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Allergy and Airway

Chest. 2014;145(3_MeetingAbstracts):1A. doi:10.1378/chest.1822040

SESSION TITLE: Asthma Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Case report

CASE PRESENTATION: 44 y/o M with history of asthma, GERD, vertigo and multiple Intubation x24times in past attributed to Peanut allergy since age 19, present with worsening shortness of breath and stridor after smelling peanut butter. In ED he was hypoxic and has stridor audible from distant. Epinephrine IM , Solumedrol, Benadryl and pepcid was given and LMA was used first w/o success so orotracheal intubation performed in ED under fiberoptic laryngoscope. No visible laryngeal edema or obstruction observed during intubation. Patient self extubated next day but again had a similar episode of stridor and difficulty in breathing and was hypoxic to high 80s. Direct laryngoscope exam showed paradoxical vocal cord movements with no airway obstruction or laryngeal edema. Patient responded well to anxiolytic avoiding an intubation. Later on support the diagnosis was tested negative for Peanut allergy and Hereditary Angioedema.

DISCUSSION: PVCM is a disease entity defined as inappropriate adduction of vocal cord during respiration. Prevalance F>M. Categorized in Primary (Psychological) and Secondary causes. Treatment is based on etiology . Treatment involves primarily behavioral changes without medication or tracheostomy. Most effective treatment would be speech therapy, stress reduction and relaxation techniques. Simple technique such as pursed lip expiration or deep inspiration through nose would also help to keep laryngeal airway open. It should be determine by laryngoscopy which method is suitable for individual to keep laryngeal airway patent. Meanwhile treatment of associated comorbid conditions such as asthma, GERD, laryngitis, neuropathies would also help to alleviate symptoms

CONCLUSIONS: The diagnosis of PVCM is often very difficult to made given episodic nature and it usually mimics severe asthma or angioedema as with our patient. Treatment needs to be individualized based and also psychiatric aspect of illness need to be addressed as well.

Reference #1: Forrest LA, Husein T, Husein O, et al. Paradoxical Vocal Cord motion: classification and treatment. Laryngoscope 2012 Apr;122(4):844-53

DISCLOSURE: The following authors have nothing to disclose: Parth Rali, Hardik Soni, Win Naing

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Chest. 2014;145(3_MeetingAbstracts):2A. doi:10.1378/chest.1826003

SESSION TITLE: Asthma Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: We present a 52 year old patient masquerading as a “difficult to control asthmatic”. Her ultimate diagnosis is common variable immunodeficiency complicated by recurrent pulmonary infections, follicular bronchitis, and organizing pneumonia. This diagnosis is rare, but should be entertained in our patient’s age group. The common variable immunodeficiencies (CVID) are relatively frequently encountered syndromes of various types of B-cell activation or differentiation defects, most often diagnosed during late childhood or early adult life. (1-4) Clinical manifestations of CVID include recurrent infections of the respiratory tract and, less frequently, autoimmune, granulomatous, or lymphoproliferative disorders.

CASE PRESENTATION: This is a 52 year old female asthmatic nonsmoker presenting with eleven years of recurrent pneumonias, asthma exacerbations and weight loss. She had persistent cough, fatigue, and dyspnea after a bout of pneumonia treated with azithromycin. Frustrated, she presented for a second opinion. Chest CT showed bilateral airspace disease and bronchiectasis predominantly in the lower lobes. Transbronchial biopsies revealed “possible” cryptogenic organizing pneumonia and moderate haemophilus influenza on culture. A workup was negative for connective tissue disease and HIV, but revealed profound IgG, IgA, and IgM deficiencies. Due to serial CT scans over the years showing interstitial changes, a VATS biopsy was done exhibiting follicular bronchitis, bronchiectasis, constrictive bronchiolitis, and acute organizing pneumonia. She has begun lifelong immunoglobulin replacement therapy and will soon begin corticosteroid therapy.

DISCUSSION: The age of onset for CVID is usually in the second to third decade of life. (6-9) Long-term outcome is significantly influenced by delay of diagnosis and treatment in the presence of chronic inflammatory complications. (6) Our patient did not come to diagnosis until age 52, despite multiple physician encounters over many years.

CONCLUSIONS: CVID should be considered in adults of any age when presenting with recurrent pneumonias and bronchospasm, as this could significantly improve outcomes if diagnosed before chronic lung changes occur. This case reminds us of the old adage that “all that wheezes is not asthma!”

Reference #1: Murray JF, Nadel JA: Textbook of Respiratory Medicine: 5th Edition. Saunder, an imprint of Elsevier, Philadelphia, 2010.

Reference #2: Hermans, PE, Diaz-Buxo, JA, Stobo JO: Idiopathic late-onset immunoglobulin deficiency. Clinical observations in 50 patients. Am J Med. 61: 221-237, 1976.

Reference #3: Cunningham-Rundles C: Clinical and immunological analysis of 150 patients with common variable immunodeficiency. J Clin Immunol. 9:22-33, 1989.

DISCLOSURE: The following authors have nothing to disclose: Susan Mucha, Mark Lega, Marvin Balaan

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Chest. 2014;145(3_MeetingAbstracts):3A. doi:10.1378/chest.1826982

SESSION TITLE: Asthma Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Management of status asthmaticus requires more than guidelines-guided therapy. Occasionally, unusual therapeutic interventions may provide significant benefits. The role of bronchoscopy in fatal asthma is still not clearly defined.

CASE PRESENTATION: A 43-year-old woman presented with acute severe asthma. Her initial arterial blood gases showed pH 6.90; PaCO2 114 mmHg; PaO2 30.0 mmHg; and HCO3 13.4 mEq/L.. . The patient was sedated with ketamine and relaxed with rocuronium infusion and placed on mechanical ventilation Lung mechanics revealed high-peak airway and plateau pressure . she was started with bronchodilators , inhaled and intravenous corticosteroids, and bolus of magnesium sulfate . Salbutamol infusion and intermittent doses of subcutaneous adrenaline were added. Urgent flexible bronchoscopy was performed for diagnostic purposes and removal of mucus plug as warranted.Immediately after bronchoscopy, the patient’s respiratory condition began to improve. A 36-year-old male, presented with severe acute asthma. Blood gases before intubation (pH 7.01; PaCO2 108; PaO2, 106 HCO3 27.8) Treatment included inhaled bronchodilators, inhaled and intravenous steroids, antibiotics, and a bolus dose of magnesium sulfate. Patient was placed on mechanical ventilation (Lung mechanics revealed high peak pressures and intrinsic PEEP) . Salbutamol Iinfusion and intermittent subcutaneous adrenaline was started . Bronchoscopy was performed and revealed inflamed airways and obstruction of middle-sized airways with mucus plugs that were removed. The patient was successfully weaned from mechanical ventilation on the following day.

DISCUSSION: The clinical course and severity of symptoms in asthma follows the sequence of air flow limitation leading to ventilation perfusion mismatch, hypoxemia, hypercarbia, and respiratory failure. infections and severe mucus plugging;may further worsen air flow obstruction, atelectasis,. It has already been observed[1)] that the necropsic finding of patients who died after fatal asthmatic attack revealed blockade of airway; primarily due to thick mucus plugs . . Early reports highlighted the successful use of bronchoscopy in patients with severe asthma who were on mechanical ventilation.[2,] Removal of mucus plugs helped in improvement of PCO2 and expedites ventilator withdrawal. A recent report of 41 pediatric patients showed improvement in ventilator weaning after performing therapeutic bronchoscopy.[3]

CONCLUSIONS: These two cases support that bronchoscopy may facilitate respiratory recovery in patients with resistant status asthmaticus who are on mechanical ventilation. Further studies are warranted to explore the potential role of bronchoscopy in these patients.

Reference #1: Houston JC, De Navasquez S, Trounce JR. A clinical and pathological study of fatal cases of status asthmaticus. Thorax 1953;8:207-13

Reference #2: Walker PE, Marshall M. Bronchial lavage in status asthmaticus. Br Med J 1969;3:31-2. Pulmonol 2012;47:1180-4.

Reference #3: Maggi JC, Nussbaum E, Babbitt C, Maggi FE, Randhawa I. Pediatric fiberoptic bronchoscopy as adjunctive therapy in acute asthma with respiratory failure. Pediatr

DISCLOSURE: The following authors have nothing to disclose: Muhammad Khan, Hadil Al Otair, Abdul Aziz AlZeer, Alaa Elgishy

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Chest. 2014;145(3_MeetingAbstracts):4A. doi:10.1378/chest.1833090

SESSION TITLE: Asthma Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Vocal cord dysfunction (VCD) is a syndrome characterized by glottic obstruction due to vocal cord adduction, with symptoms of wheezing and dyspnea (1). It is often mistakenly diagnosed as asthma, though the use of laryngoscopy can aid in the diagnosis, as was done in this case (2).

CASE PRESENTATION: A 76 year old female was evaluated for two months of wheezing and progressive dyspnea. She has a medical history including coronary artery disease with coronary artery bypass grafting (CABG), pulmonary embolism, and left MCA stroke with residual right-sided weakness and complete expressive aphasia. She had been evaluated on three previous occasions by ENT with direct laryngoscopy for wheezing, though no diagnosis had been made. She underwent pulmonary function testing that demonstrated a mild obstructive pattern, and she had a negative upper endoscopy. The patient was hospitalized for the third time in two months for dyspnea. During this admission, a pulmonary consult was obtained and laryngoscopy was repeated by our department. When the scope was advanced into the laryngopharyngeal area, the arytenoids were drawn forward towards the epiglottis during the episodes, obstructing the supraglottic aperture. There was noticeable inspiratory glottic narrowing to 50% in addition to posterior trachea bulging. When distracted, it resolved quickly but returned when she was not distracted. With her stroke, she failed speech therapy due to apraxia and therapy for anxiety was intensified.

DISCUSSION: Other etiologies of upper airway wheezing, including laryngomalacia, CNS causes, and vocal cord paresis are often difficult to differentiate from true VCD (1). Brainstem compression, upper and lower motor neuron injury, and movement disorders can all lead to dysfunction as well (2).

CONCLUSIONS: In this case, the patient began to wheeze shortly after her MCA stroke, thus this is the likely culprit of her arytenoid dysfunction and adds to the spectrum of functional diseases often called vocal cord dysfunction.

Reference #1: Morris M, Kent C. Diagnostic Criteria for the Classification of Vocal Cord Dysfunction. Chest. 2010; 138 (5).

Reference #2: Kenn K, Balkissoon R. Vocal cord dysfunction: what do we know? Eur Respir J. 2011: 37: 194-200.

DISCLOSURE: The following authors have nothing to disclose: Kaiser Lim, Sarah Narotzky

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Topics: dyspnea , wheezing
Chest. 2014;145(3_MeetingAbstracts):6A. doi:10.1378/chest.1832854

SESSION TITLE: Asthma Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: The sensitivity of impulse oscillometry (IOS) to reflect different aspects of airway obstruction in obese men after intensive challenge has not been comprehensively appreciated. In obese subjects evaluated with spirometry we need more sensitive devices to assess exercise-related restrictive and obstructive abnormalities that hinder an exercise program for obese men who are going to be engaged in such programs. The objective was to measure airway responses following room temperature exercise challenge in healthy obese young men.

METHODS: 14 obese participants (BMI > 35) with well-preserved FEV1/FVC ratio underwent an exercise bronchial provocation test (EBPT). The results were compared to data obtained from control group including 10 non-asthmatic lean (BMI < 25) men. IOS and spirometry measurements were collected at baseline and for 20 minutes after challenge at 5-min intervals. All subjects completed a recommended-8-minutes-running on treadmill. Exercise intensity was verified based on Heart rate and Kilojoules of workload. For obese individuals, the equation (HRpeak=200-0.5×Age) was used.

RESULTS: Correlations were found between resting FEV1 and IOS, except for the area of reactance (Ax) in obese group. IOS and spirometry identified significant differences in respiratory resistance between two groups (p<0.05). Spirometry revealed significant differences in post-challenge percent changes only at 5 minutes after exercise; however IOS identified significant differences in respiratory resistance at 5 and 10-min post-challenge time points. The sensitivity for R5 was significantly greater than for R20 in obese group (p<0.05).

CONCLUSIONS: IOS parameters especially X at 5Hz and Ax maybe more sensitive for respiratory resistance evaluation in obese men after exercise challenge. IOS detected differences in degree of response in obese group more than that was detected by spirometry.

CLINICAL IMPLICATIONS: We recommend therefore that appropriate pulmonary function testing is required when fitness experts need subjecting obese individual to exercise programs. In the case of obese subjects, due to their unique conditions, IOS diagnosis may be more reliable than spirometry.

DISCLOSURE: The following authors have nothing to disclose: Mustafa Moradi, Esmaeil Idani

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Chest. 2014;145(3_MeetingAbstracts):8A. doi:10.1378/chest.1748893

SESSION TITLE: Asthma Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: This study aimed to determine if the use of low dose oral corticosteroid is a safe and effective alternative treatment for children with moderate persistent asthma.

METHODS: Forty patients, 6 to 15 years old, with newly diagnosed moderate persistent asthma were randomized into two groups. For 3 months, the control group received inhaled corticosteroid (budesonide) at 200mcg twice daily while treatment group received a single morning dose of oral corticosteroid (prednisone) at 0.5mg/kg (maximum dose:10mg/day). Efficacy was assessed based on daytime and nighttime coughing, limitation of activity, use of bronchodilators, FEV1, PEFR and level of asthma control. Safety parameters evaluated were blood pressure, pre and posttreatment determination of serum cortisol and fasting blood sugar levels.

RESULTS: Study participants from both groups showed comparable improvement in daytime and nighttime cough, need for bronchodilators and limitation of activity. PEFR is the only parameter that showed a significant difference, participants under the inhaled corticosteroid group showed lower PEFR values than the oral corticosteroid group throughout the entire study period. There was no significant difference in their FEV1 but basically had the same trend as that of the PEFR. There was no significant difference in the safety parameters evaluated. Study participants from both groups showed a decrease in cortisol levels after 3 months of treatment but none had signs and symptoms of adrenal insufficiency.

CONCLUSIONS: There was no significant difference in the safety and efficacy of oral versus inhaled corticosteroid in the treatment of children with moderate persistent asthma after 3 months of treatment.

CLINICAL IMPLICATIONS: These findings do not aim to replace inhaled corticosteroid as the mainstay of treatment for persistent asthma but to find a suitable, effective and more importantly, a safe alternative treatment for patients with uncontrolled asthma in third world countries.

DISCLOSURE: The following authors have nothing to disclose: Yadnee Estrera, Arnel Gerald Jiao, Jemaila Valles, Josy Naty Venturina

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Chest. 2014;145(3_MeetingAbstracts):9A. doi:10.1378/chest.1822282

SESSION TITLE: Asthma Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: To determinate the prevalence of bacterial colonization in severe persistent bronchial asthma and variables related airway inflammation, systemic, pulmonary function and clinical behavior

METHODS: 28 patients with severe persistent asthma who are medically indicated bronchoscopy in a stable situation were recruited. We obtained health resource utilization, ACT, according MRC dyspnea, quality of life (AQLQ-Sydney), and pulmonary function laboratory data. Telescoping catheter (CTT) and bronchoalveolar lavage (BAL) cell count were performed.

RESULTS: Of 28 patients, 7 were men. No smoker and only one ex-smoker. Mean age: 57 years, mean FEV1%: 56%. Mean ACT: 17. In 8 of 28 patients (28.6%) had positive culture CTT, 6 for Haemophilus influenzae and 2 for Pseudomonas aeruginosa. The sample was divided in two groups depending on colonization. We observed that the colonized group had significantly higher serum CRP (7,4 VS 2,6 mg/dl; p:0.04), fibrinogen (457vs386; p=0.030) and segmented leucocytes % of the BAL (31.4vs7.8; p=0.003). They also had lower serum albumin(40vs43 mg/dl; p=0.004) and Hb (12.7 vs 14; p=0.049). The values of FEV1 (53.4 vs 64.4%) and FEV1/FVC (57.6 vs 62.8%) were lower, but not significant. The 23 patients with FEV1/FVC%<70% had a higher % of colonization (34.7%). Of the 5 non-obstructive no one was colonized

CONCLUSIONS: Bronchial colonization is common in patients with severe persistent asthma: 28.6%; and higher in patients with bronchial obstruction: 34.7%. No relation was established with health resource utilization, symptoms or quality of life. It was related to systemic and airway inflammatory parameters. The colonized patients had lower levels of Hb and albumin and worse lung function.

CLINICAL IMPLICATIONS: In patients with severe persistent asthma and airflow obstruction, take into account the possibility of bronchial colonization to optimizing treatment, with the impact this could have on the use of health resources

DISCLOSURE: The following authors have nothing to disclose: Estefania Sanchez, Carlos martinez Rivera, Felipe Andreo, Pere Serra, Cristina Prat, Jose Sanz, Jose Dominguez, Joan Ruiz, Marisa Rivera Ortún, David Ramos, Gloria Bonet

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Chest. 2014;145(3_MeetingAbstracts):10A. doi:10.1378/chest.1836166

SESSION TITLE: Asthma Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Despite optimal treatment, some asthmatic remain symptomatic with frequent exacerbations and persistent obstruction of the airways. Tiotropium addition is associated with reduced risk of exacerbations and sustained bronchodilatation(BD). Objectives: Characterization of asthmatic patients with optimized treatment and treated with tiotropium. Assess the role of tiotropium in symptomatic control and lung function.

METHODS: Retrospective cohort study with asthmatic patients observed during 2012 and treated with tiotropium for at least 6 months. Data Collected: Demographic, anthropometric; Lung Function tests; co-morbidities and disease control.

RESULTS: 41 patients (32-78% women) which correspond to 10% of all patients followed. Mean age: 53,92 years(min:23;max:77) and mean BMI:30,31 Kg/m2 . 4(9,8%) are smokers, 19(46,1%) with rhinitis, 5(12,2%) sinusitis, 16(39%) GERD, 10(24,4%) depression and 19(46,3%) atopic. Inicial asthma severity: 1(2,4%) mild persistent; 16(39%) moderate persistent; 24(58,5%) severe persistent. Before triotropium: 16(39%) partly controlled; 25(61%) uncontrolled. After triotropium: 22(53,7%) controlled; 13(31,7%) partly controlled and 6(14,6%) uncontrolled. Before tiotropium the mean FEV1 preBD was 1,55L(61,76%) and postBD of 1,7 L(65,5%). After tiotropium mean FEV1 preBD was 1,64 L(68,65%) and postBD of 1,74 L(73,19%). There was an increase in FEV1 in the majority (68.3%, n = 28), with an average increase of 90 ml in preBD FEV1.

CONCLUSIONS: Most patients have co-morbidities and high BMI. In uncontrolled asthmatics despite optimal therapy, it was identified a better disease control and an increase in FEV1 with the addition of tiotropium.

CLINICAL IMPLICATIONS: Some asthmatic remain symptomatic with frequent exacerbations despite optimal treatment .Tiotropium addition may be an option in this patients.

DISCLOSURE: The following authors have nothing to disclose: Ana Gonçalves, Ricardo Lima, Ivone Pascoal, João Moura, Miguel Guimarães, Raquel Duarte, Aurora Carvalho

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Topics: asthma , tiotropium
Chest. 2014;145(3_MeetingAbstracts):12A. doi:10.1378/chest.1836671

SESSION TITLE: Asthma Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: To assess the knowledge about asthma from employees of a public school in a large urban center in Brazil

METHODS: Cross-sectional study carried out from November to December 2012. Teachers and the school staff was assessed by means of of a structured questionnaire consisted of 5 domains: D1- concept; D2 - triggering factors; D3 - treatments; D4 - signs and symptoms/action plan and D5 - myths on asthma. The general score the was composed according to the proportion of correct responses for each domain as: deficient (up to 25%), satisfactory (up to 50%), good (up to 75%) and excellent (above 75%).

RESULTS: 28 employees were evaluated, of both genders, (67.9% females and 32.1% males) with average ages of 43.6 ± 9.9 years. 18 subjects (64.3%) showed satisfactory knowledge about asthma, 6 (21.4%) good, 3 (10.7%) deficient, 1 (3.6%) excellent. In the analysis by domain it was also verified that 12 (42.9%) presented good knowledge on the concept of asthma; 15 (53.6%) good knowledge on triggering factors; 13 (46.4%) deficient knowledge on the relief and maintenance treatment and good knowledge on the use of action plan and myths on asthma with 9 (32%) and 10 (35.7%), respectively.

CONCLUSIONS: The knowledge of employees in a school under study was largely presented as satisfactory. Nevertheless, it was verified that knowledge is still deficient in relation to treatment, one of the most important aspects for the control of the disease and rescue in the case of exacerbation

CLINICAL IMPLICATIONS: In Salvador, asthma affects around ¼ of children and teenagers in school age. The knowledge about asthma of all those that are part of the school staff could positively influence the control of the disease and early attendance up until emergency medical treatment in cases of exacerbation.

DISCLOSURE: The following authors have nothing to disclose: Ana Carla Coelho, Carolina Souza-Machado, Thiara Silva de Oliveira, Tássia Nascimento, Jane Cabral, Adelmir Souza-Machado

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Chest. 2014;145(3_MeetingAbstracts):13A. doi:10.1378/chest.1834340

SESSION TITLE: Asthma Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: to compare the perception of dyspnea (POD) during cycle exercise testing and airway challenge to adenosine in non-asmathic (group 1) fictitious asthmatic (group 2), and asthmatic (group 3) obese subjects.

METHODS: fictitious asthma was considered when patients have used bronchodilator or corticoid inhaler medication during the last year despite not having a positive bronchial responsiveness testing or elevation of exhaled nitric oxide (NO). Anxiety and depression questionnaires (State-Trait Anxiety Inventory for Adults [STAI] and Beck Depression Inventory [Beck], respectively), body impedance assessment, exhaled NO, spirometry and body plethysmography measurements were performed in all patients. POD was measured in both, adenosine challenge and cycle ergometer testing, using the modified 10-point Borg scale. Finally, incremental exercise testing was conducted on an electronically cycle ergometer (Oxycon Alpha, Viasys).

RESULTS: we included 73 patients (group 1=27, group 2=22, group 3=24). Groups were not different by demographic (age, sex, smoking habit) and anthropometric variables. Group 2 had higher Trait anxiety scoring than group 1 (30.9±13.8 vs.19.1±13.4, p<0.05). Pulmonary function testing were similar between groups 1 and 2. During adenosine challenge, POD assessed by the rate of change in Borg score was greater in group 2 than in group 1 (1.95±1.66 vs. 0.57±1.12, p<0.05). Also, relationship between adenosine concentration and changes of the Borg score was greater in group 2 than in group 1 (p=0,051). Likewise, in the exercise testing, the intercept (but not the slope) for work intensity-Borg ratings was significantly lower in group 2 and 3 than in group 1 (13.7±11.6; 12.5±6.7; 30.6±10.8, p<0.001, respectively). Finally, fictitious asthmatic patients had lower intercept and higher slope for oxygen uptake-Borg rating than non-asthmatic patients (p<0.001).

CONCLUSIONS: in obese patients, POD during exercise testing is greater in fictitious asthmatic than in non-asthmatic subjects but similar to asthmatic patients. Also, perceptual response to bronchoconstriction is higher in fictitious asthma than in non-asthma patients.

CLINICAL IMPLICATIONS: overdiagnosis of asthma in obese subjects could be due to a greater POD

DISCLOSURE: The following authors have nothing to disclose: Carlos Carpio, Francisco García-Río, David Romero, Isabel Fernández, Raul Galera, Carlos Villasante, Rodolfo Álvarez-Sala

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Chest. 2014;145(3_MeetingAbstracts):14A. doi:10.1378/chest.1829243

SESSION TITLE: Asthma Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: EBT is being researched as a biomarker for airway inflammation in Asthma with increased plateau temperature indicating exacerbation in asthmatics. But seasonal variation in plateau temperature and its slope in not reported. Aim of the study was to assess the seasonal variation in the kinetics of EBT in stable North Indian asthmatics where extremes of temperature exist between peak summers and winters.

METHODS: 14 stable patients(on constant dose of ICS and LABA) with Allergic Bronchial Asthma(BA) and 11 healthy volunteers were prospectively made to perform EBT using X-halo(Delmedica inc) during summer season(May-June) and again during winters(Dec- Jan) along with healthy volunteers. The ambient temperature in room was kept constant at around 20-25 degree Celsius in both the seasons. Paired sample t-test was used to check for seasonal variability on EBT in asthmatics and normal volunteers. Independent sample t-test was used to see the group variability. The significance level was kept at p<0.05.

RESULTS: There was significant increase (P=0.025) in the plateau temperature from recording in summer(32.05+/-2.04 degree Celsius) to that in winter(34.96+/-2.05 degree Celsius) in patient with BA. But there was no seasonal change in plateau temperature and slope in normal volunteers(31.29+/-1.95 degree Celsius in summers to 31.02+/-1.67 degree Celsius and 0.20+/-0.04 degree Celsius in summers to 0.18+/-0.05 degree Celsius in winters respectively P=0.382).

CONCLUSIONS: There was no significant seasonal variations in EBT in normal subjects. But, EBT in stable asthmatics showed rise during winters despite constant ambient temperature. This could be due to dynamic change in environment allergens. Hence, increase in EBT in asthmatics during winters need to be interpreted with caution.

CLINICAL IMPLICATIONS: EBT is a marker of airway inflammation in asthmatics and may predict exacerbations especially during season change. Further studies are required to monitor EBT in allergic asthmas in all seasons before this can be used as biomarker of exacerbating asthma.

DISCLOSURE: The following authors have nothing to disclose: Mayuri Johari, Pallavi Periwal, Deepak Talwar

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Chest. 2014;145(3_MeetingAbstracts):15A. doi:10.1378/chest.1824454

SESSION TITLE: Asthma Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: The cost of inhalers for asthma in the United States is about $15 billion annually. Obese patients with asthma use more inhalers compared to their nonobese counterparts. Asthma seen in obese patients differs from classical atopic asthma, and symptoms have been shown to improve with weight loss. We sought to examine the change in inhaler use among morbidly obese patients with asthma following bariatric surgery.

METHODS: This was a retrospective chart review and longitudinal cohort study of 716 morbidly obese patients. Inclusion criteria required body mass index (BMI) > 40 kg/m2, history of either gastric bypass surgery or sleeve gastrectomy, and diagnosis of asthma at time of surgery. The primary endpoint was percent change in the number of patients using inhalers at the point of maximum weight loss from date of surgery. Only patients with a diagnosis of asthma (by chart review) were included. Differences, before and after surgery, were analyzed using paired sample t-tests for continuous variables, and chi square for categorical variables.

RESULTS: We reviewed 605 patients with a diagnosis of asthma. The average change in BMI was -16.2 kg/m2. There was a decrease in the number of patients using short acting beta agonists (SABA) by 12.7% (p<0.0001), resulting in a number needed to treat (NNT) of 8 patients. There was a decrease in the number of patients using long acting beta agonist/inhaled corticosteroid combination (LABA/ICS) by 8.1% (p<0.004), resulting in a NNT of 12 patients. The number of patients using short- or long-acting muscarinic antagnonists (SABA, LAMA) decreased by 1.5% (p < 0.4). Overall, there was a 14.7% reduction (p < 0.05) in the number of patients using inhalers postoperatively with a NNT of 7 patients.

CONCLUSIONS: We concluded that weight loss via bariatric intervention probably reduces the need for inhalers in morbidly obese patients diagnosed with asthma.

CLINICAL IMPLICATIONS: Weight loss from bariatric surgery, in addition to its other health benefits, may lead to thousands of dollars saved on inhalers annually per patient with asthma.

DISCLOSURE: The following authors have nothing to disclose: Randall Schwartz, Marlow Hernandez, Franck Rahaghi, Jose Ramirez, Raul Rosenthal, Gustavo Ferrer

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Chest. 2014;145(3_MeetingAbstracts):16A. doi:10.1378/chest.1836296

SESSION TITLE: Asthma Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Children with asthma frequently seen in the emergency room and hospital often lack care coordination and are discharged to poorly resourced and/or chaotic environments. Affected caregivers may benefit from a central healthcare liaison who equips them to navigate clinical asthma management. The purpose of this study is to determine whether asthma education and care coordination conducted by practice-based asthma navigators improves asthma control for children. This is a preliminary report of the first 76 families enrolled and followed for one year.

METHODS: Children ages 0- 16 years old who have moderate or severe persistent asthma with 1 inpatient or 2 ED visits in the past year. Once consented, caregivers complete a needs assessment which informs care coordination goals. In the practice, families receive asthma education, care coordination resources and are taught how to properly use asthma devices by the asthma navigator. AN’s conduct three home visits tailored to help identify and reduce asthma triggers. AN’s also meet families at follow up visits at 3-, 6-, 9- and 12 months in the practices to assess asthma control, monitor progress of attaining goals, reinforce asthma management principles and provide asthma management resources as needed.

RESULTS: Mean age is 4.83 years and 65% are male. 90% of the caregivers are mothers. 88% are African American. 86% of the caregivers have completed high school and 9% have completed college. At baseline, 1/3 were well-controlled, 1/3 poorly controlled and 1/3 uncontrolled.Compared to baseline there was a mean reduction of 2 days in use of albuterol (p.001) at 12 months.There was a mean reduction of 3 days in daytime (p.001) and nighttime asthma symptoms (p.002) at 12 months. Emergency room visits were reduced by 69% (p.000) and inpatient visits by 76% (p.001) compared to the year prior to enrollment. Top goals met were: learn how to use asthma medicines (92%), reduce asthma triggers (98%), make and keep follow-up appointments (80%).

CONCLUSIONS: Preliminary results indicate that integrating community health workers as asthma navigators into primary care offices helps families of children with moderate and severe persistent asthma improve asthma control. Future analysis will compare this cohort to a prospective case-matched control group

CLINICAL IMPLICATIONS: The use of non-traditional health care workers in the clinical setting is feasible and supports the transition to activated patient and proactive health care team.

DISCLOSURE: The following authors have nothing to disclose: Tyra Bryant-Stephens, Caroline West

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Chest. 2014;145(3_MeetingAbstracts):17A. doi:10.1378/chest.1822198

SESSION TITLE: Asthma Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Aspirin Exacerbated Respiratory Disease (AERD) is commonly associated with chronic rhinosinusitis with nasal polyps (CRSwNP). Few information is available on the correlation between aspirin sensitivity and severe asthma. The aim of this study was to investigate the association between aspirin sensitivity and severe asthma and the presence of CRSwNP in a cohort of asthmatic patients.

METHODS: In a prospective study carried out in 2010-2011 by pneumonologists and ENT specialists in 23 centres, 492 asthmatic patients (mean age 45(15) yo, 70.5% female) were included according to GINA severity: 17.3% intermittent and 82.7% persistent (mild 24.6%, moderate 31.4%, and severe 26.7%). The frequency of allergic (AR) and non-allergic (NAR) rhinitis and chronic rhinosinusitis with (CRSwNP) and without (CRSsNP) nasal polyps were evaluated according to ARIA and EPOS guidelines. Aspirin sensitivity was assessed by clinical history (anamnesis) and/or aspirin challenge and CRSwNP by nasal symptoms, nasal endoscopy, and sinus CT scan.

RESULTS: 15% (72/473) of asthmatic patients were aspirin sensitive, this condition being strongly associated with asthma severity (4.2% intermittent, OR=1; 23.6% in mild persistent, OR=4.3; 29.2% in moderate persistent, OR=4.3; and 43.1% in severe persistent, OR=7.8; p<0.05). In addition, CRSwNP was highly associated to severe persistent asthma (48%, OR=3.4, p<0.001). The presence of CRSwNP in asthmatic patients was also associated with aspirin sentivitity (38.9%, OR=9.05, p<0.001), showing a higher CT score (p<0.03) than aspirin tolerant asthmatics.

CONCLUSIONS: . Aspirin sensitivity may be considered a clinical marker for severe asthma and for the presence of CRS with nasal polyps, and potentially a marker for united airway disease.

CLINICAL IMPLICATIONS: To contribuit to identify severe asthma and improve the treatment.

DISCLOSURE: The following authors have nothing to disclose: Jose Castillo, Cesar Picado, Vicente Plaza, Gustavo Rodrigo, Berta Juliá, Joaquim Mullol

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ClinicalTrials.gov ID: NCT01513837

Chest. 2014;145(3_MeetingAbstracts):18A. doi:10.1378/chest.1798371

SESSION TITLE: Asthma Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Galectins are a family of b-galactoside-binding animal lectins with functions in a variety of biological processes, including inflammation and allergic pathologies. To explore the contribution of galectins in human asthma, induced sputum samples were collected from asthma patients and healthy controls. Expression of galectin (gal)-1, gal-3 and gal-9 was analysed by flow cytometry.

METHODS: Twenty-four asthmatic subjects with stable asthma (19 women/5 men) without systemic steroids and 18 healthy controls (9 women/9 men) were included. Asthma severity was scored according to the criteria of the Global Strategy for Asthma Management and Prevention (GINA) based on current therapy. Clinical parameters: age, sex, pulmonary function, asthma severity, atopic status, ACT, FeNO, ICS, number of years since diagnosis and history of smoking, rhinitis and nasal polyps were collected. Sputum cells from both group were labelled with PO-anti-CD45, PE-anti-HLADR, PB-anti-CD16 and APC-H7-anti-CD14. For galectin detection, cells were stained with goat polyclonal anti-gal-1, anti-gal-3 or anti-gal-9 followed by Alexa Fluor 647-DAG.Surface expression of galectin proteins in sputum cells was determined by flow cytometry. Using sputum samples we determined whether galectins were expressed differentially in the main subsets of sputum leucocytes observed in cytospin. Differential expression of HLA-DR was used to distinguish macrophages (CD16+DR+) and neutrophils (CD16+DR-) and the expression of galectins was studied in both subpopulations.

RESULTS: Macrophages are the main sputum cells expressing gal-1 and gal-9. Gal-1 and gal-9 were expressed only on macrophages, while gal-3 expression was detected on both macrophages and neutrophils.

CONCLUSIONS: Sputum induction is thus a valuable, non-invasive means of obtaining viable cells from the lower airway for evaluation of airway inflammation. - Using this method to obtain airway cells, we have identified macrophages as the cells from sputum expressing gal-1 and gal-9.

CLINICAL IMPLICATIONS: The balance of pro- and antiinflammatory signals determines the final outcome of the immune response, and proteins as gal-1 and gal-9 is probably may contribute to the inflammatory response present in human asthma.

DISCLOSURE: The following authors have nothing to disclose: Silvia Sanchez, Rosa Girón Moreno, Rosa Gomez Punter, Emma Vazquez, Gonzalo Segrelles, Carolina Cisneros, Julio Ancochea Bermúdez

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Topics: leukocytes , sputum
Chest. 2014;145(3_MeetingAbstracts):19A. doi:10.1378/chest.1799420

SESSION TITLE: Asthma

SESSION TYPE: Slide Presentations

PRESENTED ON: Saturday, March 22, 2014 at 12:15 PM - 01:15 PM

PURPOSE: Several studies have shown that there is significant clinical improvement, better control of symptoms and reduce of oral corticosteroids and itraconazol, in patients with ABPA treated with omalizumab. The aim of the study was to determine the effect of omalizumab treatment on clinical efficacy in 6 ABPA patients.

METHODS: We followed 6 cases with ABPA treated with omalizumab. Oral and inhaled corticosteroid and itraconazol doses previous and during omalizumab treatment, indication of treatment, spirometric evolution, clinical improvement and side effects, were analyzed.

RESULTS: 6 patients (3 asthma and 3 cystic fibrosis) were recluted. The mean age was 40,67 years. The main purpose of treatment was reducing side effects of maintenance oral corticosteroids therapy in 3 patients, poor clinical control despite optimal treatment in 2 patients and worsening of immunodeficiency due to oral corticosteroids in 1 HIV patient. The mean treatment period was 18 months (±4). The mean prednisone dose was 19 mg daily (±6). Oral corticosteroids were discontinued in 5 patients. Mean BDP equivalent was 1550 µg (±843). 5 patients were treated with itraconazol and it was stopped in all of them. Spirometry was performed in 5 patients: initial mean FEV1% was 58,4 and after 12 months mean FEV1% was 79. ACT values improvement were observed. GETE rating was excellent in 3, good in 2 and moderate in 1 patient. 2 of them developed local erythema.

CONCLUSIONS: In this case series study, all patients had positive clinical response to therapy with omalizumab, showing a good safety profile. Oral corticosteroids and itraconazol were discontinued in the majority of them.

CLINICAL IMPLICATIONS: Although Omalizumab treatment is not already indicated, there are some reports about successful response to Omalizumab in cystic fibrosis or asthma complicated with ABPA. According to this case series study, as well as in previous reports, the use of Omalizumab to control ABPA in steroid dependent patients is recommended. Further studies are needed to define its therapeutical role.

DISCLOSURE: The following authors have nothing to disclose: María del Valle Somiedo Gutiérrez, Carolina Cisneros, Rosa Girón Moreno, Gilda Fernandes Vasconcelos, Gonzalo Segrelles, Silvia Sanchez

Omalizumab treatment is not already indicated but there are some reports about successful response to Omalizumab in cystic fibrosis or asthma complicated with ABPA.

Chest. 2014;145(3_MeetingAbstracts):20A. doi:10.1378/chest.1805515

SESSION TITLE: Asthma

SESSION TYPE: Slide Presentations

PRESENTED ON: Saturday, March 22, 2014 at 12:15 PM - 01:15 PM

PURPOSE: Asthma is a heterogenous disease with distinct clinical phenotypes, including the exacerbation-prone phenotype. This subset of patients contributes to disproportionately high morbidity, mortality and healthcare utilization among all asthma patients. We aimed to investigate the factors that are associated with frequent asthma exacerbations in patients with severe asthma.

METHODS: 262 patients from the Singapore General Hospital-Severe Asthma Phenotype Study (SGH-SAPS) were screened. These patients fulfilled World Health Organization criteria for “treatment-resistant severe asthma” and were all on combination of high-dose inhaled corticosteroids and long-acting beta-2 agonists. We retrospectively assessed admissions and emergency visits over two years prior to recruitment into the study. 17 patients were excluded from analysis due to incomplete data. The remaining patients were classified as frequent exacerbators if they had > 2 admissions or emergency visits in any one year (n=52). Otherwise, they were classified as non-frequent exacerbators (n=193). Demographic and clinical parameters between the two groups were compared.

RESULTS: There was a significantly higher prevalence of eczema, gastro-esophageal reflux disease, anxiety, depression, vocal cord dysfunction and active or past smokers in frequent exacerbators. Frequent exacerbators also had higher body mass index and were more likely to have a history of near-fatal asthma. Multiple logistic regression showed that eczema (odds ratio, OR=5.887), anxiety (OR=8.375) and a history of near-fatal asthma (OR=5.419) were independently associated with the exacerbation-prone phenotype. The number of admissions and emergency visits correlated well with the number of steroid bursts per year.

CONCLUSIONS: The frequent asthma exacerbator phenotype was independently associated with the eczema, anxiety and a history of near-fatal asthma.

CLINICAL IMPLICATIONS: Future studies should focus on identification and aggressive treatment of these factors to reduce exacerbation rates and improve asthma outcomes.

DISCLOSURE: The following authors have nothing to disclose: Jessica Tan, Mariko Koh, Anthony Yii, Adrian Chan

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Chest. 2014;145(3_MeetingAbstracts):21A. doi:10.1378/chest.1834201

SESSION TITLE: Asthma

SESSION TYPE: Slide Presentations

PRESENTED ON: Saturday, March 22, 2014 at 12:15 PM - 01:15 PM

PURPOSE: To assess the changes in incidence, length of stay (LOS) and costs of patients hospitalized for asthma exacerbations (AE), between 2002 and 2010.

METHODS: We included patients hospitalized for AE between 2002 and 2010 (ICD9-CM codes 493.0x-493.9x). We analyze, on the one hand, pediatric patients (0-15 years old) and, on the other hand, young adults (16-45 years old).The data were collected from the National Hospital Discharge Database (entire population). We analyzed the incidence, LOS and costs per patient in the two groups from 2002 to 2010.

RESULTS: We included a total of 12,038 pediatric patients and 2,792 young adults with AE. Overall crude incidence decreased from 20.5 to 18.7 AE per 100.000 inhabitants in the pediatric group (p<0.05), and also decreased from 4.12 to 3.68 AE per 100.000 inhabitants in the adult group, from 2002 to 2010 (p<0.05). The mean LOS decreased progressively in both groups during the study period, from 3.71 (SD 2.28) to 3.16 (SD 2.11) days in the pediatric group and from 5.36 (SD 4.02) to 5.16 (SD 5.39) days in the adult group, from 2002 to 2010 (p<0.05). During the study period, the mean cost per patient decreased from 1558.53 (SD 443.63) to 1378.41 (SD 472.71) euros in the pediatric group (p<0.05), while it increased from 2183.44 (SD 783.15) to 2564.32 (SD 1933.98) euros in the adult group (p<0.05).

CONCLUSIONS: Our results suggest a decrease in the incidence of hospital admissions for AE with concomitant decrease in LOS in asthmatic patients, both in pediatric age as young adults. Although the mean cost has decreased in pediatric patients group, in young adults group has increased.

CLINICAL IMPLICATIONS: Better management of disease may explain the improvement in the incidence and outcomes.

DISCLOSURE: The following authors have nothing to disclose: Irene Jarana Aparicio, Javier De Miguel Díez, Rodrigo Jimenez García, Julio César Vargas Espinal, Milagros Llanos Flores, Alicia Oliva Ramos, Valentín Hernández Barrera, Pilar Carrasco Garrido

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Chest. 2014;145(3_MeetingAbstracts):22A. doi:10.1378/chest.1783148

SESSION TITLE: Asthma

SESSION TYPE: Slide Presentations

PRESENTED ON: Saturday, March 22, 2014 at 12:15 PM - 01:15 PM

PURPOSE: The progression and development of asthma across the menopausal transition has not been thoroughly addressed, or clearly separated from the effects of age. The present study evaluates the effects of menopause on asthma severity, quality of life and healthcare utilization using a propensity score model.

METHODS: The analyses were conducted using data from participants enrolled in the Severe Asthma Research program (SARP). Ten sites enrolled asthmatics between 2002 to 2011, and contributed a standardized set of data to a central coordinating center [AJRCCM 2012;185:356-62]. Data on 166 menopausal and 538 non-menopausal asthmatic women, older than 18 years of age was available for analyses. The effect of menopause on asthma control, asthma quality of life, and all secondary endpoints was analyzed after conducting a Propensity Score matching with subsequent multivariate analysis using conditional logistic regression to adjust for the effect of the covariates that remained unbalanced after matching. Those unbalanced covariates were: the age at enrollment, gastroesophageal reflux disease, and hypertension.

RESULTS: Compared to non-menopaused women, menopaused women were older, reported more gastroesophageal reflux disease, sinusitis history and used more inhaled corticosteroids. They were less likely to have atopy or test positively on skin testing. Unadjusted analysis showed that menopaused women had an odds ratio of 5.62(95 CI: 3.83; 8.26) of severe asthma compared to non-menopaused women. They were more likely to require healthcare utilization. After Propensity Score matching with subsequent multivariate adjustment menopause was neither associated with greater incidence of severe asthma [OR:1.75 (95 CI: 0.52; 5.9)], or with a worse asthma quality of life [mean difference: 0.31 (95 CI: -0.30; 0.93)].

CONCLUSIONS: The increased unadjusted asthma severity, increased need for treatment and health care utilization in menopaused women are more likely due to other age associated co-morbidities and/or aging dependent conditions.

CLINICAL IMPLICATIONS: In elderly women, menopause is unlikely to be the reason for increased risk of severe asthma or worse quality of life.

DISCLOSURE: Suzy Comhair: Grant monies (from sources other than industry): NIH (HL69170) The following authors have nothing to disclose: Joe Zein, Eugene Bleecker, William Busse, William Calhoun, Mario Castro, K. Fan Chung, Raed Dweik, Anne Fitzpatrick, Benjamin Gaston, Elliot Israel, Nizar Jarjour, Wendy Moore, Gerald Teague, Sally Wenzel, Serpil Erzurum

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Topics: aging , menopause , asthma

Cardiothoracic Surgery

Chest. 2014;145(3_MeetingAbstracts):23A. doi:10.1378/chest.1723693

SESSION TITLE: Surgery Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Incidence of hiatal hernias (HH) increases with age. Approximately 60% of individuals aged 50 or older have a HH. [1] A giant HH is a hernia that includes at least 30% of the stomach in the chest, although a uniform definition does not exist; most commonly, a giant HH is a type III hernia with a sliding and paraesophageal component [2]. Patients with a giant HH generally present with pain, heartburn or a history of heartburn, dysphagia, vomiting, and anemia. We present a case of giant HH presenting with hematemesis.

CASE PRESENTATION: An 83-year-old non-smoking female patient, with breast cancer who underwent breast biopsy and sentinel node dissection 2 days prior, presented to her local hospital with severe lower chest discomfort, nausea and vomiting with episodes of hematemesis. Initial workup with chest x-ray revealed a giant chest abnormality (figure 1). Further review of imaging revealed a giant paraesophageal hiatal hernia with most of her stomach residing in the chest. The stomach was massively dilated and appeared volvulized. She had an endoscopy and a liter of fluid was drained from her stomach. A nasogastric tube was placed. However, the stomach remained massively dilated and did not appear to be emptying. She was transferred for further care. Upon transfer, the patient was on a 100% nonrebreather due to difficulty breathing. Her pain and nausea had improved; however, she remained dyspneic. She had mild tenderness in the epigastrium and her white count was elevated at 18,000. She was taken to the operating room by cardiothoracic surgery urgently for reduction of her giant paraesophageal hiatal hernia. Post op chest x-ray revealed impressive improvement (figure 2). On the date of discharge, she was satting 93% on room air. Pathology of the hernia sac revealed mesothelial lined fibrous tissue consistent with hernia sac.

DISCUSSION: HH is the protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm. A HH is classified by type as follows: type I indicates sliding hernia; type II, paraesophageal hernia ( 5%); type III, mixed sliding and paraesophageal hernia; and type IV, herniation of additional organs (eg, colon, omentum, spleen). [3] A giant HH is a hernia that includes at least 30% of the stomach in the chest and most commonly is a type III hernia with a sliding and paraesophageal component. This case illustrates the varied presentations of giant HH and the need for early suspicion given the need for surgical intervention.

CONCLUSIONS: This case illustrates the need to consider giant HH in the presence of hematemesis. Early recognition of this rare entity can lead to early surgical intervention.

Reference #1: Goyal Raj K, "Chapter 286. Diseases of the Esophagus". Harrison's Principles of Internal Medicine, 17e.

Reference #2: Mitiek, MO “Giant Hiatal Hernia” Annl Thor Surg 2010 Jun;89(6):S2168-73.

Reference #3: Landreneau RJ et al. Management of paraesophageal hernias Surg Clin North Am 2005;85:411-432

DISCLOSURE: The following authors have nothing to disclose: Anita Rajagopal, Anthony Ascioti

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Topics: hernia, hiatal
Chest. 2014;145(3_MeetingAbstracts):24A. doi:10.1378/chest.1825527

SESSION TITLE: Surgery Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Aortic arch abnormalities are rare, but right-retroesophageal-subclavian-artery is the most common of them. It is usually asymptomatic. Dysphagia lusoria and fistulas, associated with hematemesis have been reported, with a very high mortality rate. There is no standard therapeutic approach for them.

CASE PRESENTATION: A 67 year old man came with hematemesis and dysphagia. A retrotracheal, right subclavian artery, with a 68mm aneurysm was found on a CT-scan. Oesophageal endoscopy was performed, but it didn’t find the bleeding's origin. Emergency endovascular prosthesis was placed on the aortic arch covering the supraortic branches to stop the bleeding, and an open arterial by-pass surgery was required to recover their normal flow. A second esophageal endoscopy found an aneurismal-esophageal fistula forty-eight hours after the surgery. Conservative treatment was decided, and the patient stayed at the intensive care unit during four weeks. Ventilation difficulties motivated a new CT-scan, and a late broncho-esophageal-arterial fistula on the right main bronchus was suspected and then confirmed with a bronchoscopy. The bronchoscope was able to pass from the trachea to the esophagus and the isolated aneurismal remaining cavity. A tracheal-Y-stent was placed in order to seal the air leakage unsuccessfully, and progressive worsening led the patient to death on the tenth week.

DISCUSSION: Right-retroesophageal-subclavian-arteries can produce a pulsatile compression that can lead to tissue necrosis and fistulas. It has been associated specially with long term semirigid-catheter placement.

CONCLUSIONS: The initial management of vascular malformations associated to bleeding must be focused on damage control and survival of the patient. Nevertheless, we always have to take into consideration the damage that we can produce with each of our decissions. Teamwork is very important in the therapeutical approach of patients, with diseases that overlap on the limits of different medical specialities.

Reference #1: MillerRG, RobieDK, et-al. Survival after aberrant right subclavian artery-esophageal fistula: Case report and review. JVascSurg 1996;24;271-275.

Reference #2: InmanJC, KimP, Retroesophageal-subclavian-artery-esophageal fistula: Rare complication of salivary bypass tube. Wiley Periodicals, head and neck 2008 DOI: 10.1002 / hed.20854, 1120-1123.

DISCLOSURE: The following authors have nothing to disclose: José González García, Sebastian Peñafiel, Eugenia Libreros Niño, Diana Baquero Velandia

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Chest. 2014;145(3_MeetingAbstracts):25A. doi:10.1378/chest.1824573

SESSION TITLE: Surgery Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Reexpansion Pulmonary Edema is a rare complication with high mortality rate; it usually occurs after rapid re-expansion of large pneumothorax drainage. It is crucial to identify risk factors (young age, >3 days collapsed-lung, application of negative intrapleural pressure)1. Once PRE is diagnosed immediate therapy is required.

CASE PRESENTATION: A 39-year-old male was referred to our hospital for a right pneumothorax. During the last month he presented with cough, shortness of breath and pleuritic chest pain. A thoracostomy tube was placed and partial pulmonary expansion was confirmed in a chest X-ray (figure 1). Five hours after the procedure patient started with frothy sputum, hypoxemia and gradually worsening dyspnea. A chest computed tomography showed patchy areas of consolidation, ground glass opacity in right lung and extensive pneumomediastinum (figure 2). High flow oxygen supply, intravenous diuretics and morphine were administered and continuos cardiopulmonary monitoring was established. Clinical improvement was evident during the next 2 days; total lung expansion and areas of consolidation disappeared in successive chest X-ray. However, persistent air leakage lasted for 7 days. Via right posterolateral thoracotomy a 3 centimeter bullae in the middle lobe was resected with a stapler and pleurodesis was performed. Patient was discharged 48 hours prior surgery.

DISCUSSION: RPE appears to be caused by multiple mechanisms. Increased capillary permeability due to hypoxic injury, re-perfusion injury with release of toxic oxygen free radicals and surfactant depletion, are all thought to play a major role2. Clinical features are variable and may range from asymptomatic patients to pinkish sputum, severe dyspnea, pleuritic chest pain and adult respiratory distress syndrome. Chest X-ray findings are non specific and variable, although typically unilateral airspace opacities appears 1 - 2 days and resolve within a week3. Treatment is supportive, mainly consisting of supplemental oxygen and, if necessary, mechanical ventilation. The disease is usually self-limited.

CONCLUSIONS: RPE is a rare but potencially lethal complication to consider after rapid re-expansion of large pneumothorax drainage. The mechanisms by which re-expansion pulmonary edema can occur are complex and controversial. In this case report the clinical features suggest a large period (one month approximately) of collapsed-lung before it was drained.

Reference #1: Komatsu T., Shibata S., Ryutaro Seo R; Unilateral re-expansion pulmonary edema following treatment of pneumothorax with exceptionally massive sputum production, followed by circulatory collapse; Can Respir J. 2010 Mar-Apr; 17(2): 53-55.

Reference #2: Sohara Y. Reexpansion pulmonary edema. Ann Thorac Cardiovasc Surg. 2008 Aug;14(4):205-9.

Reference #3: Baik JH, Ahn MI, Park YH, Park SH., High-Resolution CT Findings of Re-Expansion Pulmonary Edema Korean J Radiol. 2010 Mar-Apr;11(2):164-8.

DISCLOSURE: The following authors have nothing to disclose: Sebastian Peñafiel, Eugenia Libreros Niño, José González García

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Topics: pulmonary edema
Chest. 2014;145(3_MeetingAbstracts):26A. doi:10.1378/chest.1775455

SESSION TITLE: Surgery Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Congenital anomalies of the lower respiratory tract are rare. Bronchopulmonary sequestration (BPS) is estimated to comprise 0.15 to 6.4% of all congenital pulmonary malformations, making it an extremely rare disorder. In several reports, even tertiary care referral centers diagnose less than one case per year. We report a rare congenital malformation known as BPS in an uncommon age range, middle aged adult.

CASE PRESENTATION: We present a 37-year-old caucasian male with no significant past medical history who was first evaluated for abdominal discomfort. CT abdomen during the initial work up was notable for a left lower lobe mass which was followed with serial CT chest exams. While the patient denied respiratory symptoms, there was interval growth in the mass requiring further evaluation. PET scan (image 1) was notable for hyper metabolic activity within the left lower lobe mass. Suspicion arose for malignancy, AVM, granulomatous disease, and fungal infection. Subsequent bronchial biopsy and brushings were non diagnostic and a VATS was scheduled for pathologic diagnosis. A left thorascopic resection of the mass was performed and notably, there was an artery originating from the descending aorta that was traveling through the inferior pulmonary ligament and entering the mass in the left lower lobe (image 2), defining an intralobar intrapulmonary sequestration. Pathology revealed extensive inflammation with no evidence of malignancy.

DISCUSSION: The term sequestration, first used in 1946 by Pryce, refers to an abnormality in which a segment of bronchopulmonary tissue has an anomalous systemic arterial blood supply [1]. Two types have been described. Intralobar sequestration, which accounts for 75% of cases, is a segment of lung contained within the normal visceral pleura. In contrast, in extralobar sequestration the bronchopulmonary tissue is outside the visceral pleura and may be enveloped in its own pleura. The arterial supply derives from the aorta, predominantly the descending thoracic aorta (75%) and less frequently the abdominal aorta. Intralobar sequestration is typically diagnosed in pediatric or adolescent patients, at age 20 years or younger in approximately 50% to 60% of cases, and it is rarely found in patients older [2]. Here, we present a confirmed case of intralobar BPS in a 37 year old adult patient.

CONCLUSIONS: Due to the relatively small prevalence and often asymptomatic presentation of this disease entity, one must have a heightened awareness of this process even in older adults. While it was not the case in our patient, this entity may be the unrecognized cause of recurrent pneumonias, abscesses, hemoptysis, and heart failure from persistent left-to-right shunting.

Reference #1: Pryce DM. Lower accessory pulmonary artery with intralobar sequestration of lung: a report of seven cases. J Pathol Bacteriol.1946;58:457-467

Reference #2: Gustafson, et al. Intralobar sequestration: a missed diagnosis. Ann Thorac Surg. 1989;47:841-84

DISCLOSURE: The following authors have nothing to disclose: Anita Rajagopal, Edward Mintz, Anthony Ascioti

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Chest. 2014;145(3_MeetingAbstracts):27A. doi:10.1378/chest.1835236

SESSION TITLE: Surgery Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Amiodarone induced thyrotoxicosis (AIT) is a serious complication of amiodarone treatment. After failure of medical treatment, total thyroidectomy allows to stop hyperthyroidism and restart the antiarrhythmic.

CASE PRESENTATION: A 52 years old man with obstructive hypertrophic cardiomyopathy (OHCM), echocardiography with severe left ventricular hypertrophy, preserved systolic function, SAM phenomenon and dynamic subaortic gradient, who started amiodarone after six episodes of rapid atrial fibrillation and four electrical cardioversion (EC). Two weeks later presented chest tightness, dyspnea, insomnia, warmth and loss of 2 kg. Thyroid profile shows TSH<0.008 ng/dL, T4 7.22 ng/dL, T3 406 ng/dL with no history of thyroid disease. Amiodarone was stopped, initiating antithyroid drug, propranolol and dexamethasone. After poor response (fT4 11.41 ng/dL, T3 262.40 ng/dL) plasmapheresis was made and due to the non-improvement (fT4 9.36 ng/dL, T3 297.46ng/dL) a total thyroidectomy with general anesthesia was decided. Esmolol was required as premedication with midazolam. Anesthesia induction with remifentanil, etomidate, rocuronium and maintained with sevoflurane was performed. An intraoperative EC and two more in early postoperative period was given. At 8th day post-thyroidectomy presented a new episode of atrial fibrillation requiring amiodarone impregnation. T4 was progressive decreased and levothyroxine was started.

DISCUSSION: Amiodarone may be the only effective antiarrhythmic. Its suspension can be followed by a rebound increase of triiodothyronine that can take months to resolve. AIT treatment includes antithyroid drugs, corticosteroids, betablockers at high doses and plasmapheresis that may temporarily improve the clinical situation. Thyroidectomy is most commonly performed under general anesthesia technique. Adequate premedication with esmolol to control heart rate and benzodiazepines for proper anxiolysis is recomended. Etomidate was used for its almost nonexistent cardiovascular effects. Neuromuscular blocking agents should be used with caution in hyperthyroidism by association with myopathy. During anesthesia maintenance, assumes particular importance the early detection of thyroid storm as well as hemodynamic changes associated to the OHCM. The aim is to preserve systolic volume, reduce contractility and sympathetic discharge, increase afterload, reducing oxygen demand and ensure a correct systemic vascular resistance. Intraoperative transesophageal echocardiography allows to detect early any mechanical dysfunction.

CONCLUSIONS: Thyroidectomy is ideally performed when the patient is euthyroid however manifestations of thyrotoxicosis and its influence on cardiac function may precede surgery. Surgery seems to be an effective and safe option when hyperthyroidism unresponsive to medical treatment and amiodarone is required.

Reference #1: Tomisti L, et al. J. Clin. Endocrinol. Metab. 2012;97(10):3515-21.

Reference #2: Poliac LC,et al. Anesthesiology. 2006;104(1):183-92.

DISCLOSURE: The following authors have nothing to disclose: Nuno Ferreira, Alejandro Arbelaez, Anna Gonzalez, Marius Roca

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Chest. 2014;145(3_MeetingAbstracts):28A. doi:10.1378/chest.1836593

SESSION TITLE: Surgery Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Bronchogenic cysts are developmental anomalies of the ventral foregut arising from abnormal budding of the primitive tracheobronchial tree. Usually they acquire an intra-thoracic location primarily mediastinal or intraparenchymal, though atypical locations including cervical, intradiaphragmatic, interatrial septum and retroperitoneal have been reported. We present an extremely rare, aberrant location of a bronchogenic cyst within the thymic tissue that was minimally resected with robotic assistance.

CASE PRESENTATION: A 45 year old previously healthy male presented with shortness of breath, wheezing, productive cough and hypoxia on initial examination. Chest X-ray was normal and was followed by a CT angiogram to rule out a pulmonary embolism. The scan revealed an anterior mediastinal mass measuring 3.3x1.8x2.1cm consistent with a thymic neoplasm. Surgical resection was planned and the patient underwent a right-sided robotic-assisted thymectomy and lymphadenectomy. Pathological examination revealed an intra-thymic bronchogenic cyst present in the right side of the thymus filled with serous fluid. Histologically, the lining wall of the cyst was composed of respiratory type epithelium with focal squamous metaplasia.

DISCUSSION: Bronchogenic cysts developing within the thymus are extremely rare entities with less than five reported cases in the English literature [1]. The mechanism is not completely understood. Bronchogenic cysts are usually fluid filled and the variability of the cyst content results in soft tissue attenuation on computed tomography [2] leading to a misdiagnosis of thymoma. We advocate minimally invasive surgical excision when identified due to their potential for malignant transformation [3] regardless of the presenting symptoms.

CONCLUSIONS: Intra-thymic bronchogenic cysts are very rare and should be considered in the differential of an anterior mediastinal mass. Minimally invasive resection is ideal for these benign lesions.

Reference #1: Suen HC, Mathisen DJ, Grillo HC, LeBlanc J, McLoud TC, Moncure AC, Hilgenberg AD. Surgical management and radiological characteristics of bronchogenic cysts. Ann Thorac Surg. 1993;55:476-481

Reference #2: McAdams HP, Kirejczyk WM, Rosado-de-Christenson ML, Matsumoto S. Bronchogenic cyst: imaging features with clinical and histopathologic correlation. Radiology. 2000; 217:441-6.

Reference #3: Tsai JH, Lee JM, Lin MC, Liau JY. Carcinoid tumor arising in a thymic bronchogenic cyst associated with thymic follicular hyperplasia. Pathol Int. 2012; 62 :49-54.

DISCLOSURE: The following authors have nothing to disclose: Maria Siddiqui, Adnan Al-Ayoubi, Sadiq Rehmani, Faiz Bhora

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Chest. 2014;145(3_MeetingAbstracts):29A. doi:10.1378/chest.1780893

SESSION TITLE: Surgery Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Tension Pneomothorax is a life threatening emergency, and often diagnosed clinically, with hypotension, hypoxia, absent breath sounds, and tracheal deviation. Rarely, will a CXR be available, as these patients are clinically too unstable; a CXR would show accumulation of air under pressure in the pleural space, resulting in a mediastinal shift.

CASE PRESENTATION: Acute Care Surgery team was consulted for a 57 y/o male with concern for tension pneumothorax given following CXR (Figure 1). This was followed by CT chest (Figure 2). The patient was hemodynamically stable, and had CXR performed as part of his routine office check up visit. Review of the imagining studies suggested this to be a giagantic bleb and not a tension pneumothorax. Thoracic surgery service was consulted, and Video-Assisted Thoracoscopic Surgery (VATS) was performed, which showed a giagantic bleb adhessed to the chest wall; the bleb was resected.

DISCUSSION: Patients who have clinical suspicion for a tension pneumothorax should undergo immediate decompression, usually with needle decompression, followed by thoracostomy tube placement. On the other hand, if someone is otherwise clinically stable, and presents with a CXR similar to figure 1, then they may have a giagantic bleb instead. Placing a chest tube into a gigantic bleb may result in a bronchopleural fistula and a persistant air leak.

CONCLUSIONS: Accumulation of air under pressure in the pleural space resulting in a mediastinal shift does not neccessarily indicate a tension pneumothorax and may not warrent placement of emergent chest tube, unless they have associated clinical signs and symptoms of a tension pneumothorax. In our case, the patient had giagantic bleb that was successfully treated with an elective VATS.

Reference #1: Vega ME, Civic, B. A Tension Bulla Mimicking Tension Pneumothorax. N Engl J Med 2011; 365:1915

Reference #2: Mehran RJ, Deslauriers J. Indications for Surgery and Patient Work-up for Bullectomy. Chest Surg Clin N Am 1995; 5(4);717-34

DISCLOSURE: The following authors have nothing to disclose: John Agapian, Yuxuan Wang, Jose Tschen, Afshin Molkara

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Chest. 2014;145(3_MeetingAbstracts):30A. doi:10.1378/chest.1832269

SESSION TITLE: Surgery Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: We report a patient in whom pleuroperitoneal communication was diagnosed following the initiation of peritoneal dialysis (PD), in whom the PD could be continued after thoracoscopic partial resection of the diaphragm.

CASE PRESENTATION: A 58-year-old woman developed proteinuria at the age of 45 years and was diagnosed as having IgA nephropathy by kidney biopsy. With worsening of the renal function, peritoneal dialysis was initiated. We placed an indwelling PD catheter and introduced PD liquid (1.5%, 1,500 ml ×3/day), however, the patient began to complain of a feeling of pressure on the chest, and a chest CT revealed retention of pleural fluid in the right thoracic cavity . The patient was diagnosed as having pleuroperitoneal communication, because the pleural effusion persisted even after PD drainage , drainage of the pleural fluid revealed a higher glucose level (395 mg/dL) of the pleural fluid than the serum glucose level (78 mg/dL). We performed thoracoscopic observation of the right thoracic cavity under general anesthesia and found several tears in the central tendon of the diaphragm that allowed passage of the dialysis fluid, therefore, we performed partial resection of the diaphragm including the tears and closed the wound with sutures. We restarted PD on the following day and could continue the PD without any problems, with no further retention of the pleural fluid or chest symptoms. At present, six years after the operation, the PD is still being continued.

DISCUSSION: Existence of congenital defects in the diaphragm and occurrence of tears in the diaphragm caused by elevation of the abdominal pressure have been considered as causes of pleuroperitoneal communication, although no pathologic findings were observed in the diaphragm in this case, and hyalinization of the tendon tissues caused by aging was assumed to be the cause of the diaphragmatic tears. Medical practices in anticipation of a spontaneous cure include discontinuation of PD and reduction of the dialysate infusion, pleurodesis, and open thoracoscopic surgery have also been performed. However, considering its reliable curative effect and low invasiveness, thoracoscopic surgery should be considered proactively for this condition, although general anesthesia would be required.

CONCLUSIONS: Because thoracoscopic diaphragm plication allows us to restart PD on the day of the operation and is low invasive, effective use of it should be considered positively.

Reference #1: Nomoto Y, Suga T, Nakajima K, Sakai H, et al. Acute hydrothorax in continuous ambulatory peritoneal dialysis--a collaborative study of 161 centers. Am J Nephrol. 1989;9(5):363-7.

Reference #2: Mak SK, Nyunt K, Wong PN, et al. Long-term follow-up of thoracoscopic pleurodesis for hydrothorax complicating peritoneal dialysis. Ann Thorac Surg. 2002 Jul;74(1):218-21.

Reference #3: Kumagai H, Watari M, Kuratsune M. Simple surgical treatment for pleuroperitoneal communication without interruption of continuous ambulatory peritoneal dialysis. Gen Thorac Cardiovasc Surg. 2007 Dec;55(12):508-11.

DISCLOSURE: The following authors have nothing to disclose: Ryo Takahashi, Yuuichirou Takahashi

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Chest. 2014;145(3_MeetingAbstracts):31A. doi:10.1378/chest.1835855

SESSION TITLE: Surgery Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Chronic expanding thoracic hematoma (CETH) is a rare clinical entity mimicking invasive soft-tissue neoplasms in the thorax. It is reported to occur in patients with a history of trauma or surgery or tuberculosis. It is considered a form of chronic empyema and has also been designated as chronic hemorrhagic empyema. We present a case of a CETH, treated successfully with surgical resection.

CASE PRESENTATION: A 30- year old male presented with complaints of left-sided chest pain and exertional shortness of breath for 3 months. No history of fever, chills, night sweats or cough or weight loss. Past medical history was significant for a motor vehicle accident two year back, that necessitated abdominal surgery at that time but old records of the procedure were unavailable. Examination revealed normal vital signs. No pallor, icterus or cyanosis. No JVD or lymphadenopathy. Lung exam revealed diminished breath sounds at left base with increased dullness to percussion. Cardiac exam normal heart sounds without any murmur. No organomegaly or localized tenderness on abdominal exam. Chest-xray showed opacity at left base suggestive of pleural effusion with atelactasis. CT Chest revealed a large heterogeneous mass (8.5 X 6.7 X 8.2 cm) with large central fluid component in the left lower hemithorax. Contiguous diaphragmatic margin was indistinct with absence of fat plane with the spleen. A sulphur colloid scan was performed which ruled out the possibility of this representing a splenic pseudocyst. Patient deferred further diagnostic tests initially but returned a few months later with worsening complaints. Repeat CT chest showed mild increase in the size of the mass. A biopsy was attempted; the needle aspirate revealed necrotic material and the patient was sent for surgical resection of the lesion. On thoracotomy, extensive adhesions were noted involving the left lower lobe of the lung and the chest wall. Extensive dissection and lysis of adhesions were performed. The left lower lobe of the lung appeared destroyed by the loculated collection which was drained and necrotic material obtained was sent for routine bacterial, AFB and fungal stain and culture. The left lower lobe was resected and the residual collection in the lobe on sectioning appeared as a rubbery, fibrinous mass with an abscess cavity. Histopathology of this mass revealed multifocal chronic inflammation with dense scar. No evidence of malignancy was seen. Microbiological studies were all negative. The final diagnosis was chronic expanding hematoma with liquefactive necrosis, aka chronic hemorrhagic empyema. Following surgery, the patient has done well with resolution of symptoms.

DISCUSSION: CETH presents as a progressively enlarging thoracic mass in patients with history of trauma or surgery. In Japan and Korea, CETH has been reported to occur with a history of tuberculosis. It is considered a form of chronic empyema and has also been designated as chronic hemorrhagic empyema. The pathogenesis of CETH is poorly understood but hypothesized to be an inflammatory process caused by the breakdown products of blood and fibrin that damages the capillaries of the hematoma capsule causing intermittent bleeding that makes it expand over time. Commonest presenting symptom is dyspnea, usually related to lung compression from a slowly growing mass. On CT chest, CETH appears as a heterogeneous mass with variable wall thickness. Surgical resection at an early stage is the treatment of choice. Surgery is warranted as it is often difficult to differentiate CETH from malignancies. Surgery should be a complete resection as drainage and curettage of contents or removal of the inner substance without whole capsule excision, has been reported to cause uncontrollable bleeding from residual hypervascular capsule or recurrence of the hematoma within several years.

CONCLUSIONS: 1) CETH is a rare condition. 2) The diagnosis should be considered in patients with a thoracic mass who have a history of trauma, surgery or tuberculosis. 3) Surgical resction is the treatment of choice.

Reference #1: Roper CL, Cooper JD. Chronic expanding hematoma of the thorax. J Thorac Cardiovasc Surg 2001; 122:1046-1048

Reference #2: Kwon YS, Koh W, Kim TS et al. Chronic expanding hematoma of the thorax. Yonsei Medical Journal 2007;48(2):337-340.

Reference #3: Hata Y, Sakamoto S, Shiraga N et al. A case of chronic expanding hematoma resulting in fatal hemoptysis. J Thorac Dis 2012; 4(5):508-511.

DISCLOSURE: The following authors have nothing to disclose: Danae Delivanis, Vanessa Yap, Daniel Fusco, Debapriya Datta

No Product/Research Disclosure Information

Topics: dyspnea , hematoma
Chest. 2014;145(3_MeetingAbstracts):32A. doi:10.1378/chest.1824932

SESSION TITLE: Surgery Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Chest-wall osteonecrosis is a rare surgical complication. It is mostly seen after radiotherapy. There are several options for its repair, but we always must assure first there is no infection, that can compromise the placement of prosthetic materials. And in that case, we should avoid the use of posthetic materials and look for different options. Vaacum-assisted therapy (VAC) can be a very usefull tool.

CASE PRESENTATION: A 65-year-old man with a diagnosed thoraco-abdominal aortic-aneurysm, DeBakey IIIB aortic-dissection, was operated doing a thoraco-phreno-laparotomy. A 28mm prosthesis was used to replace the aneurysm, and because of bounteous bleeding some intercostal-arteries had to be closed. The patient developed chest-wall necrosis within two weeks, and led to infection by Enterobacter Cloacae and later sepsis. Continuous debriding of necrotic-tissue was necessary and we decided to use complementary VAC therapy. After 3 months the wound was cleaned up and could be closed. The chest-wall defect was unexpectedly reduced enough to perform a simple thoraco-myoplasty with Latissimus dorsi and serratus anterior muscles, that were directly sewed to rectus abdominalis. Full recovery was achieved after 4 months.

DISCUSSION: A good option for chest-wall reconstruction is to use alone myocutaneous flaps. It gives enough stability to the chest-wall and involves less infectious risk than when using prosthetic materials. VAC therapy is useful to clean the wound in the case of infection and also can reduce the size of the defect.

CONCLUSIONS: Simple closure was possible due to timely indication of VAC therapy, with close and continuous follow-up of the patient. Nevertheless we are used or not to use prosthetic materials in chest wall reconstruction, or we prefer any of the different surgical techniques available, the most important thing is to think carefully on each step we take in the treatment of our patients. We also should always remember about team work. That will always help us to provide our patients the best options available in our means.

Reference #1: O’Connor J, Kells A, Henry S, Scalea T. Vacuum-Assisted Closure for the Treatment of Complex Chest Wounds. The Annals of Thoracic Surgery. April 2005;Vol 79;Issue 4;1196-1200.

Reference #2: M Makboul, M Ayyad. Is myocutaneous flap alone sufficient for reconstruction of chest wall osteoradionecrosis? Interactive CardioVascular and Thoracic Surgery 2012;15;447-451. doi:10.1093/icvts/ivs146

DISCLOSURE: The following authors have nothing to disclose: José González García, Sebastian Peñafiel, Eugenia Libreros Niño, Diana Baquero Velandia, Carlos Jordá Aragón

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Chest. 2014;145(3_MeetingAbstracts):33A. doi:10.1378/chest.1825095

SESSION TITLE: Surgery Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Chest wall tumors are rarely seen in the manubrium of the sternum. They are usually metastases, but the most common malignant-primary-tumor is chondrosarcoma.

CASE PRESENTATION: 59-year-old male patient had a palpable mass in the manubrium of the sternum, painless and without any other symptoms. CT scan showed a hypo-isointense mass of 90 x 45mm, with no metastases and needle-biopsy confirmed the diagnosis of a primary chondrosarcoma. In a supine position, with a vertical sternum-midline incision, after separating pectoralis major muscles on both sides, a full-thickness resection of the manubrium was performed involving both sternoclavicular joints. The reconstruction was made using an iliac-crest autologous bone graft and three locking-compression-plates (LCP). One 3.5mm curved LCP and one T-shaped-pilon-LCP were used to fix the bone graft to both clavicles and the remaining sternum. Twelve screws were used for the bone graft and remaining parts of the clavicles, and three screws were used for the remaining sternum. An extra 3.5mm reconstruction LCP (130mm, 11 holes) was used. It was fixed at the level of the second ribs with three screws on each side, in order to give strenght to the thoracic cage. No immediate postoperative complications were reported, and the patient was successfully extubated with normal ventilation movements of the thoracic-wall. Follow-up after two years showed no recurrence evaluated with a PET scan, and plates remained in a correct position. The plate used to replace the sternum with the bone graft was surrounded by soft tissue that progressively developed ossifying process. The same happened with the bone graft that merged with the pilon-plate, and the second rib plate merged with the remaining sternum.

DISCUSSION: Sternoclavicular joint compromise raises the difficulty of chest wall constructions. Surgery is the only treatment for this tumors, as there is no effective chemotherapy and chondrosarcomas are relatively radioinsensitive. Four centimeter surgical limits are recommended; this enlarges the size of chest’s area to be taken and complicates its repair.

CONCLUSIONS: Preservation of normal dynamics of respiration and healthy soft tissue coverage of the underlying organs must be the objectives of the surgery. Team work with other speciality colleagues can help us to acquire successful results.

Reference #1: Widhe B, Bauer HC. Surgical treatment is decisive for outcome in chondrosarcoma of the chest wall: a population-based Scandinavian Sarcoma Group study of 106 patients. J Thorac Cardiovasc Surg 2009;137:610-4.

Reference #2: Burt M, Fulton M, Wessner-Dunlap S, Karpeh M, Huvos AG, Bains MS et al. Primary bony and cartilaginous sarcomas of chest wall: results of therapy. Ann Thorac Surg 1992;54:226-32.

Reference #3: Chapelier A. Resection and reconstruction for primary sternal tumors. Thorac Surg Clin 2010;20:529-34.

DISCLOSURE: The following authors have nothing to disclose: José González García, Sebastian Peñafiel, Eugenia Libreros Niño, Diana Baquero Velandia, Carlos Jordá Aragón, Ángel García Zarza

No Product/Research Disclosure Information

Chest. 2014;145(3_MeetingAbstracts):34A. doi:10.1378/chest.1836698

SESSION TITLE: Surgery Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Radical chest wall tumor resections result in large chest wall defects that expose intrathoracic organs to injury, risk lung herniation or scapular entrapment, and create flail chest segments that negatively impact respiration.

CASE PRESENTATION: A 68-year-old woman with 15-cm right posterolateral chest wall rhabdomyosarcoma. After doxorubicin chemotherapy, radical tumor debulking was recommended prior to further chemotherapy. She underwent radical right posterolateral chest wall resection, including ribs 4-9, en bloc resection of the right scapular tip and involved portions of latissimus, serratus, and rhomboid muscles. Resection of ribs 4-9 required disarticulation at their costovertebral joints. Chest wall reconstruction was performed by fixation of 6 Synthes titanium rib plates anterolaterally to the transected ribs and posteromedially to corresponding transverse processes. Bioabsorbable mesh was sewn to the chest wall defect edges to cover the titanium plates. Right latissimus myocutaneous flap was rotated to cover the chest wall soft tissue defect, and remaining exposed area chest wall inferiorly was covered by split-thickness skin graft (STSG) and WoundVAC. The patient was extubated immediately postoperatively, but required BiPAP until perioperative pain was controlled. She required return to OR on postoperative day (POD) #5 for video-assisted thoracoscopic evacuation of loculated right pleural effusion, doxycycline pleurodesis, revision of the myocutaneous flap posterior edge, evacuation of subcutaneous right flank hematoma, and revision of the STSG. She was extubated on POD#3, after which she became ambulatory with physical therapy. Her chest tubes and all but one submuscular drains were removed, and she was discharged from hospital to a rehabilitation facility on POD#18 from her initial chest wall resection and reconstruction.

DISCUSSION: Reconstruction of chest wall defects with titanium rib plates and bioabsorbable mesh results in rigid support of extrathoracic musculature but allows ribs to maintain individual “bucket handle” motion compared to reconstruction with non-rigid mesh alone or with rigid but en masse reconstruction with methylmethacrylate.

CONCLUSIONS: Reconstruction of chest wall defects with titanium rib plates and bioabsorbable mesh maintains the proper chest wall mechanics required for normal respiration.

Reference #1: None.

DISCLOSURE: The following authors have nothing to disclose: Eric Toloza, Christian Sobky, Jose Pimiento, Joseph Garrett, Effie Pappas-Politis, Jeremiah Deneve, David Kim, David Plank, Paul Smith, Ricardo Gonzalez

Use of the Synthes MatrixRib Fixation System is not yet approved for fixation onto the thoracic spine.

Chest. 2014;145(3_MeetingAbstracts):35A. doi:10.1378/chest.1836701

SESSION TITLE: Surgery Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Radical manubriectomy for manubrial tumors often destabilizes one or both upper extremities, but current reconstructive techniques prevent lateral but not medial clavicular displacement.

CASE PRESENTATION: Patient #1 is a 44-year-old man with manubrial plasmacytoma. Patient #2 is a 41-year-old man with upper chest basal cell carcinoma involving the manubrium. Patient #3 is a 64-year-old woman who is 14 months status post radical manubriectomy for metastatic thyroid cancer and whose clavicles were initially stabilized with daisy-chained loops of sternal wires, which broke while closing a car door. The three patients had mean age 49.7+7.2 yr, mean BSA 2.2+0.18 m2, mean BMI 39.3+5.8 kg/m2, and mean smoking history 15.0+7.6 pk-yr. After radical manubriectomy in the 1st two patients and removal of the broken sternal wires in the 3rd patient, each patient underwent interclavicular stabilization using angled titanium plates from the Synthes Sternal Fixation System. Pt#2 also had bilateral pectoralis muscle flaps. Mean operative (skin-to-skin) time was 153+23.3 min; mean intraoperative estimated blood loss was 273+153 mL. Patient #2 was returned to OR on postoperative day (POD)#3 for right chest hematoma, and Patient #3 was returned to OR on POD#4 for left clavicular titanium sternal plate refixation. Additional perioperative complications occurred in Patient #2 (hypoxia from pneumonia) and in Patient #3 (hemorrhoids from loose stools). Mean hospital length of stay was 5.7+1.3 days. Follow-up of the 3 patients at 3 years, 3 months, and 2 years, respectively, (mean 668+292 days) revealed no sternal plate dehiscence, despite Patient #1’s routinely unloading and reloading his airboat onto its trailer and his learning to SCUBA.

DISCUSSION: Interclavicular stabilization with angled titanium sternal plates prevent lateral or medial displacement of the shoulders for optimum position of the upper extremities to maximize range of motion and function. The Synthes sternal titanium plate also has a midline release pin in case of need for emergent sternal entry.

CONCLUSIONS: Interclavicular titanium sternal plates effectively prevent both lateral and medial clavicular displacement after radical manubriectomy.

Reference #1: None.

DISCLOSURE: The following authors have nothing to disclose: Eric Toloza, Kathryn Rodriguez, Christian Sobky, Lori Brown, Joseph Garrett, Christy Chai, Carla Moodie, Rajendra Bhati, Gerard Mosiello, Jonathan Zager

Use of Synthes Sternal Fixation System is not yet approved for interclavicular stabilization.

Chest. 2014;145(3_MeetingAbstracts):36A. doi:10.1378/chest.1836712

SESSION TITLE: Surgery Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Pancreaticopleural fistulae (PPF) are rare communications between the pancreatic duct and the pleural cavity. More commonly the sequelae of alcoholism, PPF occasional results from peripancreatic surgery.

CASE PRESENTATION: A 26-year-old man had elevated liver enzymes, thrombocytosis, and leukocytosis during postoperative follow-up after splenectomy with en bloc diaphragm resection for idiopathic thrombocytosis purpura (ITP). Abdominal CT scan revealed moderate left pleural effusion and segmental portal vein thrombosis. After initiation of intravenous (IV) heparin and left thoracentesis (800 mL), repeat chest imaging studies revealed larger left pleural effusion, right lower lobe pulmonary emboli, and diaphragmatic defect adjacent to intrabdominal fluid around the pancreatic tail. Percutaneous left pleural catheter drainage revealed elevated intrapleural amylase and lipase levels, confirming pancreaticopleural fistula. Intravenous antibiotics and subcutaneous octreotide (100 mcg TID) were initiated. With the patient in lateral decubitus, robotic-assisted video-thoracoscopic surgery was performed via 3 port incisions, including a 4-cm camera port incision, which doubled as an assistant’s access port, along the 6th intercostal space at the anterior axillary line and instrument ports along the 3rd intercostal space at the anterior axillary line and along the 9th intercostal space at the posterior axillary line. The diaphragmatic defect edges were freed from intraperitoneal adhesions and closed primarily with absorbable barbed suture, then oversewn with non-absorbable suture, then imbricated with another absorbable barbed suture. Doxycycline pleurodesis was performed. The patient was reinitiated on IV heparin 4 hours postoperatively. Pleural fluid analysis on postoperative day (POD)#1 revealed low chest tube outputs and normal amylase levels. He underwent ERCP, sphincterotomy, and pancreatic duct stent placement on POD#4 and required left thoracoscopic evacuation of hemothorax and repeat doxycycline pleurodesis on POD#5, with all chest tubes removed by POD#9. The patient was discharged home on POD#13, tolerating regular diet. Outpatient follow-up at 1 week and at 15 months revealed no recurrent pleural effusion or peripancreatic fluid.

DISCUSSION: Multi-modality approach is often required to successfully manage pancreaticopleural fistulae.

CONCLUSIONS: We report the first successful robotic-assisted video-thoracoscopic closure of pancreaticopleural fistula.

Reference #1: None.

DISCLOSURE: The following authors have nothing to disclose: Eric Toloza, Christian Sobky, Anna Cheng, Christy Chai, Ian Smithson, Lori Brown, Carla Moodie, Joseph Garrett, Colin Parsons, Pamela Hodul, Mokenge Malafa

No Product/Research Disclosure Information

Chest. 2014;145(3_MeetingAbstracts):37A. doi:10.1378/chest.1836721

SESSION TITLE: Surgery Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Completion pneumonectomy after prior ipsilateral lung resection is associated with higher morbidity and mortality compared to primary pneumonectomy. Robotic-assisted video-thoracoscopic surgery is being used more commonly for pulmonary lobectomy but has rarely been used for pneumonectomy and has not been reported for completion pneumonectomy.

CASE PRESENTATION: A 57-year-old man, who is 6 years status post right lower lobectomy for pT1N0M0 adenocarcinoma with adjuvant chemotherapy, is diagnosed with right upper lobe recurrent non-small cell lung cancer and right hilar lymphadenopathy. Preoperative staging studies revealed no distant metastasis, and the patient consented to robotic-assisted video-thoracoscopic completion pneumonectomy and mediastinal lymph node dissection. With the patient in lateral decubitus, three thoracoscopy ports were utilized, including a 4-cm camera port incision, which doubled as the assistant’s access port, along the 6th intercostal space at the anterior axillary line and 1-cm instrument ports along the 3rd intercostal space at the anterior axillary line and along the 9th intercostal space at the posterior axillary line. After pleurolysis, the remaining right lung was resected in 3 intraoperative stages, first right middle lobectomy, then right upper lobectomy, and then resection of the remaining right hilar bronchial and pulmonary arterial sleeves at the right mainstem bronchus and right main pulmonary artery, respectively, with the 3 components individually removed in an endopouch through the 6th intercostal port incision. Frozen section confirmed negative final resection margins. Operative (skin-to-skin) time was 457 min; intraoperative estimated blood loss was 600 mL. Hospital course was complicated by sinus tachycardia requiring beta-blockade and urinary tract infection requiring antibiotics, The patient was discharged home on postoperative day#8. Pathology revealed 2.5-cm right upper adenocarcinoma, with right middle lobe and level 11 lymph node metastases (pT4N1M0).

DISCUSSION: Minimally-invasive video-assisted thoracoscopic (VATS) surgery has significant advantages for patients, but is more challenging to surgeons, compared to open thoracic surgery via thoracotomy. Robotic-assisted video-thoracoscopy provides ergonomic, visual, and technical advantages for the surgeon compared to VATS surgery.

CONCLUSIONS: We have successfully performed the first reported robotic-assisted video-thoracoscopic completion pneumonectomy.

Reference #1: None.

DISCLOSURE: The following authors have nothing to disclose: Eric Toloza, Anna Cheng, Carla Moodie, Vanessa Prowler, Joseph Garrett

No Product/Research Disclosure Information

Chest. 2014;145(3_MeetingAbstracts):38A. doi:10.1378/chest.1836732

SESSION TITLE: Surgery Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Surgical resection is gold standard for early stage lung cancer and early stage esophageal cancer.

CASE PRESENTATION: A 72-year-old man was diagnosed with synchronous TTF1-positive right lower lobe (RLL) adenocarcinoma and TTF1-negative T3N1 gastroesophageal adenocarcinoma. After neoadjuvant chemoradiation for esophageal cancer, he consented to concurrent robotic-assisted Ivor-Lewis esophagectomy and robotic-assisted RLLobectomy. Gastric mobilization, celiac and paraaortic lymphadenectomy, pyloric botulinum injection, and feeding jejunostomy were performed via hand-assisted laparoscopy in supine position. Robotic-assisted video-thoracoscopic RLLobectomy, with mediastinal lymph node dissection (MSLND), was then performed in left lateral decubitus with 3 thoracoscopy ports, including a 4-cm camera port along the 6th intercostal space (ICS) at the anterior axillary line, which doubled as the assistant’s access port, and two 1-cm instrument ports along the 3rd ICS at the anterior axillary line and along the 9th ICS at the posterior axillary line. Robotic-assisted right transthoracic esophagogastrectomy and primary reanastomosis (with circular endostapler and orally-introduced anvil) were performed through the same thoracoscopy ports. Total operative (skin-to-skin) time was 517min, with RLLobectomy and MSLND taking 131min. Total intraoperative estimated blood loss was 100mL. Esophagram on postoperative day (POD)#4 revealed no anastomotic leak, and chest tube was removed on POD#6, but dysphagia delayed oral intake until POD#8, with nutrition via jejunostomy. Pseudomonas and E. coli jejunostomy site infection required antibiotics, but he was discharged home on POD#12 tolerating post-esophagectomy diet. Pathology revealed pT2N0M0 lung adenocarcinoma and no residual esophageal cancer. He was readmitted on POD#16 with aspiration pneumonia, contained anastomotic leak, and grade 1/2 sacral decubitus (treated with IV antibiotics, NPO with nutrition via jejunostomy, and sacral wound care) and discharged to skilled-nursing facility on hospital day#19. At 5-month follow-up, he was tolerating oral diet but had gastritis and small gastric ulcer, resolved with sucralfate by 8-month and 11-month follow-up.

DISCUSSION: Concurrent robotic-assisted RLLobectomy and Ivor-Lewis esophagogastrectomy was associated with postoperative complications related to feeding and nutritional intake.

CONCLUSIONS: We successfully performed the first reported concurrent robotic-assisted pulmonary lobectomy and robotic-assisted right transthoracic esophagogastrectomy.

Reference #1: None.

DISCLOSURE: The following authors have nothing to disclose: Eric Toloza, Lindsey Bendure, Christian Sobky, Joseph Garrett, Nasreen Vohra, Dale Han, David Kim, Kenneth Meredith

No Product/Research Disclosure Information

Chest. 2014;145(3_MeetingAbstracts):40A. doi:10.1378/chest.1779418

SESSION TITLE: Surgery Cases

SESSION TYPE: Case Reports

PRESENTED ON: Sunday, March 23, 2014 at 09:00 AM - 10:00 AM

INTRODUCTION: Cystic Fibrosis (CF) is a disease which can develop lung destruction and cause respiratory insufficiency in children. Lobar lung transplantation from adult donors has arisen as a treatment in some cases of respiratory failure in pediatric patients.

CASE PRESENTATION: A 9 years old female was admitted to the pediatric ICU due to a refractive respiratory failure. She was diagnosed of CF at the age of 18 months with homozygous F508Δ mutation. She had bilateral bronchiectasis colonized by MRSA and Pseudomona aeruginosa. Her evolution was torpid, indicated by more than 6 admissions in a year. Besides, she was on the waiting list for over 12 months as she did not have a suitable donor. Therefore we had to accept an adult donor. She needed respiratory support with invasive ventilation and was included into the Urgent Transplant Code. After six days she received a bilateral lobar lung transplant from a cadaver adult donor. The surgery was done with extracorporeal membrane oxygenation (ECMO) support. Both native lungs were resected and the procedure was completed from left side to right side. The donor lower left and right lobes were transplanted and anastomoses performed in this order: bronchus, pulmonary vein, and pulmonary artery. The postoperative evolution was satisfactory and the patient was discharged from ICU at day 8 and discharged from the hospital at day 40. Two years after the lobar lung transplant she is well and can run and play as similar-age children. Her FEV1 is 1’01 (67% of predicted) and her FVC 1’36 (60% of predicted).

DISCUSSION: CF patients on the waiting list for lung transplant can develop severe hypoxemic life-threatening situations. Pediatric patients have a higher mortality rate on waiting lists due to the scarcity of donors, especially in the end stage of CF. In the 90’s the first lobar transplantations were performed using live donors. Despite these years of experience of live lung transplants, cadaver lobar transplants are not frequent. Although it is a surgical practice that has demonstrated to increase survival in pediatric CF patients.

CONCLUSIONS: This case illustrates the difficulty in acquiring an adequate number of donors to serve pediatric lung transplantation candidates. Using adult lung lobes in our patient had a successful outcome. Our team proposes that cadaver adult donors should be taken into account in order to reduce the waiting list mortality rate experienced by this age group.

Reference #1: Bonnette P. Lung transplantation for cystic fibrosis: satisfactory results in specialized centres. Eur J Cardiothorac Surg. 2012 Feb;41(2):440-1.

Reference #2: Algar F.J, Moreno P, Cano J.R, Espinosa D, Alvarez A, Cerezo F, et al. Urgency-Code Lung Transplantation for Cystic Fibrosis: Experience and Results. Transplant Proc. 2008 40, 3067-3069.

Reference #3: Espinosa D, Algar F. J, Moreno P, Illana J, Álvarez A, Cerezo F, et al. Experience of the Reina Sofia Hospital in Lobar Lung Transplantation. Transplant Proc. 2010 42, 3214-3216.

DISCLOSURE: The following authors have nothing to disclose: Juan Pablo Reig, Amparo Sole, Emilio Ansótegui, Juan Escrivá, Juan Antonio Pastor

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Chest. 2014;145(3_MeetingAbstracts):41A. doi:10.1378/chest.1823710

SESSION TITLE: Surgery Cases

SESSION TYPE: Case Reports

PRESENTED ON: Sunday, March 23, 2014 at 09:00 AM - 10:00 AM

INTRODUCTION: Thymoma show a variable and unpredictable evolution, ranging from an indolent non-invasive attitude to a highly infiltrative and metastasising one. For invasive thymoma, the optimal treatment method remains controversial. We present the case of a woman with a thymoma with pleural and pericardial dissemination who received multimodality therapy.

CASE PRESENTATION: A 46-year-old woman was admitted to our hospital with a one year history of pain in the left arm and dorsal region, accompanied by dyspnea and weight loss of 6 Kg. A chest CT scan revealed abundant left pleural effusion and multiple nodules throughout the pleural cavity and in the left upper lobe; probable clinical diagnosis was mesothelioma. On thoracocentesis hematic fluid was negative for malignant cells. Left thoracosopy with pleural biopsy and talc pleurodesis was performed. Final pathology showed a lymphocytic type B1 thymoma of the WHO classification, metastatic to pleura; Masaoka stage IVa. Systemic chemotherapy with cisplatin, doxorubicin and cyclophosphamide was administered during 3 cycles with partial response. Subsequently, PET-CT scan demonstrated a slight decrease of the lesion with intense metabolic uptake in all lesions within the pleura and a hypermetabolic mediastinal mass became apparent due to absence of pleural fluid. Radical resection was proposed after a thorough clinical assessment. A left pleuropneumonectomy with resection of the thymoma, pericardium, diaphragm and rib was performed. Pathology was lymphocyte-rich thymoma (WHO B1) widely invasive to the pleura, extended to the skeletal muscle of diaphragm, mediastinal tissue and lung, without vascular or lymphatic invasion (Masaoka’s stage IVa). Reconstruction of the diaphragm was achieved with a dual Polypropylene-Goretex mesh. The patient was discharged on the ninth postoperative day. She has completed radiation to the thorax with 6 Gy. Ten months post pleuropneumonectomy a thoracic CT-scan is free of disease.

DISCUSSION: The treatment of thymomas involves combinations of surgery, radiation, and chemotherapy depending mostly by the stage of the disease. Although surgical resection is considered the treatment of choice for thymoma, the standard therapy for thymoma with pleural and pericardial dissemination has not been established. It is also know that thymomas have a propensity for late recurrence even after complete resection, so it is very important to monitor closely the clinical outcome of the patients.

CONCLUSIONS: Multimodal treatment of extensive Masaoka IVa thymoma with chemotherapy, pleuropneumonectomy and radiation can be an option in selected cases prolonging the survival of these patients.

Reference #1: Venuta F, Anile M, Diso D, et al. Thymoma and thymic carcinoma. Eur J Cardiothorac Surg 2010;37:13-25.

DISCLOSURE: The following authors have nothing to disclose: Rocio Carrera-Ceron, Juan Jacinto-Tinajero, Luis Marcelo Argote Greene, Patricio Santillán Doherty

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Topics: thymoma
Chest. 2014;145(3_MeetingAbstracts):42A. doi:10.1378/chest.1823505

SESSION TITLE: Surgery Cases

SESSION TYPE: Case Reports

PRESENTED ON: Sunday, March 23, 2014 at 09:00 AM - 10:00 AM

INTRODUCTION: We present a case of a patient diagnosed with synovial sarcoma of the left arm with pulmonary metastasis.

CASE PRESENTATION: In March 2004, the patient, a 20-year old male, presented a rounded, consistent mass of 10x15 cm size, bulking at the left axilla and affecting the left arm and scapula, without cutaneous affection but with important collateral circulation (Fig 1). After a CT guided needle biopsy, the mass was diagnosed of synovial sarcoma. Radical surgical treatment was performed, based on the complete left scapula and clavicle disassembling broaden to thoracic wall (4 first ribs, major and minor pectorals, mayor serratus and latissimus dorsi), wall reconstruction with a PTFE mesh (Dualmesh ®) and partial myocutaneous flap closure of scalenus, deltoid, supra and infraspinosus muscles (Fig. 2).The treatment was completed with adyuvant Ifosfamid and Adriamicin. 9 months later, a follow up CT scan showed a 7 cm lesion in left lower lobe, compatible with metastasis, which was managed with surgical resection plus Cisplatin and DTIC. In April 2006, three more nodules appeared in the right lung. They were treated with surgery plus Gemcitabin and Docetaxel. In March 2007, a new pulmonary nodule was located in left lower lobe requiring a left lower lobectomy. In August 2007, multiple bilateral nodules were detected. As complete resection of all the nodules was impossible, surgical treatment was rejected. Therefore, the nodules were treated with high dose Ifosfamid, achieving a complete pulmonary remission. In March 2008, right pleural effusion was diagnosed. A thoracentesis detected the presence of malignant cells. The patient received 9 more cycles of Trabectedin, attaining a complete remission. 9 years after the patient is asymptomatic and has continued his follow up without evidence of local or distant recurrence.

DISCUSSION: The factors involved in the recovery of the disease are the histology of the lesion, the tumor spread, the response to the systemic treatment and the possibility of surgical resection of the lesion.

CONCLUSIONS: In this case report the initial surgical aggressive attitude against the primary tumor as well as against the recurring metastatic lesions and the good response to chemotherapy made possible the total control of the disease.

Reference #1: Treasure T, Fiorentino F, Scarci M, et al. Pulmonary metastasectomy for sarcoma: a systematic review of reported outcomes in the context of Thames Cancer Registry data. BMJ Open 2012;2:e001736. doi:10.1136/bmjopen-2012- 001736.

DISCLOSURE: The following authors have nothing to disclose: Gemma Gonzalez Velasco, María Teresa Gómez Hernández, Maria Rodríguez, Nuria María Novoa Valentín, Marcelo Fernando Jiménez López, Jose Luis Aranda Alcaide, Gonzalo Varela Simó

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Chest. 2014;145(3_MeetingAbstracts):43A. doi:10.1378/chest.1836524

SESSION TITLE: Thoracic Surgery Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: To delineate a successful approach to treating synchronous primary lung cancers arising simultaneously with one primary in each lung. The primary which appears to be more advanced clinically is resected first. The second is resected as soon as possible after the patient has rcovered adequately from the first procedure.

METHODS: A 76 year old woman who was being followed for successfully treated breast cancer was found to have two new nodules in her lungs on routine CT of the chest. The larger nodule in the superior segment of the lower lobe of the right lung proved to be squamous cell carcinoma of pulmonary origin on needle biopsy. The smaller nodule located in the superior segment of the left lung was adenocarcinoma of pulmonary origin on needle biopsy. The patient's comorbidities included COPD secondary to smoking, hypertension, and coronary artery disease. The patient was prepared for limited sequential resections of the primaries due to her compromised pulmonary reserve.

RESULTS: A Video-assisted right superior segmentectomy was attempted in August,2010, but had to be converted to an open procedure since the patient could not tolerate having the right lung collapsed. A successful R0 resection of the superior segment was achieved without complications. Based on the experience gained from this resection, an open superior segmentectomy conducted through a limited thoracotomy achieved an R0 resection of the lesion in the lower lobe of the left lung in November, 2010. Pathologic examination confirmed that both lesions were Stage IA (T1N0M0) primary lung cancers of the types diagnosed earlier by needle biopsies. Sequential CT scans have denoted no recurrences.

CONCLUSIONS: 1.) Synchronous primary lung cancers can be resected successfully using sequential limited incisions and resections even in patients with respiratory compromise. 2.) The lesion which is more clinically advanced should be treated first. 3.) Preoperative confirmation of the pathologic nature of both lesion should be conducted p to direct appropriate therapy.

CLINICAL IMPLICATIONS: Patients who have compromised pulmonary function can have more than one lung primary resected with good clinical outcome.

DISCLOSURE: The following authors have nothing to disclose: Geoffrey Graeber, Syed Quadri, Karl Uy

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Topics: lung , carcinoma
Chest. 2014;145(3_MeetingAbstracts):44A. doi:10.1378/chest.1815598

SESSION TITLE: Thoracic Surgery Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Video-assisted thoracic surgery (VATS) sympathectomy is the definitive therapy for primary palmar hyperhidrosis with high success rates and low recurrence. Classically, a 3-port bilateral VATS approach is utilized. We report our novel application and experience of single-port VATS sympathectomy with the VasoView® endoscopic vein harvesting devices.

METHODS: Fourteen patients underwent single port VasoView® sympathectomy between June 2011 and February 2013. The patients received general anaesthesia and double lumen endobronchial tube intubation. A single incison for surgical access was made bilaterally at the axillary region. Operative details and outcomes are analyzed.

RESULTS: Ten sympathectomy patients (71%) were females, with mean age of 24.7 years (range 17- 36). Bilateral thoracic sympathetic nerve from top R3 to R4 was thermally ablated. Maquet VasoView® Hemopro 1 device was utilized in 8 cases, Hemopro 2 in 3 cases, and 7XS in 3 cases. The mean operative time to complete bilateral procedure was 64 minutes (range 55-82 minutes). The procedure was successful in all patients, with no residual hyperhidrosis. Mean postoperative hospital stay was 1.2 days (range 0.7-1.9 days). Mean visual analogue pain score at discharge was 1.8 (range 1.2-3.4). There was no postoperative complication or mortality. Compensatory hyperhidrosis (truncal predominance) was seen in 2 (14.3%) patient, and there was no recurrence during follow-up. The mean follow-up is 13 months (range 5-24 months).

CONCLUSIONS: Single port VasoView® sympathectomy for primary palmar hyperhidrosis is a safe and effective procedure. The long term outcomes and potential benefits of a single port technique warrant further investigation

CLINICAL IMPLICATIONS: The development of novel minimal invasive surgical instruments and surgeons' innovation further minimize surgical trauma.

DISCLOSURE: The following authors have nothing to disclose: Rainbow Lau, Calvin Ng, Randolph Wong, Eugene Yeung, Micky Kwok, Innes Wan, Malcolm Underwood

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Chest. 2014;145(3_MeetingAbstracts):45A. doi:10.1378/chest.1796315

SESSION TITLE: Thoracic Surgery Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: To study the prevalence of post-operative pyrexia after thoracic endovascular aortic repair ( TEVAR ) and discuss the appropriate management.

METHODS: We conducted a retrospective review on patients underwent TEVAR in our institution from 2008 to 2013. Patients’ demographics, operative procedures, post-operative complications including bleeding, stroke, paraplegia and fever (> 38oC) and mortality were recorded. For patients with fever, onset of fever from the time of operation, white cell count (WCC), C-reactive protein values and presence of positive microbiological cultures were recorded.

RESULTS: A total of 73 patients received TEVAR during the study period. The overall mortality is zero. There were 6 patients with total aortic debranching, 34 patients with extra-anatomical bypass of head and neck vessels to facilitate TEVAR. Two patients developed post-operative bleeding requiring re-exploration. Three patients developed minor stroke and 2 patients developed paraplegia that resolved after CSF drainage. Post-operative pyrexia were present in 75% of patients and only 3% of patient had positive microbiological cultures ( 2 from sputum and 1 from urine ). Increase in WCC and CRP were observed in 70% of patient which peak on day 3 after TEVAR. None of our patients developed significant sepsis that required escalating inotropes or upgrading antiobiotics.

CONCLUSIONS: Post TEVAR pyrexia is common and its clinical course is benign. Antibiotics therapy is unlikely helpful unless in patients with positive cultures.

CLINICAL IMPLICATIONS: Cautious use of antibiotics is recommended in post TEVAR pyrexia.

DISCLOSURE: The following authors have nothing to disclose: Randolph Wong, Calvin Ng, Rainbow Lau, Micky Kwok, Simon Chow, Innes Wan, Song Wan, Simon Yu, Malcolm Underwood

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Topics: aorta , stent , fever
Chest. 2014;145(3_MeetingAbstracts):47A. doi:10.1378/chest.1822813

SESSION TITLE: Thoracic Surgery Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: The aim of this study was to establish the incidence of pulmonary contusion, using our database.

METHODS: We reviewed the hospital records of 212 patients with blunt chest trauma with rib fractures - 72 (33,96 %) with fractures of one or two ribs and 140 (66,04 %) with multiple fractured ribs. Chest radiography, thoracic computed tomography and autopsy were used to determine the pulmonary contusion.

RESULTS: Pulmonary contusion was established in 139 of patients (65,56%): 15 (20,83) cases with one or two fractured ribs and 124 (88,57 %) of cases with multiple fractured ribs. Bilateral pulmonary contusion was established in 26 (12,26 %) patients - all of them with bilateral fractured ribs. The severity of pulmonary contusion was determined as: mild - 41 (29,49 %) cases;, moderate - 22 (15,02 %); severe - 65 (46,76 %); very severe - 11 (7,91 %). Other thoracic injuries, associated with pulmonary contusion were established: hemothorax - in 36 (25,89 %) patients; pneumothorax - 33 (23,74 %); hemopneumothorax - 24 (17,27); lung lacerations - in 3 (2,16 %) patients; sternal fractures - 6 (4,32 %); clavicular fractures - 11 (7,91 %) and scapular fractures - 5 (3,59 %) patients.

CONCLUSIONS: We present the cases of pulmonary contusion in blunt chest trauma, all of them associated with other thoracic injuries. According to our data, pulmonary contusion is the second most common thoracic injury, after rib fractures.

CLINICAL IMPLICATIONS: The incidence and the severity of pulmonary contusion in blunt thoracic trauma correlate with the number of fractured ribs.

DISCLOSURE: The following authors have nothing to disclose: Ivan Novakov

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Chest. 2014;145(3_MeetingAbstracts):48A. doi:10.1378/chest.1836680

SESSION TITLE: Thoracic Surgery Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Poor pulmonary function tests have been shown to be predictors of respiratory complications after lung resection via thoracotomy. Expanding surgical options to lung cancer patients with marginal pulmonary function must be balanced with maintaining patient safety. We sought to determine the role of forced expired volume in one second (FEV1), diffusion capacity to carbon monoxide (DLCO), arterial blood gas (ABG) partial pressures of carbon dioxide and of oxygen (PaCO2, PaO2), smoking status, and smoking history in predicting respiratory complications after robotic-assisted pulmonary lobectomy.

METHODS: We retrospectively analyzed the smoking status, pack-year smoking history, preoperative pulmonary function tests and room-air arterial blood gases, and postoperative respiratory complications of 201 consecutive patients who underwent robotic-assisted pulmonary lobectomy at our institution over 33 months. Student’s t-tests determined differences between patients with and without respiratory complications. Logistic regressions determined whether any observed variables were significant predictors of respiratory complications.

RESULTS: In 201 patients who underwent robotic-assisted pulmonary lobectomy, a total of 63 (31%) respiratory complications occurred. Patients with respiratory complications (mean age = 68.9 yr; mean BMI = 28.0 kg/m2) were compared to those without respiratory complications (mean age = 65.6 yr; mean BMI = 27.8 kg/m2). There was no significant difference (p>0.05) in smoking status (current versus former versus never) between patients who had respiratory complications versus those without respiratory complications. Logistic regression revealed that preoperative FEV1 (%), DLCO (%), PaCO2 (mmHg), and PaO2 (mmHg) were not significant predictors of respiratory complications (p>0.05). However, pack-year smoking history was found to correlate with respiratory complications (p<0.001).

CONCLUSIONS: Respiratory complications after robotic-assisted pulmonary lobectomy are not associated with smoker status, decreased preoperative pulmonary function tests, or decreased preoperative arterial blood gases. In contrast, pack-year smoking history does correlate with respiratory complications after robotic-assisted lobectomy.

CLINICAL IMPLICATIONS: Patients who undergo robotic-assisted pulmonary lobectomy and who are current smokers should undergo even more aggressive pulmonary toilet than routinely provided in the postoperative period.

DISCLOSURE: Eric Toloza: Other: Honoraria for proctoring & observation site The following authors have nothing to disclose: Kathryn Rodriguez, Frank Velez-Cubian, Wei Wei Zhang, Tawee Tanvetyanon, Matthew Thau, Carla Moodie, Joseph Garrett, Jacques-Pierre Fontaine, Lary Robinson

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Chest. 2014;145(3_MeetingAbstracts):49A. doi:10.1378/chest.1825690

SESSION TITLE: Thoracic Surgery Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Surgery is the best treatment choice for most of pulmonary lesions. Pulmonary function tests (PFT) play an important role in this process by assessing the risks and the functional effects of the procedure. Our goal was to evaluate the impact of lung resection surgery on pulmonary function.

METHODS: Retrospective analysis of all patients submitted to a lung resection surgery, with pre and postoperative PFT performed between 2010 and 2012.

RESULTS: We included 26 patients, with an average age of 56 years. PFT were normal in 65% of cases. A wegde resection was performed in 2 patients, a segmentectomy in 6, a lobectomy in 13 and a pneumectomy in 4. A benign lesion was identified in 54% of cases. After surgery, we observed a global reduction of the forced expiratory volume in 1 second (FEV1) (pre mean: 2,62L/99,3%; post; 2,13L/81,5%), and of the forced vital capacity (FVC) (pre mean: 3,14L/ 101%; post: 2,79L/88%), but only in 7 patients for values < 80%. In 2 cases the values of FEV1 and FVC improved after surgery and in 4 there was only an increase in FVC. All of these 6 patients were non smokers and in 50% the preoperative pulmonary function tests were normal; 4 underwent a lobectomy and 2 a segmentectomy; all were submitted to postoperative respiratory rehabilitation. FEV1 worsened in 24 patients, with a mean reduction of 20,3%, and FVC in 20 patients, with a mean reduction of 17,6%. The worsening of FEV1 and FVC was statistically related to the type of surgery, with a greater reduction after lobectomy and pneumectomy.

CONCLUSIONS: Our results illustrate a negative, but not highly significant, functional impact of lung ressection surgery. As discussed in literature, the impact is greater after larger surgical resections.

CLINICAL IMPLICATIONS: Evaluate the real functional impact of the pulmonary resection in our patients and contribute to a better selection of them for surgery.

DISCLOSURE: The following authors have nothing to disclose: Marta Sousa, Vitor Melo, Eloisa Silva, Jorge Vale, João Silva, Bárbara Rodrigues, António Torres

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Chest. 2014;145(3_MeetingAbstracts):50A. doi:10.1378/chest.1794100

SESSION TITLE: Thoracic Surgery Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Advances in video-assisted thoracic surgery (VATS) techniques and associated technology have allowed the rapid development of uniportal VATS (UniVATS) lung resection in recent years. UniVATS may be associated with less access trauma and pain, quicker recovery and improved cosmesis. We review our experience and early outcomes for patients following UniVATS wedge resections (W), lobectomies (L) and pneumonectomy (P).

METHODS: Retrospective study of UniVATS lung resection performed between May 2012 and July 2013 at our institution. Preoperative, intraoperative and postoperative data were reviewed.

RESULTS: We performed UniVATS for 8 wedge resections (2 hook wire guided), 2 left lower lobectomies, 1 left upper lobectomy, 2 right lower lobectomies, 1 right middle lobectomy, 2 right upper lobectomies and 2 left pneumonectomy. The pathology for W were 3 benign, 3 granulomas, 2 metastatic lesions (both for colonic carcinoma metastases). Lobectomies and pneumonectomy were performed for early stage non-small cell lung carcinoma. Median port length were 3.5, 4.2, and 5.5 cm for groups W, L, and P respectively. Median intraoperative blood loss for W was 5 mls, L 80 mls and P 100 mls. Median operative durations were 47, 152, 175 minutes for W, L and P groups respectively. Median postoperative chest drainage in first day were W 90 mls, L 140mls, and P 180mls. Median chest drain duration were 1.5 days for W, 2 days for L and 1 day for P. Patients were discharged home at median postoperative day 2 for W, day 3 for L, and day 5 for P. There was no mortality or major morbidity. There were 2 minor wound infections in L group at follow-up. (median follow-up 7 months (range 0 to 14 months)).

CONCLUSIONS: Our early experiences with UniVATS lung resections suggest that it is a safe procedure with good early clinical outcomes. The long term results will need further investigation.

CLINICAL IMPLICATIONS: UniVATS approach for major lung resections can potentially further reduce surgical access trauma and improve clinical outcomes for patients.

DISCLOSURE: The following authors have nothing to disclose: Rainbow Lau, Calvin Ng, Micky Kwok, Randolph Wong, Eugene Yeung, Innes Wan, Song Wan, Malcolm Underwood

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Chest. 2014;145(3_MeetingAbstracts):51A. doi:10.1378/chest.1832357

SESSION TITLE: Thoracic Surgery Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Totally minimally invasive Ivor Lewis esophagectomy(MIIE) with per-oral placement of anvil has been reported elsewhere, but MIIE with manual pursestring and per-thoracic port placement of anvil has been seldomly reported. 27 cases with the later technique were conducted in this prospective study.

METHODS: Patients with mid-lower thoracic esophageal cancer were prospectively treated with totally MIIE at Shanghai Cancer Center of Fudan University from Feb. 28,2013 to Aug. 31,2013. Laproscopic intracorporeal construction of the gastric conduit and needle catheter J-tube were performed in the first stage of MIIE procedure. In the second stage a hand sewn pursestring was made with endo-stitch system and the anvil of EEA stapler was inserted via the tenth inter costal port prior to the intrathoracic anastamosis. Short-term clinicopathologic outcomes were collected.

RESULTS: 27 cases were treated with totally MIIE( mean age 59, range 48-68, 3 female:24male). There was one conversion to open surgery in this group of patients. The median duration of operation was 210 minutes(range 200-438 minutes). Median totally intraoperative blood loss was 240ml(range 100-450ml).There were no perioperative blood transfusion. All the patients were margin negative and pathalogically staged from T1N0M0 to T3N2M0. The lymph node yields were 16.8. All patients took oral feeding on the 6th postoperative day and the median postoperative hospital stay was 7days. There was no mortality. Minor morbidity occurred in 2 patients (9.5%) after discharge and they were complicated with late stage gastric paralysis which began 2 or 3 days after oral feeding and both recovered in 1 month. Major morbidity occurred in 2 patients (9.5%) after discharge and one patient was complicated with intestinal obstruction and the other one was with minor anastamotic leakage which were endoscopically demonstrated on the 14th day postoperatively and the patient recovered in 1 month.

CONCLUSIONS: MIIE with regular EEA stapler and intrathoracic anastamosis is feasible in patients with mid-lower thoracic esophageal cancer. Prospective randomized clinical trials could be conducted to compare the open procedure and totally MIIE with regular EEA stapler.

CLINICAL IMPLICATIONS: Totally minimally invasive Ivor-Lewis surgery could be safely conducted for mid-lower thoracic esophageal cancer.

DISCLOSURE: The following authors have nothing to disclose: Hecheng Li, Longfei Ma, Yiliang Zhang, Yawei Zhang, Jiaqing Xiang, Haiquan Chen

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Chest. 2014;145(3_MeetingAbstracts):53A. doi:10.1378/chest.1824433

SESSION TITLE: Thoracic Surgery Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: In this study, we have assessed the ability of mesenchymal stromal cells MSCs to differentiate and to contribute in lung repair and how these cells are able to integrate in the initial healing process after a lung parenchyma injury in an animal model.

METHODS: MSCs were obtained from a human bone marrow aspirate and were grown in vitro. They were applied directly to lung parenchyma injuries induced in sterile conditions in eleven white rats using a fibrin polymer system (Tisseel®). Lung specimens were analyzed after 2, 4, 7 and 14 days of the application of the MSCs according to the different healing phases. The analysis consisted of hematoxylin-eosin staining and immunohistochemical study using antibodies binding specifically to human mitochondria.

RESULTS: MSCs identified by anti-human mitochondrial antibodies were found in all phases of the lung parenchyma scarring. After two days, these cells showed morphological characteristics of macrophages. Four days after, some of these cells had turned into fibroblasts. During the differentiation phase, coinciding with the seventh day, MSCs-derived fibroblasts were predominant. Fourteen days after the injury, only a small number of cells binding human mitochondrial antibodies were detected and they were well integrated in the repaired areas.

CONCLUSIONS: These findings indicate that human bone marrow-derived MSCs have the ability to integrate in the damaged parenchyma expressing different morphological features along the main healing phases and they can be effectively delivered using a fibrin sealant system.

CLINICAL IMPLICATIONS: Recent studies have suggested that mesenchymal stromal cells (MSCs) are promising candidates for cell-based tissue engineering, to repair or replace damaged tissues.

DISCLOSURE: The following authors have nothing to disclose: M. Teresa Gómez-Hernández, Maria Rodríguez, Marcelo Fernando Jiménez López, Dolores Ludeña, Begoña García-Cenador, Consuelo Cañizo

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Chest. 2014;145(3_MeetingAbstracts):54A. doi:10.1378/chest.1834709

SESSION TITLE: Thoracic Surgery Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: To minimize the risk of therapeutic and diagnostic actions

METHODS: The use of new technologies based on the principles of evidence-based medicine. Endovideothoracoscopic research manipulation: stop bleeding, the elimination of the pneumothorax. Radiographic (X-ray digital), computer tomography.

RESULTS: Reduction of complications of injuries and diseases of the chest, disability and mortality due to accidents and spontaneous pneumothorax; -reducing the number of deaths due to polytrauma coordinated action of different services, those engaged in the provision of medical care, transportation of victims according to standards developed by the organization of trauma and thoracic surgical care; - Improvement of the organization and improving the quality of diagnosis, treatment of patients with injuries of the chest and in the spontaneous pneumothorax.

CONCLUSIONS: The following clinical protocol for diagnosis and treatment of post-traumatic and spontaneous pneumothorax results in a reduction in the number of complications of injuries and diseases of the chest, disability and mortality due to accidents and spontaneous pneumothorax;

CLINICAL IMPLICATIONS: the development and implementation of the clinical protocol for the diagnosis and treatment of post-traumatic and spontaneous pneumothorax with high evidence base (level. I A and II, B), the introduction of the "gold standard" in the pre-hospital level possible to help the victims in accordance with international standards, reducing the number of disability, morbidity and mortality in complex injuries of the chest and spontaneous pneumothorax.

DISCLOSURE: The following authors have nothing to disclose: Kulsara Rustemova

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Chest. 2014;145(3_MeetingAbstracts):56A. doi:10.1378/chest.1836658

SESSION TITLE: Thoracic Surgery

SESSION TYPE: Slide Presentations

PRESENTED ON: Saturday, March 22, 2014 at 09:00 AM - 10:00 AM

PURPOSE: We investigated whether robotic-assisted video-thoracoscopic surgery improves lymph node (LN) dissection and LN metastasis detection.

METHODS: We retrospectively analyzed all patients who underwent robotic-assisted lobectomy for non-small cell lung cancer (NSCLC) by one surgeon over 34 months. Clinical stage was determined by computerized tomography, positron-emission tomography, brain imaging studies, and endobronchial ultrasonography. Pathologic stage was based on final pathology. Tumor histology, the numbers of all LN stations and of all individual LNs analyzed and their locations, and the numbers of mediastinal (N2) LN stations and of individual N2 LNs and their locations were noted. Changes from clinical stage to pathologic stage were noted

RESULTS: Of 159 patients (mean age 67.6+/-0.8yr; range 39-86yr), mean tumor size was 3.3+/-0.2cm (range 0.8-11.0cm), most commonly adenocarcinoma (63.5%), squamous cell carcinoma (20.8%), and neuroendocrine carcinoma (8.2%). Assessment of >3 N2 stations occurred in 156 (98.1%) patients, with 141 (88.7%) having >3 N2 stations reported. Mean total LN stations assessed was 5.6+/-0.1 stations; mean N2 stations assessed was 4.1+/-0.1 stations. Mean total LNs reported was 13.4+/-0.5 LNs; mean N2 LNs reported was 7.2+/-0.3 LNs. There were 118 (74.2%) patients who were clinical stage I versus 96 (60.4%) who were pathologic stage I, with 49 (30.8%) patients upstaged (including 13 patients from N0 to N1, 13 patients from N0 to N2, and 4 patients from N1 to N2) and 20 (12.6%) downstaged. In comparison: D’Amico et al (Ann Thor Surg 2011;92:226) reported 66% of video-assisted thoracoscopic (VATS) lobectomies and 58% of open lobectomies assessed >3 N2 stations, with 8.8% upstaged by VATS and 14.5% by thoracotomy; Watanabe et al (Surgery 2005;138:510) reported highest upstaging of 20.1% by VATS and 30.3% by thoracotomy; and Park et al (J Thorac Cardiovasc Surg 2012;143:383) reported 21% upstaging for robotic lobectomy.

CONCLUSIONS: Mediastinal LN dissection during robotic-assisted lobectomy results in more LN stations and more LNs assessed and greater upstaging than during VATS or thoracotomy.

CLINICAL IMPLICATIONS: Upstaging translates to more adjuvant treatment, which translates to fewer recurrence and improved survival.

DISCLOSURE: Eric Toloza: Other: Honoraria for proctoring & observation site The following authors have nothing to disclose: Frank Velez-Cubian, Wei Wei Zhang, Kathryn Rodriguez, Matthew Thau, Carla Moodie, Joseph Garrett, Jacques-Pierre Fontaine, Lary Robinson

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Chest. 2014;145(3_MeetingAbstracts):57A. doi:10.1378/chest.1816609

SESSION TITLE: Thoracic Surgery

SESSION TYPE: Slide Presentations

PRESENTED ON: Saturday, March 22, 2014 at 09:00 AM - 10:00 AM

PURPOSE: Surgical treatment for colorectal cancer (CRC) lung metastases requires resection of all malignant lesions. Computed Tomography (CT) findings may not agree with pathological ones. This lack of agreement can result in incomplete resection. The aim of this study was to estimate the determinants of disagreement between findings provided by CT and surgical pathology in patients undergoing removal of CRC lung lesions.

METHODS: Multicenter longitudinal study of the GECMP-CCR-SEPAR. Data collection was prospective. Patients included in the analysis underwent open-surgery for first time CRC pulmonary metastasectomy with complete resection by direct viewing and bi-manual palpation, and at least one metastatic lesion removed.

RESULTS: The complete series included 543 patients; 404 (74.4%) were eligible for this analysis. Radiological unilateral involvement was documented in 345 patients (85%), and 253 (63%) presented only one nodule. The number of nodules per patient was higher with bilateral than with multiple unilateral involvement. Radiological and malignant pathological findings were concordant in 316 (78%) patients. Univariate analysis showed that disagreement is more likely in patients with CRC advanced stages (III, IV), liver metastases, radiological bilateral involvement, multiple nodules on CT, smaller mean radiological nodule size per patient. The joint prognostic performance of determinants of disagreement in nodule count was estimated with logistic modeling. The two variables included in the final model were “uni/bilateral involvement” and “nodule count on CT”. The model explained 28% of the variability in the proportion of disagreement (R2=0.28), and it discriminated between agreement and disagreement in 85% of patients (AUC=0.85). Both in patients with unilateral and bilateral involvement, disagreement increased with nodule count, by an OR of 6.17 (4.08;9.33) for one nodule increase. For similar nodule count (>1, 2, 3, or ≥4), lower disagreement was observed in bilateral than in unilateral involvement (OR 0.2 (0.07;0.55).

CONCLUSIONS: Disagreement between radiological and pathological findings was documented in one in five patients. The combined prognostic information of number of nodules and uni/bilateral involvement showed the best performance for predicting disagreement.

CLINICAL IMPLICATIONS: The individualization of the radiological findings allows us to estimate the probability of achieving complete resection. Some patients require open surgical access to resect the maximum tumor load.

DISCLOSURE: The following authors have nothing to disclose: Carmen Marron Fernandez, Javier de la Cruz, David Lora, Pablo Gamez, Juan Jose Rivas, Raul Embun, Laureano Molins

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Chest. 2014;145(3_MeetingAbstracts):58A. doi:10.1378/chest.1835110

SESSION TITLE: Thoracic Surgery

SESSION TYPE: Slide Presentations

PRESENTED ON: Saturday, March 22, 2014 at 09:00 AM - 10:00 AM

PURPOSE: To examine the morbidity, mortality, and efficacy of an Ivor Lewis esophagectomy for esophageal carcinoma , we reviewed our experience.

METHODS: A retrospective review of all Ivor Lewis esophagectomies for cancer from 2006 to 2012 (n=1342) was performed. Two time periods were compared: period I (January 2006 to December 2010) and period II (January 2011 to December 2012).Logistic regression analyses determined independent predictors of anastomotic leakage, pneumonia, chylothorax and death.

RESULTS: Ivor Lewis esophagectomies for cancer were performed in 49.7% of all esophagectomies . The median age was 60 years , with a male to female ratio of 4.5:1 and a predominance of squamous cell carcinoma (95.4%). Operative mortality was 1.0%; 28.7% experienced complications, including pneumonia(11.5%), anastamotic leak (3.8%), and chylothorax (2.5%). Only pneumonia was predictive of mortality(P<0.001),which was associated with a 7.1% incidence of death and responsible for 43% of deaths. Predictive factor of anastamotic leak was BMI <18.5(P=0.023). Factor predictive of pneumonia was long operation duration (P=0.021). High BMI(BMI>=25) was an adverse predictor of chylothorax (P=0.032). When period I and II were compared, pneumonia reduced from 13.2% to 9.4%(p=0.039), with correspondingly shorter hospital stay (P<0.001) and shorter operation durations(P<0.001). The lower thoracic esophageal cancers were more likely to metastasize to the abdominal cavity (P<0.001) and lower mediastinum(P<0.001) than middle thoracic esophageal cancers.

CONCLUSIONS: Ivor Lewis esophagectomy for esophageal cancer can be performed with a low mortality rate (1.0%) and an acceptable morbidity rate (28.7%). Pneumonia is the predictor of mortality. Underweight is associated with increased anastomotic leak rates. High BMI is associated with decreased incidence of chylothorax . Abdominal and lower mediastinal lymph node dissection should be conducted more vigorously for lower thoracic esophageal cancers.

CLINICAL IMPLICATIONS: Recently, MIE(minimally invasive esophagectomy )have been adopted in an attempt to decrease the morbidity and mortality of open esophagectomy. To establish a benchmark for open esophagectomy prior to the widespread use of MIE, we reviewed our experience with the Ivor Lewis procedure.

DISCLOSURE: The following authors have nothing to disclose: Longsheng Miao, Haiquan Chen, Jiaqing Xiang, Yawei Zhang, Bin Li

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Chest. 2014;145(3_MeetingAbstracts):59A. doi:10.1378/chest.1835240

SESSION TITLE: Thoracic Surgery

SESSION TYPE: Slide Presentations

PRESENTED ON: Saturday, March 22, 2014 at 09:00 AM - 10:00 AM

PURPOSE: Patients with non-small cell lung cancer (NSCLC) and synchronous brain metastases (BMs) on initial diagnosis, who presented with neurological deficits, had a short median survival and lower quality of life (QOL). We analyzed our experiences with surgical treatment of patients with NSCLC who had neurologically symptomatic, synchronous BMs.

METHODS: We performed a single-center, retrospective review of 36 patients who presented with synchronous BMs from NSCLC between April 2006 and December 2011. Patients were divided into three groups according to manifestation of neurological symptoms and the surgery received for BMs: asymptomatic patients (AS group; n = 14), symptomatic patients received neurosurgical resection (NSR group; n = 11) or non-neurosurgical resection (non-NSR group; n = 11). We analyzed overall survival (OS), intracranial progression-free survival (PFS), and quality of life.

RESULTS: In survival, there was no difference between patients with NSR (OS, 12.7 months) and non-NSR (OS, 10.4 months; p = 0.6419). Likewise for intracranial PFS, there was no significant survival difference (8.4 months in the NSR and 5.4 months in non-NSR group (p = 0.0624)). Reliable neurological 1-month follow-up by the Medical Research Council neurological function evaluation scale was available in 22 symptomatic patients. The scale improved in eight (73%) patients in the NSR group, but only in three (27%) in the non-NSR group.

CONCLUSIONS: Patients with synchronous BMs from NSCLC presenting with neurological symptoms showed no survival benefit from combined treatment with neurosurgical resection, but local BMs control and quality of life were improved.

CLINICAL IMPLICATIONS: we analyzed the outcomes of surgical treatment in patients with non-small cell lung cancer (NSCLC) who had neurologically symptomatic, synchronous brain metastasis. As a result, patients with synchronous brain metastasis from NSCLC presenting with neurological symptoms showed no survival benefit from combined treatment with neurosurgical resection, but local brain metastasis control and quality of life were improved.

DISCLOSURE: The following authors have nothing to disclose: Minkwang Byun, Wou-Young Chung

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Cardiovascular Disease

Chest. 2014;145(3_MeetingAbstracts):60A. doi:10.1378/chest.1825069

SESSION TITLE: Cardiovascular Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Central venous catheters (CVC) are placed in large caliber veins, and though relatively safe, complications can occur. When chest radiograph cannot verify proper CVC placement, further assessments are mandated. We present a case of questionable placement of a left-sided CVC.

CASE PRESENTATION: 58 y/o female presented with diarrhea and severe hypokalemia. An ultrasound-guided LIJ was placed and radiograph revealed the catheter tip bordering the left margin of the aortic knob and toward the spine. Analysis revealed venous blood. Saline flushing caused left sided back pain.

DISCUSSION: Despite proper technique CVCs can terminate in what appears to be undesired locations. Complication rates range from 15-33%. The left side is more circuitous, an increased transverse lie exists, and more tributaries are present. In this case, the catheter was placed in a tributary of the left brachiocephalic: internal thoracic, pericardiophrenic, or the least common of the three, superior intercostal veins. AP radiographs show the internal thoracic to be most medial of the three, the pericardiophrenic traveling along the left cardiac border, and the superior intercostal descending along the left mediastinum, arching along the aortic knob and revealing an “aortic nipple.” In lateral radiographs, the internal thoracic vein will lie in the anterior mediastinum, the pericardiophrenic vein medially, and the superior intercostal vein in the posterior mediastinum, toward the vertebral bodies. Tributary cannulations result in thoracic pain during rapid flush. A non-dilated left-sided tributary veins are usually too narrow for CVC cannulation, however congenital or acquired causes of enlargements can provide dilation and cannulation at greater than 4.5mm. Given the radiographic findings and clinical indicators described above, the superior intercostal vein is most likely the site.

CONCLUSIONS: Our case demonstrates possible cannulation routes and clinical significance. It is imperative to understand the limitations of these catheters. When tributary vein cannulation is likely, treating it as a peripheral line is recommended: avoid vasopressors and medications with sclerosing properties. A theoretical risk of thrombus formation and small vessel infection due to the physical trauma must also be considered.

Reference #1: Tong MK, et al. Misplacement of a right internal jugular vein haemodialysis catheter into the mediastinum. Hong Kong Med J. 2004; 10: 135-8.

Reference #2: Ball JB, Proto AV. The variable appearance of the left superior intercostal vein. Radiology 1982; 144: 445-52.

Reference #3: Friedman AC, Chambers E, Sprayregen S. The normal and abnormal left superior intercostal vein. AJR Am J Roentgenol 1978; 131: 599-602.

DISCLOSURE: The following authors have nothing to disclose: Andrew Oh, Andrew Schaffrinna

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Chest. 2014;145(3_MeetingAbstracts):61A. doi:10.1378/chest.1823725

SESSION TITLE: Cardiovascular Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Cardiogenic pulmonary edema occurring unilaterally is rare and presents diagnostic difficulties.

CASE PRESENTATION: A 72 year-old male presented with persistent right lower zone consolidation. He had a background of ischaemic heart disease with mitral regurgitation requiring coronary artery bypass surgery and mitral annuloplasty. A recent echocardiography revealed markedly impaired left ventricular ejection fraction of 16%, with mild mitral regurgitation and stenosis. He presented initially with fever, cough and right lower zone consolidation on chest radiography. Diagnosis of community-acquired pneumonia was made and he received antibiotics. Three months later, he continued to experience persistent cough with exertional dyspnea. Investigations revealed blood leukocytosis of 15.36 x 106/ul with neutrophilic predominance. Blood serologies and sputum bacteriologies did not reveal any causative organisms. Chest radiography showed persistent right lower zone consolidation. Computed tomography of the thorax revealed bilateral pleural effusions, unilateral right-sided ground glass changes with consolidative changes in the right lower lobe. Cardiomegaly was demonstrated with preferential left ventricular and atrial dilatation associated with prominent mitral annulus calcifications.The patient received an increased dose of diuretics with symptomatic improvement and radiological resolution.

DISCUSSION: Unilateral cardiogenic pulmonary edema (UCPE) has been described in association with severe mitral regurgitation [1], congestive heart failure [2], peripartum cardiomyopathy [3] and unilateral pulmonary artery hypoplasia. UCPE is commonly associated with mitral regurgitation due to a regurgitant jet affecting the right pulmonary veins resulting in an increase in mean capillary pressures of the right lung. A case series of UCPE secondary to mitral regurgitation by Attias et al [1] showed that delay in appropriate treatment was frequent and associated with increased risk of mortality. UCPE has also been described in left ventricular failure. In a case series of 12 pregnant women, Choi et al [3] described underlying etiologies of peripartum cardiomyopathy and mitral stenosis. These patients were initially misdiagnosed with pneumonia with mean delay to treatment of 4-5 days.

CONCLUSIONS: UCPE is an uncommon presentation; it should be considered in patients with unilateral pulmonary infiltrates and severely impaired left ventricular function or mitral valve diseases to avoid delay in diagnosis and appropriate treatment.

Reference #1: Attias D, Mansencal N. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema. Circulation. 2010;122:1109-1115.

Reference #2: Nitzan O, Saliba WR, Goldstein LH. Unilateral pulmonary edema: a rare presentation of congestive heart failure. Am J Med Sci. 2004; 327: 362-364

Reference #3: Choi HS, Choi H, Han S, et al. Pulmonary edema during pregnancy: unilateral presentation is not rare. Circ J 2002;66:623-6

DISCLOSURE: The following authors have nothing to disclose: Jessica Quah, Tan Keng Leong

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Topics: pulmonary edema
Chest. 2014;145(3_MeetingAbstracts):62A. doi:10.1378/chest.1836736

SESSION TITLE: Cardiovascular Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: For regional anesthesia, lidocaine bupivacaine combination is popular due to the advantage of quick onset action of lidocaine and longer duration of action of bupivacaine. Although a safe procedure, toxicity from local anesthetics can result from local absorption and/or inadvertent direct IV injection. Direct cardiac toxic effects of local anesthetics involve arrhythmias and/or direct myocardial injury/ suppression. A recent study showed that bupivacaine induce mitochondrial swelling in myocarium with resultant negative inotropic effects. Bupivacaine in high doses or unintentional intravascular injection may lead to high plasma levels and related depression of the myocardium, heart block, hypotension, bradycardia, ventricular arrhythmias, and cardiac arrest. There is very limited echocardiographic and ventriculographic evidence of bupivacaine induced cardiac dysfunction.

CASE PRESENTATION: A 35 year old otherwise healthy African-American male presented for left wrist arthroscopy. As he received left axial nerve block with bupivacaine and lidocaine prior to the procedure, he lost consciousness. After intubation his initial ABG showed pH 7.09, pCO2 50, pO2 27 and CXR demonstrated extensive pulmonary edema. Pink, frothy sputum was suctioned from endotracheal tube. EKG showed only sinus tachycardia. Patient was resuscitation with IV fluids, vasopressor Norepinephrine and inotropic agent Milrinon. Bedside echocardiogram showed normal LV size with severe diffuse hypokinesia. Estimated EF was 15-20%. Only the apical region showed contractility. Angiography did not demonstrate any coronary disease. Left ventriculography showed apical contractility with complete akinesia and dyskinesia at the base of the heart, with the appearance of an inverse takotsubo cardiomyopathy. A left ventricular assist device, Impella, was implanted percutaneously with a maintained cardiac output of 3L/min based on the Impella Device measurement. On day 2, cardiac index improved to 3.0 L/min/m2. Ventilator and oxygen requirements decreased as the patient’s pulmonary edema improved. Norepinephrine and milrinone were gradually weaned off. On day 3 a repeat echo demonstrated major improvement in LV function. Measured cardiac index was 3.7 L/min/m2. The Impella device was removed without complications.

DISCUSSION: Despite the well-established cases of cardiac toxicity, documented echocardiographic evidence of cardiomyopathy by bupivacaine is lacking. This case report describes development of acute inverted takotsubo cardiomyopathy immediately following bupivacaine/lidocaine injection and ultimately leading to sudden and near catastrophic cardiac failure.

CONCLUSIONS: This case describes inverted takotsubo cardiomyopathy as a mechanism for bupivacaine induced cardiac suppression and demonstrates the need for increased awareness of the rare but serious cardiotoxic effects of bupivacaine when used for nerve blocks.

Reference #1: Coyle DE et el Anesth Analg. 1994 Aug; 79(2):335-339

DISCLOSURE: The following authors have nothing to disclose: Martinus Dyrud, Rakesh Gupta, Rumi Khan

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Chest. 2014;145(3_MeetingAbstracts):63A. doi:10.1378/chest.1836506

SESSION TITLE: Cardiovascular Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Cafergot is an ergotamine commonly prescribed to treat migraine headaches. As a serotonin agonist, it works at 5-HT2B receptors to cause selective vasoconstriction. In this case, a 62 YO WF who had been taking Cafergot for 15 years developed sudden onset transudative recurrent pleural effusions, all common causes ruled out by negative cytology, chemistry, culture, and cell count. She eventually developed severe multiple valvulopathy, pulmonary hypertension, and congestive hepatopathy. This case is unique in its presentation with recurrent pleural effusions of unknown etiology, with delayed diagnosis of ergotamine-induced valvulopathy given its slow progression.

CASE PRESENTATION: A 62-year-old white female whose medical history included only quiescent rheumatoid arthritis on no treatment and migraines, who had a URI culture positive for Pseudomonas and Staph aureus. This was treated successfully with antibiotics. Subsequently, a recurrent effusion prompted three thoracenteses showing transudate with normal glucose and RF. Eventually, an indwelling catheter was placed. All common causes of effusion were ruled out: negative cytology and microbiology, no infectious or neoplastic parameters, and normal glucose levels. CA-125 level of 130U/mL prompted an abdominal CT that showed progressive liver cirrhosis, confirmed with transjugular hepatic biopsy, which was negative for malignancy or autoimmune process. Two months after catheter placement, she had recurrence of contralateral effusion with epigastric pain and lower extremity edema. After negative bronchoscopy, a thoracoscopy and pleurodesis were performed. Cardiac catheterization revealed increased pulmonary wedge pressure, and transthoracic echocardiogram demonstrated severe tricuspid regurgitation and mitral regurgitation and stenosis. The likely etiology of the recurrent effusions and congestive hepatopathy was felt to be valvular fibrosis induced by chronic Cafergot use. She had mitral and tricuspid valve replacements. One-year follow-up revealed no recurrence of dyspnea or pleural effusion.

DISCUSSION: This case suggests that use of chronic ergotamine alkaloid can cause severe fibrotic valvulopathy. Ergotamine-induced valvulopathy had been reported but remains little-known, its pathology poorly understood. Postulated pathophysiology is activation of 5-HT2B, which increases TGF-b activity to increase ECM material in the valvular interstitial cells, leading to fibroblast and smooth muscle cell proliferation. This results in restricted mobility and incomplete closure of leaflets in systole.

CONCLUSIONS: Physicians who prescribe long-term ergotamines should encourage regular follow-up with serial echocardiograms.

Reference #1: Smith SA, Wagonner AD, de las Fuentes L, Davila-Roman VG. Role of serotoninergic pathways in drug-induced valvular heart disease and diagnostic features by echocardiography. Journal of American Society of Echocardiography. 2009 Aug;22(8):883-9.

DISCLOSURE: The following authors have nothing to disclose: Rachel Felber, Hassan Bencheqroun

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Chest. 2014;145(3_MeetingAbstracts):64A. doi:10.1378/chest.1832842

SESSION TITLE: Cardiovascular Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Primary pulmonary hypertension is severe and progressive disease with incidence of 1-2 cases / million / annum. Without treatment, survival is 2-3 years. Only 10% survive for 10 years. Co-existence of PPH with Marfanoid Habitus has not been reported till date in any literature or case study.Large series of 120 PPH patients from Mayo clinic by Fuster et al showed thrombotic mechanism by microemboli and plexogenic arteriopathy due to hyper reactive pulmonary arteries by open lung biopsies.

METHODS: A 32 yr non smoker male presented with progressive dyspnea, chest pain and dry cough. He denied history of fever, joint pains, skin rash or any drug intake. Patient had consulted physicians for last 6 months without relief. Family history was noncontributory & no sudden deaths. On examination he was tall, thin with arm span greater than the height, arachnodactyly. He had tachypnea, BP- 100/60 mmhg & oxygen saturation- 82%. Auscultation- loud P2, pansystolic murmur at lower sternal border. Remaining systems were normal. ECG -right heart strain pattern. Routine blood investigations were normal.Collagen profile and serology was negative.Chest radiography -enlarged left pulmonary conus. DLCO was decreased . TEE showed PASP of 165mmhg, severe TR, RA and RV dilatation besides other abnormal findings.No left to right shunt and left heart was normal. HRCT thorax was normal. CT pulmonary angiography revealed PA diameter of 3.7cm and no evidence of pulmonary embolism. Patient was not willing for cardiac catheterization.

RESULTS: Careful examination and investigations led us to diagnose this rare & interesting case of Primary Pulmonary Hypertension with combination of Marfanoid Habitus. Treated with drugs as per protocol, O2 and life style modifications with improvement.

CONCLUSIONS: One of the rare causes of dyspnea is PH & PPH further itself is a very rare entity and due to its greivous nature and high mortality, active consideration, special investigations and early treatment should be initiated when other commom causes are excluded. Further research into understanding the pathogenesis and treatment of PPH is imperative to decrease the high mortality associated with the disease.

CLINICAL IMPLICATIONS: Hypoxia is a potent exacerbating factor in PPH hence strenous activity should be avoided. Treatment includes oxygen supplementation, anti-coagulants, diuretics, calcium channel blockers, prostanoids, endothelin receptor antagonist, phosphodiesterase-5 inhibitors. Influenza and pneumococcal vaccine is strongly recommended.

DISCLOSURE: The following authors have nothing to disclose: Ram k Chopra, Sanesh Garde, Chintan Patel, Dhiraj Jain, Omkar Kajale, Rahul Jalan

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Chest. 2014;145(3_MeetingAbstracts):65A. doi:10.1378/chest.1782575

SESSION TITLE: Cardiovascular Case Report Posters I

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

PURPOSE: To describe a novel case of recurrent isolated right ventricular takotsubo cardiomyopathy and discuss the role of autonomic dysfunction and regional differences in myocardial sympathetic innervation in this condition.

METHODS: Review of patient records and literature

RESULTS: A 28-year-old man with insulin-dependent diabetes mellitus, presented with recurrent diabetic ketoacidosis and aspiration requiring mechanical ventilation. Such episodes were complicated by pulseless electrical activity, bradycardia, and ventricular tachycardia (VT) leading to cardiorespiratory arrests. Echocardiography showed hypokinesis of the mid and apical segments of the RV with hypercontractility of the basal segments. The left ventricular ejection fraction was preserved and no regional wall motion abnormalities were noted. An echocardiogram performed two months later showed resolution of RV wall motion abnormalities. A defibrillator was placed for secondary prevention of sudden cardiac death. The patient was readmitted with similar symptoms and with similar RV apical ballooning on echocardiography which resolved after 48 hours. Cardiac catheterization showed no obstructive coronary artery disease and normal hemodynamics. Further work up of the patient’s aspiration revealed elevated pressures of the upper and lower esophageal sphincters suggestive of increased vagal tone.

CONCLUSIONS: The exact mechanism of TC remains unknown. Proposed mechanisms include neurogenic “stunning” of the myocardium caused by acute cardiac autonomic dysfunction. The echocardiographic presentation of TC and its variants may be related to differences in regional sympathetic innervation and catecholamine receptor density in the myocardium in the setting of autonomic dysfunction. Our patient had a history of longstanding diabetes which may have predisposed him to dysautonomia as evidenced by episodes of bradycardia and remarkably elevated upper and lower esophageal sphincter pressures. So far, this is the first case of recurrent isolated RV stress-induced cardiomyopathy.

CLINICAL IMPLICATIONS: Patients with autonomic dysfunction may be at risk for takotsubo cardiomyopathy.

DISCLOSURE: The following authors have nothing to disclose: Joanna Paula Sta. Cruz, Jose Codolosa

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Chest. 2014;145(3_MeetingAbstracts):67A. doi:10.1378/chest.1782952

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Carfilzomib is a novel chemotherapy agent for the treatment of relapsed and refractory Multiple Myeloma (MM). It is a selective, irreversible proteasome inhibitor that induces apoptosis of myeloma cells. It was approved by US-FDA in July 2012.

CASE PRESENTATION: A 54 year old female with history of MM presented to our emergency department with sudden onset shortness of breath. The patient was diagnosed with MM 5 years ago and had suffered relapse after two prior chemotherapy regimens which included Bortezomib and immunomodulatory agents. She had been started on ‘Carfilzomib’ one day prior to the presentation. On exam, the patient was tachypneic, tachycardic and had bilateral rales. The Chest X-ray showed white out of bilateral lung fields. A CT Angiogram of Chest confirmed severe pulmonary edema (PE) and ruled out pulmonary embolism. The patient was in severe respiratory distress and had to undergo endotracheal intubation. The electrocardiogram showed ST depressions in lateral leads along with elevation of Troponin I on the lab work. The PE was thought to be cardiogenic in origin and patient underwent urgent cardiac catheterization which revealed normal coronaries. She was admitted to the CICU and aggressively treated with diuretics. The echocardiogram showed moderately reduced LV function with an EF of 35%. She was successfully extubated on day 3 and made a complete recovery.

DISCUSSION: The Phase II clinical trial of Carfilzomib reported cardiac complications in 7% of the patients [1]. These included new onset CHF or worsening of pre-existing heart failure, PE, and Cardiac Arrest including death within one day of its administration. According to the best of our knowledge, this is the first reported case of Carfilzomib induced PE outside of the clinical trial. The exact mechanism by which it causes PE is still unclear, however we recommend exercising extreme caution while using Carfilzomib in patients with history of heart failure.

CONCLUSIONS: Patients started on Carfilzomib should be monitored closely for cardiac complications.

Reference #1: KyprolisTM Prescribing Information Onyx Pharmaceuticals, South San Francisco, CA, 2012.

DISCLOSURE: The following authors have nothing to disclose: Sameer Chadha, Rahul Yadav, Kunal Teli, Guy Kulbak, Gerald Hollander, Jacob Shani

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Chest. 2014;145(3_MeetingAbstracts):68A. doi:10.1378/chest.1783035

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Spontaneous Coronary Artery Dissection (SCAD) is defined as a hemorrhagic separation of the media of the coronary artery with creation of a false lumen. It is a rare clinical entity with an estimated incidence of around 0.2% in patients undergoing cardiac catheterization for Acute Coronary Syndrome.

CASE PRESENTATION: A 38 year old male presented to our emergency department with sudden onset, substernal chest pain. He denied any associated complaints of shortness of breath, dizziness or palpitations and had no known cardiac risk factors. On examination, patient’s vital signs were stable. The respiratory and the cardiovascular exams were unremarkable. The electrocardiogram done in the ER showed ST segment elevations in leads II,III and aVF and the lab work was significant for elevated cardiac enzymes (CK-MB - 69.9 ng/ml, Troponin I - 27.23 ng/ml). Patient was rushed for an urgent cardiac catheterization which showed no obstructive coronary artery disease but revealed a spiral dissection in the mid second obtuse marginal branch of the left circumflex artery. Because of the spiral nature of the dissection, decision was made to manage the patient medically and no intervention was done. He was admitted to the Cardiac Intensive Care Unit for close monitoring. The remaining course of his stay was uneventful and a repeat cardiac catheterization done few days later showed no extension of the dissection. The patient was discharged in a stable condition and continued to do well.

DISCUSSION: SCAD was first described in a 42 year old female by Pretty in 1931 [1]. It usually affects middle-aged females and is often associated with pregnancy, use of oral contraceptives, cocaine abuse, hypertension and connective tissue disorders. The diagnosis is established by the presence of a classic ‘intimal flap’ with false lumen on coronary angiography. The subsequent expansion of this false lumen by hematoma formation or clot accumulation can compress the true lumen of the artery leading to myocardial ischemia or infarction. The management of SCAD depends upon the clinical presentation, site and extent of the dissection and territory supplied by the culprit vessel. Coronary revascularization by Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Grafting (CABG) is usually performed when dissection involves the left main coronary artery or proximal left anterior descending artery.

CONCLUSIONS: Spontaneous Coronary Artery Dissection is a rare clinical entity which can present as ST Elevation MI in young patients.

Reference #1: Pretty HC. Dissecting aneurysm of a coronary artery in a woman aged 42. BMJ 1931;i:667.

DISCLOSURE: The following authors have nothing to disclose: Sameer Chadha, Ankur Lodha, Bilal Malik, Vijay Shetty, Gerald Hollander, Jacob Shani

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Chest. 2014;145(3_MeetingAbstracts):70A. doi:10.1378/chest.1784022

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Coronary artery anomalies are rare with an estimated incidence of around 5% [1]. These anomalies include variations with respect to the number, location or the orientation of the ostia or origin of the coronary arteries. Whereas some coronary anomalies are just anatomic variants without any clinical relevance, others can present with chest pain, syncope or even sudden cardiac death.

CASE PRESENTATION: A 46 year old male presented to our emergency department (ED) with complaints of sudden onset chest pain while running. He denied any associated shortness of breath, palpitations or dizziness. On exam, patient’s vital signs were stable. The respiratory and cardiovascular exam was unremarkable. The electrocardiogram performed in the ED showed ST segment elevations in leads V2-V6. The patient was rushed for an urgent cardiac catheterization which revealed narrowing at the origin of Left Main (LM) coronary artery but no evidence of atherosclerotic disease in any of the coronaries. The narrowing at the origin of LM coronary artery did not resolve with intra-coronary nitroglycerin. A Coronary CT Angiogram was hence performed to better characterize the lesion which showed that the LM coronary artery was anomalously originating at an acute angle from the ‘right’ coronary sinus. The CT also highlighted the subsequent malignant course of the LM coronary artery between the proximal ascending aorta and the pulmonary trunk. The patient was offered corrective surgical repair for this high-risk anomaly, but he refused any intervention. The rest of his hospitalization was uneventful and he was discharged in a stable condition.

DISCUSSION: Anomalous origin of Left Main coronary artery from the Right Sinus of Valsalva is a subgroup of coronary artery anomalies that has the highest risk for clinical repercussions. It's estimated incidence is around 0.15% [1]. The outward expansion of the aortic root and pulmonary trunk during exertion can lead to external compression of the LM coronary artery which can result in acute Myocardial Infarction or Sudden Cardiac Death [2].

CONCLUSIONS: The origin of Left Main coronary artery from the right Sinus of Valsalva is an extremely rare coronary anomaly which can result in Sudden Cardiac Death in young patients.

Reference #1: Angelini P, Velasco JA, Flamm S. Coronary Anomalies: Incidence, Pathophysiology, and Clinical Relevance. Circulation 2002; 105(20):2449-54.

Reference #2: Barth CW III, Roberts WC. Left Main Coronary Artery Originating from the Right Sinus of Valsalva and coursing between the Aorta and Pulmonary Trunk. J Am Coll Cardiol 1986; 7(2):366-73.

DISCLOSURE: The following authors have nothing to disclose: Sameer Chadha, Syed Iman Husain, Elliot Borgen, Vijay Shetty, Gerald Hollander, Jacob Shani

No Product/Research Disclosure Information

Chest. 2014;145(3_MeetingAbstracts):71A. doi:10.1378/chest.1785287

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Transmural Myocardial Infarction is a potentially life threatening condition. The electrocardiogram (EKG) is a very important tool to identify patients having a Myocardial Infarction for an early intervention.

CASE PRESENTATION: A 73 year old male with history of Addison’s Disease (AD) on Prednisone for 20 years presented to our emergency department (ED) with complaints of retrosternal chest pain while walking. The pain lasted for a few minutes and was associated with shortness of breath. The patient had similar episodes of chest pain in the past which he associated with hyperkalemia from the AD. However, this time patient decided to come to the ED and upon arrival, an EKG was performed which showed symmetric peaked T waves in the anterior precordial leads. The lab work came back significant for a serum potassium of 6.3 mEq/l and mildly elevated cardiac enzymes (CK-MB - 2.7 ng/ml and Troponin I - 0.16 ng/ml). The patient was treated for hyperkalemia in the ED and as he was not complaining of active chest pain, he was admitted to a telemetry floor for EKG changes related to hyperkalemia secondary to his AD. On the telemetry floor, the second set of cardiac enzymes drawn after 4 hrs showed a CK-MB of 85.7 ng/ml and Troponin I of 11.4 ng/ml. The repeat EKG revealed newly developed Q waves in the anterior precordial leads. The patient was started on Aspirin, beta-blocker, statin and intravenous heparin and transferred to Cardiac Intensive Care Unit. The patient remained chest pain free during this course and his Troponins peaked at 50 ng/ml. He subsequently underwent a coronary angiogram which showed thrombus in the mid Left Anterior Descending Artery (LAD) with 99% stenosis. Percutaneous transluminal coronary angioplasty of the LAD was performed with placement of a drug-eluting stent and patient did well after the procedure. He was discharged in a stable condition to follow-up with Cardiology and Endocrinology.

DISCUSSION: The initial electrocardiographic changes in both ST Elevation MI and Hyperkalemia are hyper-acute T waves. In our patient, the peaked T waves in the EKG on presentation were attributed to the hyperkalemia and repeat EKG with Q waves signified that he had already infarcted the LAD territory. Hyperkalemia masked the initial presentation of a potential ST Elevation MI. As the patient remained chest pain free through out and initial CK-MB was negative, also played a role in successful masquerading.

CONCLUSIONS: EKG interpretation can be affected by electrolyte disturbances and hence serial EKGs should be performed while evaluating patients with chest pain to identify any dynamic changes.

Reference #1: N/A

DISCLOSURE: The following authors have nothing to disclose: Sameer Chadha, Geurys Rojas Marte, Sarita Konka, Jinu John, Bilal Malik, Gerald Hollander, Jacob Shani

No Product/Research Disclosure Information

Chest. 2014;145(3_MeetingAbstracts):72A. doi:10.1378/chest.1788660

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Lyme disease is a tick-borne illness caused by spirochete Borrelia Burgdorferi. Cardiac manifestations of Lyme disease mostly include conduction abnormalities which occur weeks to a few months after the onset of infection.

CASE PRESENTATION: A 19 year old male with no past medical history presented to our emergency department (ED) with an episode of syncope while walking. Patient denied any history of chest pain, shortness of breath or previous similar episodes. The physical examination was significant for a heart rate of 33 and an Erythema Migrans rash on the back. On further history, the patient admitted to going on a hiking trip in Upstate New York few weeks ago but could not remember any tick bite. The electrocardiogram done in the ED showed complete heart block. Laboratory work up came back as normal complete blood count and serum chemistry along with negative cardiac enzymes (CK-MB and Troponin I). Patient was started on intravenous Ceftriaxone for suspected Lyme Carditis and admitted to Cardiac Intensive Care Unit for observation. ELISA and Western blot analysis revealed seropositivity for Lyme disease. Patients heart block varied from 2:1 atrioventricular (AV) Block to Mobitz Type 1 AV Block in next few days and finally resolved to a 1st degree AV Block with a PR interval of 236 ms. The echocardiogram showed normal LV systolic function with an ejection fraction of 55%. Patient remained completely asymptomatic through out the course of his hospitalization and did not require temporary venous pacing. He was discharged home with a PICC Line to complete the course of intravenous antibiotics for three weeks and to follow up with Infectious Diseases Clinic and Cardiology.

DISCUSSION: Lyme Disease is endemic in Northeastern and Mid-Atlantic regions of United States. AV conduction blocks of varying severity is the most common clinical manifestation of Lyme Carditis along with palpitations and myo-pericarditis. Lyme Cardiomyopathy has not been observed in United States, but has been reported rarely in Europe where the incidence of Lyme Carditis is lower overall, probably because of a different strain. Conduction delay in Lyme Carditis usually occurs above the bundle of His, often within the AV node. The prognosis of Lyme Carditis is excellent with resolution of the conduction abnormalities with use of antibiotics and patients rarely require a permanent pacemaker.

CONCLUSIONS: Lyme Carditis should be suspected as the cause of AV conduction block in the setting of a travel history to Lyme endemic area and Erythema Migrans rash, with or without the history of a tick bite.

Reference #1: N/A

DISCLOSURE: The following authors have nothing to disclose: Sameer Chadha, Geurys Rojas Marte, Bernard Topi, Gerald Hollander, Jacob Shani

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Chest. 2014;145(3_MeetingAbstracts):73A. doi:10.1378/chest.1796194

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Atrioesophageal fistula (AEF) is an uncommon (0.15 per 1000 patients) complication following catheter ablation for atrial fibrillation. Though rare, prompt recognition is critical as unrecognized AEF formation is nearly always fatal and in the absence of death, catastrophic morbidity remains.

CASE PRESENTATION: A 58-year-old Caucasian male with atrial fibrillation on rivaroxaban presented with chest pain. The patient had paroxysmal hematemesis and was intubated. He then developed cardiac arrest. Following successful ACLS, the patient was transferred to our tertiary care center for definitive care. Upon arrival, the patient was encephalopathic with intact cough, corneal and pupillary reflexes. Initial management focused on the hematemesis, secondary anemia, cardiac arrest and fever. Within the first several hours there was interval development of dysconjugate gaze and pupillary asymmetry. Unenhanced CT Head revealed pneumocephalus and a left cerebellar hemorrhage. MRI confirmed septic emboli. No clear unifying etiology accounted for the chest pain, hematemesis, cardiac arrest, encephalopathy, fever, pneumocephalus, intracranial hemorrhage and septic shock until the patient’s local electrophysiologist called with concern as the patient was treated with radio frequency ablation (RFA) 17 days prior for atrial fibrillation. The diagnosis of AEF was highly suspected. A CT angiogram of the chest revealed a 5 mm posterior left atrial diverticulum consistent with AEF. The patient underwent surgical repair but never regained consciousness following multiple embolic strokes. The patient’s family withdraw care.

DISCUSSION: A fistula between the left atrium and esophagus may lead to severe bleeding and food or air emboli. The true incidence of AEF following RFA is unknown. One recent survey reported 6 cases AEF out of 20,425 procedures performed. All six patients developed cerebrovascular accidents; ultimately 5 of 6 died. Whereas another recent survey reported 7 cases AEF out of 45,115 procedures; 5 of 7 died. A recent review found 28 case reports of AEF following RFA. Symptoms developed 3 to 38 days after ablation. The leading symptoms reported included confusion, seizures, postprandial TIAs and bacteremia with septic emboli.

CONCLUSIONS: The recognition of a unifying diagnosis for these eclectic mix of symptoms is critical for early surgical intervention.

Reference #1: Cappato, R., Calkins, H., Shih-Ann, C., et al. Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. JACC. 2009;53(19):1798-1803.

Reference #2: Ghia, K., Chugh, A., Good, E., et al. A nationwide survey on the prevalence of atrioesophageal fistula after left atrial radiofrequency catheter ablation. J Interv Card Electrophysiol. 2009; 24:33-36.

Reference #3: Stöllberger, C., Pulgram, T., Finsterer, J. Neurological consequences of atrioesophageal fistula after radiofrequency ablation in atrial fibrillation. Arch Neurol. 2009;66(7):884-887.

DISCLOSURE: The following authors have nothing to disclose: Matthew Hammar, Gurleen Pasricha, Tiffany Dumont, Khalid Malik

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Topics: cardiac arrest
Chest. 2014;145(3_MeetingAbstracts):74A. doi:10.1378/chest.1824043

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Some important indications for use of hyperbaric oxygen therapy include treatment of diabetic ulcers, air embolism, carbon monoxide poisoning, and gas gangrene. It is usually well tolerated with very few side effects. We describe a case of acute pulmonary edema precipitated by hyperbaric oxygen treatment.

CASE PRESENTATION: An 80-year-old male with Ischemic Cardiomyopathy (ejection fraction- 25%), diabetes mellitus and peripheral vascular disease was admitted because of severe dyspnea. He was getting hyperbaric oxygen treatment for a non-healing ulcer on his foot. His vitals were stable and he was breathing comfortably before the start of therapy. Towards the end of treatment, he developed rapidly worsening dyspnea. EMS was called and he was brought to the hospital on 100% oxygen via non-rebreather mask. His vitals were: T: 98.8 F, HR: 110/min, RR: 30/min, BP: 138/74 mm Hg, SaO2: 92%. Examination was significant for diffuse inspiratory and expiratory crackles. Due to severe distress, he required intubation and mechanical ventilation. EKG didn’t show any ischemic changes. Cardiac biomarkers were negative, but his BNP was significantly elevated at 1568 pg/mL. There were pink frothy secretions in the endotracheal tube and chest X-ray showed severe pulmonary edema. Diagnosis of acute respiratory failure secondary to pulmonary edema was made, and he was admitted to the cardiac ICU. He received ventilator care and intravenous diuretics, and was successfully extubated 3 days later.

DISCUSSION: Hyperbaric oxygen (HBO) therapy has been shown to improve the rate of healing of diabetic foot ulcers. Suggested mechanisms include improved wound tissue hypoxia, enhanced perfusion, and down-regulation of inflammatory cytokines (1). Some side effects of HBO that are described include: otic barotrauma, visual changes and possible CNS oxygen toxicity. Very few cases of pulmonary edema due to HBO treatment have been described. Weaver et al described three cases in 2001- all of them had pre-existing cardiac disease, and two of them were diabetic (2). Yildiz et al demonstrated that HBO treatment led to increase of N-terminal pro-B-type natriuretic peptide (NT pro-BNP) levels in diabetics by mean of 100 pg/mL (3). Proposed mechanisms for this include: HBO induced hyperoxia leading to increased peripheral vasoconstriction and thus cardiac afterload, increased oxidative myocardial stress, decreased LV compliance by oxygen radical-mediated reduction in nitric oxide and increased pulmonary capillary permeability (2). Any of these can precipitate acute pulmonary edema in a patient with pre-existing heart disease. Treatment remains primarily supportive with diuretics, supplemental oxygen and occasionally ventilatory support.

CONCLUSIONS: Acute pulmonary edema is a rare but serious side effect of hyperbaric oxygen therapy in patients with pre-existing heart disease. Thus caution should be observed in treating patients with heart disease with hyperbaric oxygen therapy.

Reference #1: Cardiovascular and blood gas responses to hyperbaric oxygenation. Whalen RE et al. Am J Cardiol1965; 15,638-646

Reference #2: Pulmonary edema associated with hyperbaric oxygen therapy. Weaver LK et al. Chest 2001; 120(4): 1407-1409.

Reference #3: N-terminal pro-B-type natriuretic peptide levels increases after hyperbaric oxygen therapy in diabetic patients. Yildiz et al. Clinical & Investigative Medicine 31.5 (2008): E231-E235.

DISCLOSURE: The following authors have nothing to disclose: Manveen Dassan, Vishesh Paul, Sameer Chadha, Nidhi Aggarwal, Yizhak Kupfer, Sidney Tessler

No Product/Research Disclosure Information

Chest. 2014;145(3_MeetingAbstracts):75A. doi:10.1378/chest.1826467

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Atrio-esophageal fistula is a fatal complication of radiofrequency ablation, which is associated with 80% mortality rate. Incidence rate for atrio-esophageal fistula formation is reported to be less than 1%. Dissemination of the organisms from the gut into the vasculature is the major cause of mortality. Hence, early diagnosis and immediate surgical intervention is necessary. Here we present a case of atrio-esophageal fistula occurred as a complication of radiofrequency ablation, complicated with sepsis and embolic stroke.

CASE PRESENTATION: A 64 year old male with medical history of hypertension, coronary artery disease and chronic atria fibrillation, underwent radiofrequency ablation 10 days back, was admitted to hospital for declining mental status and fever for 5 days. No other systemic symptoms were reported. Exam was significant for 101 degree centigrade temperature, irregular heart rate in 140’s. Patient was obtunded, with left gaze preference without any response to pain stimulus. Diagnostic examination was significant for troponin level 60.70 ng/ml. Electrocardiogram showed atria fibrillation, heart rate in 140’s, no acute ST segment changes or Q waves. Echocardiogram showed ejection fraction of 55% and global hypo kinesis. Broad spectrum antibiotics were administered for possible sepsis. High troponin level without ST segment change, and recent ablation procedure raised the suspicion for atrio-esophageal fistula. CTA Chest revealed 9 - 10 mm wide ulceration of left atrium posterior wall communicating with distal esophagus at T7 level. CT Head showed multiple non specific cerebral lesions in left and right occipital and left frontal-parietal regions. Patient underwent emergent right thoracotomy, and Left atria repair, along with esophageal stent placement. Blood cultures were positive for Enterococci.

DISCUSSION: CT Chest with IV contrast is the best diagnostic modality which may reveal multiple findings, not limited to contrast presence in esophagus or mediastenum but may also show pneumo mediastenum, intra-atria air, posterior left atria wall thickening. Procedures like Trans-esophageal echocardiography and esophagoscopy result in air embolism. High radiofrequency pulses delivered to the mid-portion of posterior wall of left atrium where there is disproportionate and less fatty layer, predispose the development of atrio-esophageal fistula. Procedural measures like left atrium posterior wall monitoring by the use of intra-cardiac echocardiography, use of esophageal temperature probe, moving the lines to the roof or decreasing the radiofrequency power while ablating the posterior wall of LA were studied with a reasonable success to avoid injury.

CONCLUSIONS: Given the associated poor prognosis, prompt recognition and emergent intervention are mandatory to decrease the mortality.

Reference #1: Dagres N, Hindricks G, Kottkamp H, et al. Complications of atrial fibrillation ablation in a high-volume center in 1,000 procedures: still cause for concern? J Cardiovasc Electrophysiol 2009; 20:1014-

Reference #2: Cappato R, Calkins H, Chen SA, et al. Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. J Am Coll Cardiol 2009; 53:1798-803.

Reference #3: Damian Sanchez-Quintana, Jose Angel Cabrera, Vicente Climent. Anatomic Relations Between The Esophagus and Left Atrium and Relevance for Ablation of Atrial Fibrillation.Circulation. 8/29/2005

DISCLOSURE: The following authors have nothing to disclose: Sravanthi Nandavaram

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Chest. 2014;145(3_MeetingAbstracts):76A. doi:10.1378/chest.1836636

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: We present a case of progressive hypoxemia with platypnea-orthodeoxia developing after lung resection surgery for lung cancer.

CASE PRESENTATION: The patient is a 68 year-old Caucasian male who presented with progressive dyspnea and hypoxemia after right lower lobe resection 6 weeks prior for stage IIIA NSCLC. His surgery was unremarkable and post-operative course included atrial fibrillation. He was discharged on room air. After discharge, he noted increasing shortness of breath and required oxygen. He was treated with several courses of antibiotics for infiltrates on imaging studies without improvement. CT pulmonary angiogram was negative for pulmonary embolism and cardiac echo showed only diastolic dysfunction. He was readmitted with significant hypoxemia and worsening symptoms with sitting up and improvement lying down.

DISCUSSION: Clinical course included progressive hypoxemia requiring 100% FiO2 and non-invasive positive pressure ventilation. LE duplex was negative for DVT. VQ scanning was low probability for pulmonary embolism. Chest CT scan showed resolution of prior infiltrates. Post-surgery pulmonary function tests suggested restrictive disease but he could not tolerate further testing. Given concern for platypnea-orthodeoxia, and a recent echo with no intracardiac shunt, he underwent ventilation/perfusion testing with shunt calculation. This showed 36.3% shunt outside the lung (normal less than 10%). He underwent transesophageal echocardiogram that revealed a large atrial septal defect by Doppler and agitated saline contrast. There was right-to-left shunting that worsened with movement from supine to 70 degrees position. He was diagnosed with platypnea-orthodeoxia syndrome related to worsening of his ASD post-lung resection surgery. He underwent cardiac catheterization and closure of his ASD with an Amplatzer Cribiform Occluder. He was clinically improved and on room air over several days.

CONCLUSIONS: Symptoms of hypoxemia with platypnea-orthodeoxia are concerning for shunt physiology. The differential diagnosis includes sources of intracardiac (ASD, PFO) and intrapulmonary shunting. He had a prior intracardiac shunt on an earlier echo but not on the post-operative study. He had no evidence of other cardiac causes such as pericardial effusion, constrictive pericarditis or aortic aneurysm. He had an interstitial lung disease by CT scan but this was unchanged radiographically. There was no evidence of other pulmonary causes such as COPD, thromboembolic disease or an intrapulmonary shunt (arteriovenous malformation). He had no history of liver disease with shunt from cirrhosis or history of kyphoscoliosis. Platypnea-orthodeoxia was first described in 1949 and major causes are intracardiac shunts and intrapulmonary shunts. The intracardiac shunts are right-to-left and most often include atrial septal defect, patent foramen ovale or fenestrated atrial aneurysm. Other causes include pericardial effusion, lobectomy, pneumonectomy or upper abdominal surgery. This occurs from preferential blood flow towards the atrial septum that is accentuated by altered intracardiac anatomy, compliances of the right and left heart, pulmonary vascular resistance and transient right to left pressure gradients associated with respiratory and positional changes. This is generally not associated with pulmonary hypertension and atrial right-to-left shunting has been reported despite normal right-sided pressures. A right-to-left shunt is more likely to appear after a right-sided lung resection with most patients having symptoms develop a month to several months afterwards. Noncardiac causes can include intrapulmonary shunting, such as thromboembolic disease and AVMs, or cirrhosis and kyphoscolisoss. The key to diagnosis is clinical suspicion of symptoms of dyspnea and hypoxemia, induced or worsened by an upright posture. In conclusion, interatrial shunting through a PFO or ASD is a rare but clinically significant condition after thoracic surgery. There are several underlying etiologies and can occur in the immediate postoperative period or can be more delayed.

Reference #1: Interatrial Shunting After Major Thoracic Surgery: A Rare but Clinically Significant Event. Ann Thorac Surg 2012;93:1647-51

Reference #2: Dyspnoea and hypoxaemia after lung surgery: the role of interatrial right-to-left shunt. Eur Respir J 2006; 28: 174-181

Reference #3: Platypnoea-orthodeoxia syndrome. Heart 2000;83:221-223

DISCLOSURE: The following authors have nothing to disclose: Nitin Bhatt, Ulysses Magalang

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Chest. 2014;145(3_MeetingAbstracts):78A. doi:10.1378/chest.1836618

SESSION TITLE: Cardiovascular Cases

SESSION TYPE: Case Reports

PRESENTED ON: Saturday, March 22, 2014 at 04:15 PM - 05:15 PM

INTRODUCTION: Primary cardiac tumors are extremely rare with a prevalence of 0.02% in pooled autopsy studies. Lymphomas involving the heart have a prevalence between 1% to 2% of primary cardiac tumors. Diagnosis usually requires tissue biopsy either by open surgical tissue resection or image-guided biopsy. We report a case of a patient who found to have a primary cardiac T-cell lymphoma (PCTCL) of the right atrium (RA) diagnosed by biopsy guided by intracardiac echocardiography (ICE). (1, 2)

CASE PRESENTATION: A 66-year-old woman who presented with a 2 month history of progressive shortness of breath and orthopnea. Her ejection fraction decreased from 65% to 35% over a 4 year period. Coronary computed tomography angiography (CTA) revealed normal coronary arteries and a RA mass vs thrombus (Fig 1). A cardiac MRI with contrast was performed and the characteristic of the mass was suggestive of a lymphoma (Fig 2). Patient subsequently underwent percutaneous transcatheter biopsy of the RA mass using fluoroscopic and ICE guidance. Pathologic specimens demonstrated a T-cell lymphoma.

DISCUSSION: Patients with PCTCL typically remain asymptomatic until the mass leads to either obstruction of circulation, embolization, interference with valve function, decreased myocardial contractility or conduction disturbances. Histological diagnosis is made by biopsy and typically requires an open-chest procedure under general anesthesia. Transcatheter biopsy with transesophageal echocardiography guidance also requires general anesthesia. However, ICE imaging allows transcatheter biopsy of an intracardiac mass, especially of the right atrium. This can be made under direct visualization with conscious sedation, minimizing the risk for perforation. (3)

CONCLUSIONS: Intracardiac mass biopsy using ICE is an attractive modality which provides precise localization of cardiac structures under conscious sedation. This case illustrates successful use of imaging to minimize risk in the assessment of a cardiac mass.

Reference #1: Reynen K. Frequency of primary tumors of the heart. Am J Cardiol 1996;77:107-10.

Reference #2: Lam KY, Dickens P, Chan AC. Tumors of the heart. A 20-year experience with a review of12,485 consecutive autopsies. Arch Pathol Lab Med 1993;117:1027-31.

Reference #3: Kuppahally S.,Litwin S. Endomyocardial Biopsy of Right Atrial Angiosarcoma Guided by Intracardiac Echocardiography. Cardiology Research and Practice Volume 2010, Article ID 681726

DISCLOSURE: The following authors have nothing to disclose: Ahmed Al-Badri, Sean Wilson, Chad Klinger, Carlos Ruiz

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Chest. 2014;145(3_MeetingAbstracts):80A. doi:10.1378/chest.1803785

SESSION TITLE: Cardiovascular Cases

SESSION TYPE: Case Reports

PRESENTED ON: Saturday, March 22, 2014 at 04:15 PM - 05:15 PM

INTRODUCTION: Central venous catheters (CVC) are placed in large caliber veins, and though relatively safe, complications can occur. When chest radiograph cannot verify proper CVC placement, further assessments are mandated. We present a case of questionable placement of a left-sided CVC.

CASE PRESENTATION: 59 y/o female was admitted for increasing dyspnea and atrial flutter. Lines were placed for management and hemodialysis. Ultrasound-guided left internal jugular (LIJ) triple-lumen CVC was placed; for dialysis a RIJ catheter was placed. Radiograph interpretation included "arterial positioning of the catheter cannot be excluded" for the LIJ. Blood analysis revealed venous values. CT revealed a bilateral superior vena cava (SVC).

DISCUSSION: Despite proper technique, CVCs can terminate in what appears to be undesired locations. Complication rates range from 15-33%. The left side is more circuitous and an increased transverse lie of the brachiocephalic exists. A bilateral SVC is the most common anomaly of the venous circulation, present in 0.3% of patients, and 4.3% with congenital heart disease. The condition results from a persistent embryonic left anterior cardinal vein and the failure of the left brachiocephalic vein to form the seventh week of development, although the absence of the brachiocephalic vein occurs only 40% of the time. The persistent left anterior cardinal vein drains into the right atrium by way of the coronary sinus, while the right sided venous return remains normal. The failure of the anterior cardinal vein obliteration is caused by non-compression between the left atrium and the hilum of the left lung, and associated with atrioventricular canal defects, cor triatriatum, or mitral atresia.

CONCLUSIONS: Our case demonstrates a possible left internal jugular vein cannulation route and clinical significance. Further evaluation for other cardiac anomalies may be warranted. It is imperative to understand the limitations of these catheters. With bilateral SVC, the left-sided lumen is often smaller than the normal right: treating it as a peripheral line is recommended, by avoiding vasopressors and medications with sclerosing properties.

Reference #1: McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123.

Reference #2: Higgs AG, Paris S, Potter F. Discovery of left-sided superior vena cava during central venous catheterization. Br J Anaesth 81:260-261, 1998.

Reference #3: Ghatak T, et al. Malposition of central venous catheter in a small tributary of left brachiocephalic vein. J Emerg Trauma Shock. 2011; 4(4): 523-525.

DISCLOSURE: The following authors have nothing to disclose: Andrew Oh, Timothy Quast

No Product/Research Disclosure Information

Chest. 2014;145(3_MeetingAbstracts):81A. doi:10.1378/chest.1835611

SESSION TITLE: Cardiovascular Cases

SESSION TYPE: Case Reports

PRESENTED ON: Saturday, March 22, 2014 at 04:15 PM - 05:15 PM

INTRODUCTION: Paroxysmal supraventricular tachycardia (PSVT) following blunt cardiac injury (BCI) is rare but reported in the literature. AV nodal reentrant tachycardia (AVNRT) is the commonest form of PSVT encountered in clinical practice. We present a unique case of AVNRT after a blunt chest trauma with concomitant pulmonary embolism.

CASE PRESENTATION: An 18 year-old Hispanic man with no significant past medical history presented to the emergency room with two hours of palpitations after sustaining a hard blow to the left mid-sternum while playing basketball. Patient reported a presyncopal episode lasting less than one minute immediately after the blunt trauma followed by unremitting palpitations and worsening mid-sternal chest pain and dyspnea on exertion. On presentation he was in mild distress, complaining only of palpitations. His heart rate was 210 beats per minute and blood pressure was 100/45 mmHg. EKG showed SVT. Adenosine was given and he converted to normal sinus rhythm with symptom resolution. Serum troponin I peaked to 3.30 ng/mL and plasma D-Dimer Assay was elevated at 1244 ng/mL. Chest radiography showed no pathology. Echocardiogram showed mildly enlarged right ventricle. CT Angiogram of the chest showed acute right lower lobe lobar and segmental pulmonary embolus without pulmonary infarct. The patient is without risk factors for cardiopulmonary disease or clotting disorders and lower extremity venous duplex was negative for deep vein thrombosis. Patient was inducible into typical AVNRT at a rate of 200-210 beats per minute on electrophysiological study. He underwent successful radiofrequency ablation and was no longer inducible into SVT. The patient remained asymptomatic and was discharged on oral anticoagulation.

DISCUSSION: BCI is a risk factor for cardiac dysrhythmia (1). It is hypothesized that the reentrant rhythm was triggered by premature ectopic beats resulting from the blunt cardiac trauma. In the setting of dual AV nodal physiology, an ectopic beat was able to initiate sustained AVNRT (2). Thromboembolism after BCI has been reported previously (3). We hypothesize that the blunt cardiac trauma also predisposed the patient to an in situ thrombus which embolized to the pulmonary artery branches. This case of blunt chest trauma causing typical AVNRT and PE is to the best of our knowledge the first of its kind reported in the literature.

CONCLUSIONS: This case illustrates two unusual sequelae of blunt chest trauma-- pulmonary embolus and sustained AV nodal reentrant tachycardia.

Reference #1: "Trauma Associated With Cardiac Dysrhythmias: Results Froma Large Matched Case-Control Study." Ismailov et al. The Journal of Trauma Injury, Infection, and Critical Care. 2007;62.

Reference #2: "Blunt cardiac injury." Bock et al. Cardiology Clinics. Volume 30, Issue 4, November 2012.

Reference #3: “Thromboembolism as a complication of myocardial contusion: a new capricious syndrome.” Timberlake et al. Journal of Trauma. 1988 April 28(4)

DISCLOSURE: The following authors have nothing to disclose: Joy Victor, Mangalore Amith Shenoy, Sameer Chadha, Felix Yang, Gerald Hollander, Jacob Shani

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Chest. 2014;145(3_MeetingAbstracts):82A. doi:10.1378/chest.1824445

SESSION TITLE: Cardiovascular Disease Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Acute myocarditis is a clinical condition commonly encountered in Portugal in the winter season. As markers of cardiac necrosis are commonly elevated with symptoms resembling acute coronary syndromes with equivocal ECG alterations, patients undergo coronary angiography routinely. The advent of cardiac MRI with the formulation of the Lake Louise criteria has allowed for a diagnosis of acute myocarditis. The aim of the study was to audit the decision to use of coronary angiography in patients diagnosed clinically with acute myocarditis. The decision was left to the treating physician.

METHODS: Eighteen patients were admitted to a district general hospital without on-site cardiac catheterization or cardiac MRI with a diagnosis of acute myocarditis. Six patients had coronary angiography and all patients underwent cardiac MRI. The TIMI score for ACS was also calculated for each patient.

RESULTS: The cohort included 16 men, with a mean age of 31 years, with retrosternal or pleuritic chest pain present in 17, and dyspnea in one patient. 14 reported having a systemic viral syndrome, pharyngitis or tonsillitis in the preceding three weeks. Mean CK, CK-MB and Troponin I levels were 557 IU/l, 54 ng/mL and 9.94 ng/mL and 11 had an abnormal ECG with concave ST elevation in 8. The TMII score for ACS was 1 in all patients, indicating a low-risk and doubtful benefit of invasive strategy in those with ACS. A definite diagnosis of acute myocarditis based on the presence of edema and subepicardial late enhancement was present in 16 patients while two patients with only edema were considered to have probable myocarditis according to Lake Louise criteria. All six patients who underwent angiography had normal studies. All patients were discharged with no in-hospital cardiovascular events. At a follow-up of two years no patient has been readmitted for cardiovascular reasons.

CONCLUSIONS: One third of patients with a clinical suspicion of acute myocarditis underwent coronary angiography despite the fact that a definitive diagnosis of acute myocarditis was possible by cardiac MRI in 88% of cases and a low TIMI ACS score.

CLINICAL IMPLICATIONS: The use of coronary angiography routinely in patients with acute myocarditis is an example of poor resource deployment with negative effects to the patient and health care systems.

DISCLOSURE: The following authors have nothing to disclose: Dinis Mesquita, Carla Nobre, Boban Thomas

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Chest. 2014;145(3_MeetingAbstracts):83A. doi:10.1378/chest.1834748

SESSION TITLE: Cardiovascular Disease Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: The risk of stroke associated to the various means of cardiac stimulation is still limited and offers only tendencies. It is only known that patients with sinus node dysfunction are in risk of stroke and suggest that ventricular demand pacemakers do not offer protection against this risk.

METHODS: A cross-sectional analysis was made of the medical records of 74 patients with pacemakers or implantable cardioverter defibrillator (ICD) attended at a cardiology outpatient clinic of a University hospital in the city of Salvador, between September/2003 and June/2008. Socio-demographic, clinical and anticoagulant therapy information was obtained from the medical records of the patients.

RESULTS: The average age was of 60 years, 89,2% with pacemakers and 10,8% with ICD, 51,4% of the male sex, 8,1% were diabetics, 45,9% were mulatto, 52,7% presented a left ventricular ejection fraction lower than 45%, 10,8% suffered Coronary Artery Disease (CAD), 5,4% with chronic renal failure, 2,7% had a history of Pulmonary Thromboembolism, 70,3% of the patients presented chagasic cardiopathy, 93,2% did not use anticoagulants and 58,1% did not use platelet antiaggregant. With reference to the cardiac rhythm, 9,5% presented an atrial fibrillation rhythm on the electrocardiogram performed in the outpatient clinic. There were 21 cases of stroke significantly more frequent in the group of patients with CAD (odds ratio[OR] : 0.19, p= 0.024) , in diabetics ([OR]: 0.16 , p=0.030) and those with chronic renal failure ([OR]: 0.120, p=0.039). In relation to chagasic and non-chagasic patients, the use of pacemakers or ICD, atrial fibrillation, gender, race, use of anticoagulants or platelet antiaggregants, left ventricular ejection fraction lower than 45% and pulmonary thromboembolism did not evidence association with stroke.

CONCLUSIONS: Our study demonstrated a higher frequency of stroke in patients with pacemakers presenting CAD, diabetes and chronic renal failure.

CLINICAL IMPLICATIONS: Strategies for the strict monitoring and control of the cardiac rhythm is necessary to evaluate possible thrombotic complications in patients using pacemakers, as well as an early initiation of anticoagulant therapy.

DISCLOSURE: The following authors have nothing to disclose: Elieusa Sampaio, Roque Aras Júnior, José Alberto da Matta, Cristiano Macedo, Márcia Maria Oliveira, Ubiratan dos Santos Júnior, Sérgio Câmara

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Chest. 2014;145(3_MeetingAbstracts):86A. doi:10.1378/chest.1793942

SESSION TITLE: Cardiovascular Disease Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: Spatial QRS T-angle (spQRS T-a) is considered as a novel electrocardiography derived marker of independent predictive value of electrical instability in cardiac disease. Cardiac involvement in sarcoidosis is often underdiagnosed, although a significant contributor to mortality. The present study was conducted to test the hypothesis that patients with sarcoidosis have increased ventricular repolarisation heterogeneity as reflected by spQRS-Ta values.

METHODS: This cross-sectional study included newly diagnosed consecutive patients with biopsy proven sarcoidosis (n=83) and healthy subjects (n=83) who were matched 1:1 for age, gender and BMI. All patients underwent clinical and cardiopulmonary evaluation including cardiac MRI to assess spQRS T-a values and cardiac involvement and identify possible correlations.

RESULTS: SpQRS-Ta was significantly increased in sarcoidosis patients compared to healthy controls (18.3 ± 11.4 vs. 11.3 ± 5.1, p<0.01). When known criteria for the clinical diagnosis of cardiac sarcoidosis were applied spQRS-Ta was found significantly increased in patients with presence of criteria compared to totally ‘negative’ sarcoidosis patients (21.1 ± 11.8 vs. 15.8 ± 10.4, p=0.03). SpQRS-Ta values were significantly greater in those sarcoidosis patients with Lown class >III ventricular arrhythmia than the remaining patients (27.5 ± 15.7 vs. 17.1 ± 10.3, P<0.01), while univariate linear regression analysis showed that Lown classification was independently associated with spQRS-Ta values (p=0.002, b=3.236, 95% CI 1.209-5.263).

CONCLUSIONS: SpQRS T-a could be used as a noninvasive marker of electrical instability due to cardiac involvement in patients with sarcoidosis

CLINICAL IMPLICATIONS: The clinical diagnosis of cardiac sarcoidosis is feasible with combination of electrical and structural markers with ranging sensitivity and specificity. This marker seems to be useful in identifying patients with electrical instability and possible cardiac involvement.

DISCLOSURE: The following authors have nothing to disclose: Elias Gialafos, Vasileios Kouranos, Aggeliki Rapti, Efrosyni Manali, Konstantina Aggeli, Elias Perros, Theodore Papaioannou, Petros Sfikakis, Christodoulos Stefanadis, George Tzelepis, Athol Wells, Nikolaos Koulouris

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Chest. 2014;145(3_MeetingAbstracts):86B. doi:10.1378/chest.1826433

SESSION TITLE: Cardiovascular Cases

SESSION TYPE: Case Reports

PRESENTED ON: Saturday, March 22, 2014 at 04:15 PM - 05:15 PM

INTRODUCTION: Dilatation of the main pulmonary artery in the absence of pulmonary hypertension is a rare condition with numerous identified etiologies. Idiopathic pulmonary artery dilatation (IPAD) is a diagnosis of exclusion and is an extremely rare cause of pulmonary artery dilatation. Here we discuss a case of IPAD presenting as unexplained dyspnea.

CASE PRESENTATION: 48 year old obese Caucasian male presented to clinic for evaluation of episodic dyspnea. Patient noted mild exertional dyspnea, orthopnea, occasional non-exertional chest discomfort and postural dizziness. Physical examination was unremarkable. A CTPA revealed a dilated pulmonary artery measuring 6.5 cm and a 5 mm right middle lobe nodule with no other parenchymal abnormalities. Subsequent echocardiogram showed normal ejection fraction and mildly elevated right ventricular systolic pressure of 35.12 mmHg. Pulmonary function tests were normal. BNP, ANA, RF, ANCA, RPR were normal. He was noted to have mild obstructive sleep apnea (OSA) on polysomnogram. A right heart catheterization demonstrated mild pulmonary hypertension with PCWP of 14 mmHg, mPAP of 37 mmHg, no intracardiac shunt and pulmonary artery trunk measuring 5.5 cm. The patient was diagnosed with IPAD as secondary etiologies were excluded. The patient currently follows in clinic with annual CTPA to monitor pulmonary artery size which has been stable. In addition, the patient is on BPAP therapy for OSA.

DISCUSSION: IPAD is an extremely rare entity with sporadic case reports in literature. It is often diagnosed incidentally but can present with nonspecific complaints. Original criteria for diagnosis of IPAD were established by Greene et al in 1949. Deshmukh et al in 19931 suggested including normal pressure in the right ventricle and pulmonary artery as an additional criteria. Although our patient does have mild pulmonary hypertension he did meet the original diagnostic criteria established by Greene et al. Moreover, the magnitude of pulmonary artery dilatation is out of proportion to the mild pulmonary hypertension which is likely explained by previously untreated OSA. The natural history of pulmonary artery aneurysm remains largely unknown. However, aneurysms do carry an inherent risk of rupture and sudden death. There are no specific guidelines regarding management of these patients.

CONCLUSIONS: IPAD is considered to be a benign condition. However, given the inherent risk of pulmonary artery rupture, it is prudent to observe these patients closely for a prolonged period of time.

Reference #1: Idiopathic Dilatation of the Pulmonary Artery. Circulation 1960;21:710-716

DISCLOSURE: The following authors have nothing to disclose: Syed Mudassar Naqshbandi, Naveed Sheikh, Kashif Aslam, Asra Afzal, Tina Dudney

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Chest Infections

Chest. 2014;145(3_MeetingAbstracts):87A. doi:10.1378/chest.1825532

SESSION TITLE: Tuberculosis Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: The potential complications of immune reconstitution disease during antiretroviral therapy (ART) are extremely diverse and included the unmasking form of tuberculosis. TB caused by immune reconstruction inflammatory syndrome is associated with a high mortality risk although HIV-infected patients are treated with antiretroviral agents.

CASE PRESENTATION: We report 2 cases diagnosed in 2011 with unmasked TB and obvious extra pulmonary manifestations in HIV- infected women. Routine investigation included chest radiograph and CT scan, laboratory tests. Case 1- A 45 year- old white woman, smoker 20 pack yrs, co infected HIV- TB since 2009, was admitted in our clinic in March 2011. ART was initiated 4 months ago. Laboratory tests revealed negative smears for acid fast bacilli. Prolonged fever for more than 1 week and persistent abdominal pains were determined by an ovarian abscess with peritonitis revealed by CT scan. TB meningitis was diagnosed 3 weeks later and directly observed therapy (DOT) with anti tuberculosis drugs was initiated. Case 2- A 31 year old white woman with known HIV infection since 2009, was admitted to our clinic with pulmonary shadows, cough, fever, nausea and vomiting, moderate anemia and acute abdominal pain with a progressive illness after 2 months of ART. A left tubo ovarian abscess was diagnosed and, after surgical intervention recommended. The patient was readmitted to our clinic 17 days later for persistent cough, fever, night sweats and worsening shortness of breath. A new chest X-ray revealed bronchopneumonia and bacteriological exam of sputum revealed positive cultures for Mycobacterium tuberculosis. Both cases survived after DOT was ended.

DISCUSSION: In TB burden area, patients with HIV and TB co-infection who are antiretroviral treated should be routinely screened for TB disease. Manifestations of TB disease could be subtle or atypical. A high index of suspicion needs to be maintained in cases with hyper-inflammatory features that might be truly be considered life-threatening as in our case series were the very painful ovarian abscesses.

CONCLUSIONS: Described unmasked and accelerated worsening of TB disease post-ART suggest that immune reconstitution inflammatory syndrome had contributed in both cases. Because pelvic inflammation disease is considered co-epidemic with HIV, the diagnosis of TB was delayed, the progression of TB disease was fast and severe, but the prognosis was finally a favorable one.

Reference #1: Lawn SD, Meintjes G. Pathogenesis and prevention of immune reconstitution disease during antiretroviral therapy. Expert Rev. Anti Infect. Ther. 9(4), 415-430 (2011)

Reference #2: Lawn SD, Wilkinson RJ, Lipman MC, Wood R. Immune reconstitution and unmasking tuberculosis during antiretroviral therapy. Am.J. respir. Crit. Care Med. 177, 680-685 (2008)

DISCLOSURE: The following authors have nothing to disclose: Valerios Kortzis, Georgios Athanasiou, Ioan Arghir, Elena Dantes, Simona Cambrea, Paraschiva Postolache, Oana Arghir

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  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543