admitted to our Medical intensive care unit following the acute onset of diffuse rash and progressive dyspnoea and hypoxaemia requiring escalating respiratory support (continuous positive airway pressure of 10 cm H2O). Her chest X-ray was consistent with findings of non-cardiogenic pulmonary oedema. Echocardiogram was normal. Dermatology considered her skin lesions to be consistent with psoriasis vulgaris with pustular flare. In the absence of an identifiable cause for her respiratory failure, she was diagnosed with acute respiratory distress syndrome due to her psoriatic flare. Treatment with cyclosporine was initiated together with low-dose systemic corticosteroids, intravenous vitamin C and thiamine. The patient made a dramatic recovery being weaned to nasal cannulae within 24 hours after the initiation of this treatment protocol and was discharged home a few days later.