Mechanical Thrombectomy of a Submassive Pulmonary Embolism in the Second Trimester of Pregnancy.

Venous thromboembolism (VTE) represents a potentially severe and infrequent complication that can occur in the pregnant population. The nuance in recognizing and diagnosing this condition can be quite difficult due to the changes that occur during pregnancy. This case highlights the importance of diagnosing pulmonary embolism in pregnancy, classifying the degree of disease, and determining the best treatment for both mother and fetus. Although rare, early diagnosis and treatment are crucial in order to reduce morbidity and mortality.

Pulmonary hypertension predicts higher mortality in patients admitted with severe COVID-19 infection.

Objective: Patients with underlying conditions are predicted to have worse outcomes with COVID-19. A strong association between baseline cardiovascular disease and COVID-19-related mortality has been shown by a number of studies. In the current retrospective study, we aim to identify whether patients with pulmonary hypertension have worse outcomes compared with patients without pulmonary hypertension. Methods: Data from patients of ⩾18 years of age with COVID was retrospectively collected and analyzed (n = 679). Patients who underwent transthoracic echocardiography, at the discretion of the medical team, were identified and the transthoracic echocardiography was reviewed for the presence of pulmonary hypertension. Patient health parameters and outcomes were measured and statistically analyzed. Results: Of 679 consecutive patients identified with a diagnosis of COVID-19, 57 underwent transthoracic echocardiography, 32 of which were found to have pulmonary hypertension. Patients who underwent transthoracic echocardiography had a significantly higher intensive care unit admission rate (73.7% versus 25.4%, p < 0.001) and increased presence of acute respiratory distress syndrome (63.2% versus 21.6%, p > 0.001). These patients had longer intensive care unit length of stay, longer mechanical ventilation time, longer hospital length of stay, and a significantly higher mortality rate when compared to those not undergoing transthoracic echocardiography (59.7% versus 32.3%, p < 0.001). Among patients who underwent transthoracic echocardiography, those with pulmonary hypertension had significantly higher mortality compared to those without pulmonary hypertension (80% versus 43.8%, p < 0.01). Conclusion: COVID-19 in patients with pulmonary hypertension was associated with high in-hospital mortality even when adjusted for confounding factors. A number of mechanisms have been proposed for the worse outcomes in patients with pulmonary hypertension and right ventricular dysfunction, including right ventricle overload and indirect pro-inflammatory cytokine storm. Further, large-scale studies are required to evaluate the impact of right ventricular dysfunction in COVID-19 patients and to elucidate the associated mechanisms.

The Critical Role of the Adipocytokine NOV in Obstructive Sleep Apnea Induced Cardiometabolic Dysfunction: A Review.

Obstructive sleep apnea (OSA) is highly prevalent and associated with oxidative stress, chronic inflammation, and adverse cardiovascular consequences. The comorbid condition of obesity remains epidemic. Both obesity and OSA are highly comorbid in patients with cardiovascular disease including atrial fibrillation, resistant hypertension, congestive heart failure, and coronary artery disease. Patients with these preexisting cardiovascular conditions should be screened for OSA with a low threshold to treat, even if OSA severity is mild. Nephroblastoma overexpressed (NOV/CCN3) protein has been identified in multiple chronic inflammatory states, most notably in obesity and more recently in OSA, even in the absence of obesity. As such, NOV may represent an important biomarker for oxidative stress in OSA and may lead to a deeper understanding of the relationship between OSA and its clinical sequelae.

Pulmonary hypertension in metastatic breast cancer: a case of pulmonary tumour thrombotic microangiopathy.

Pulmonary tumour thrombotic microangiopathy (PTTM) and pulmonary tumour emboli (PTE) are distinct but related complications of malignancy. The incidence of each is exceedingly rare, unfortunately often being diagnosed postmortem. Patients with PTTM and PTE typically present with dyspnoea associated with a rapid onset of hypoxia due to pulmonary hypertension (PH), and respiratory failure that is almost certain to be fatal. The prognosis is grim due to the rapidity of the clinical decline and difficulty in establishing an ante-mortem diagnosis. We present a case of new-onset severe PH in a young woman with a recently discovered breast mass. She presented with shortness of breath and experienced rapid deterioration of her cardiopulmonary status which we attributed to PTTM. With early initiation of chemotherapy, systemic steroids and sildenafil, the patient dramatically improved. Case reports have identified early use of steroids, phosphodiesterase inhibitors and other alternative therapies as providing possible benefit in PTTM.

Desmosine and Isodesmosine as a Novel Biomarker for Pulmonary Arterial Hypertension: A Pilot Study.

Delayed diagnosis is common in patients with pulmonary arterial hypertension (PAH). Right-sided heart catheterization, the gold standard for diagnosis, is invasive and cannot be applied for routine screening. Some biomarkers have been looked into; however, due to the lack of a clear pathological mechanism linking the marker to PAH, the search for an ideal one is still ongoing. Elastin is a significant structural constituent of blood vessels. Its synthesis involves cross-linking of monomers by 2 amino acids, desmosine and isodesmosine (D&I). Being extremely stable, elastin undergoes little metabolic turnover in healthy individuals resulting in very low levels of D&I amino acids in the human plasma, urine, or sputum. We hypothesized that in PAH patients, the elastin turnover is high; which in turn should result in elevated levels of D&I in plasma and urine. Using mass spectrometry, plasma and urine levels of D&I were measured in 20 consecutive patients with PAH confirmed by cardiac catheterization. The levels were compared with 13 healthy controls. The mean level of total plasma D&I in patients with PAH was 0.47 ng/mL and in controls was 0.19 ng/mL (P = 0.001). The mean levels of total D&I in the urine of PAH patients was 20.55 mg/g creatinine and in controls was 12.78 mg/g creatinine (P = 0.005). The mean level of free D&I in the urine of PAH patients was 10.34 mg/g creatinine and in controls was 2.52 mg/g creatinine (P < 0.001). This is the first study highlighting that the serum and urine D&I has a potential to be a novel screening biomarker for patients with PAH. It paves the way for larger studies to analyze its role in assessing for disease severity and response to treatment.

Pulmonary hypertension and chronic cor pulmonale in COPD.

Hypoxia and endothelial dysfunction play a central role in the development of pulmonary hypertension. Cor pulmonale is a maladaptive response to pulmonary hypertension. The presence of peripheral edema in cor pulmonale is almost invariably associated with hypercapnia. Correction of abnormalities of gas exchange and ventilation can ameliorate pulmonary hypertension and improve survival. This review focuses on new information about the pathogenesis and treatment of pulmonary hypertension in COPD including information derived from lung volume reduction surgery, the role of brain natriuretic peptide, exhaled nitric oxide for diagnosis, and the treatment of cor pulmonale with recently available specific pulmonary vasodilators.

Use of admission troponin in critically ill medical patients.

Serum troponin I (TnI) is a sensitive marker of cardiac injury. A relation between elevated TnI and mortality has been suggested. In this retrospective chart review of 221 patients admitted to the medical intensive care unit (MICU) during a 6-month period, the authors studied the use of admission TnI levels in predicting mortality in MICU-admitted patients. Data retrieved included demographics, admission diagnosis, troponin, electrocardiogram, Acute Physiology and Chronic Health Evaluation (APACHE) II score, echocardiogram, requirements for mechanical ventilation and vasopressor support, development of multiorgan failure, mortality, and discharge disposition. There were 132 patients for whom TnI level was sent within 24 hours of admission; these patients comprised the study group. The median age was 70 years; 59% were female. The mean APACHE II score was 22. Troponin I was positive in 31% of patients (median level, 0.4 Ug/L; range 0-358 Ug/L). The hospital mortality was 39%. Positive TnI showed a weak association with intensive care unit (ICU) mortality (P = .049) but not with overall mortality. There was no significant correlation between admission TnI concentration and APACHE II score (P = .33), administration of vasopressor medications (P = .115), or development of multiorgan failure (P = .64). The authors concluded that there is no benefit in obtaining a routine admission troponin level in MICU patients when an acute coronary event is not suspected.

Corynebacterium afermentans lung abscess and empyema in a patient with human immunodeficiency virus infection.

Necrotizing pleuropulmonary infection in a patient with acquired immunodeficiency syndrome developed due to Corynebacterium afermentans subspecies lipophilum. Long-term combination antibiotic therapy was successful in eradicating the infection without surgery.