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Allergy and Airway

Chest. 2015;148(4_MeetingAbstracts):1A. doi:10.1378/chest.2279735

SESSION TITLE: Airways Global Case Reports I

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Klippel-Feil syndrome (KFS) is a rare condition associated with multiple congenital anomalies. It’s actual incidence is unknown. Nevertheless, it has been estimated that it occurs in approximately 1 in 40,000 to 42,000 newborns. Reported cases with pulmonary involvement includes agenesis and hypoplasia of the lung, pulmonary hypertension (PH) and bronchial asthma. To our knowledge, chronic obstructive pulmonary disease (COPD) with pulmonary hypertension in a patient with KFS has never been cited in the literature, hence we report the finding in a patient with such an association.

CASE PRESENTATION: A 54-year-old obese Filipino male diagnosed with congenital heart disease (patent foramen ovale) and hypertension was admitted at the Philippine Heart Center due to progressive dyspnea and non productive cough for twelve days. He was a previous 30-pack year smoker. Physical examination revealed a short statured-individual with low hairline, short and webbing of the neck. He has evident chest wall deformity associated with thoracolumbar scoliosis. He was in cardio-respiratory distress. Auscultation of the chest showed bibasal crackles and expiratory wheezes. Arterial blood gas analysis showed an acute respiratory acidosis with adequate oxygenation, hence he required assisted mechanical ventilatory support. Chest radiograph showed mild pulmonary congestion with pneumonic infiltrates and magnified heart. Electrocardiogram showed nonspecific ST-T wave changes with right axis deviation. Troponin I was elevated. He was then started with acute coronary syndrome regimen, antibiotics and inhaled short-acting bronchodilator. Echocardiography showed dilated right ventricle with hypertrophy and dilated main pulmonary artery with mild PH (48 mmHg). In lieu with the acute renal failure, he was referred to a nephrologist. A request of kidney ultrasound showed absent right kidney. In line with the clinical features KFS a radiography of the spine showed fusion of C1 and basal output and multiple fusion of C2, C3 and C4 cervical vertebrae, hence confirming the diagnosis. Pulmonary function test showed very severe obstructive ventilatory defect with no significant response to bronchodilator, hence a diagnosis of severe COPD was made. He was successfully liberated from ventilatory support and discharged after 3 weeks of hospitalization with treatment of inhaled long-acting bronchodilator plus steroid.

DISCUSSION: Klippel-Feil syndrome is a rare skeletal disorder primarily characterized by abnormal union of two or more cervical vertebrae. The triad of low hairline, short neck and limited neck movement which are present in the case remains to be the hallmark of the disorder. Moreover, involvement of visceral anomalies such as patent foramen ovale and right kidney agenesis merely defined the diagnosis. The association with COPD and PH is yet to be highlighted since no reports are available in the literature. Nevertheless, with the patient’s history of chronic smoking provides a strong risk factor for the development of severe airflow obstruction. The presence of patent foramen ovale is rare in this case and poses no effect in the development of PH. The combined effects of hypoxic pulmonary vasoconstriction, inflammation and loss of pulmonary capillaries due to severe COPD could be the main insult. Furthermore, Suga et al explained the contributory effect of thoracic deformity in PH. This is due to hypoventilation and restriction of the pulmonary vascular bed causing reactive pulmonary arterial vasoconstriction. Treatment of patients with KFS is directed on associated anomalies or co-morbidities. In this case, management of acute respiratory failure due to complicating comorbidities was made.

CONCLUSIONS: Klippel-Feil syndrome is a clinically well recognized disorder and commonly associated with many congenital malformations. Although rare, COPD and PH may occur with this syndrome. Clinicians should be directed towards detecting associated anomalies or co-morbidities for appropriate management.

Reference #1: Klippel M, Feil A ."Un cas d'absence des vertebres cervicales. Avec cage thoracique remontant jusqu'a la base du crane (cage thoracique cervicale)". Nouv Iconog Salpetriere 1912. 25: 223-250.

Reference #2: Tracy M, Dormans JP,. Klippel-Feil syndrome: clinical features and current understanding of etiology. Clin Orthop Relat Res 2004; (424): 183-90

Reference #3: Suga K, Motoyama K, Hara A, Kume N et al. Respiratory failure and pulmonary hypertension associated with KFS. Annals of nuclear medicine 1999. 13(6): 441-446.

DISCLOSURE: The following authors have nothing to disclose: Edgardo Tiglao, Teresita DeGuia, Maria Paz Mateo

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Chest. 2015;148(4_MeetingAbstracts):2A. doi:10.1378/chest.2279329

SESSION TITLE: Airways Global Case Reports I

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Mechanical insufflation-exsufflation (MI-E) is primarily used in patients with neuromuscular disease with reduced sputum expectoration strength. Although patients with bronchiectasis and those after airway stenting retain strength for sputum expectoration, the presence of abundant and viscous sputum and reduced ciliary motility of the airway epithelium make sputum expectoration difficult. The efficacy of MI-E for these diseases is yet to be ascertained.

CASE PRESENTATION: Case 1: An 83-year-old woman presented with advanced bronchiectasis and showed colonization of mucoid-type Pseudomonas aeruginosa. Her hospitalization frequency had increased owing to increased sputum and respiratory discomfort, and long-term antibiotic administration had resulted in drug-resistant Pseudomonas aeruginosa infection. We introduced MI-E (CoughAsist E70® Philips Respironics, Japan) with the aim of improving the symptoms through sputum expectoration. The MI-E pressure was +20/-35 cm H2O; oscillations (10 Hz, ±5 cm H2O) were simultaneously used during exhalation. The peak cough flow (PCF) was 190 L/min. A large amount of sputum was easily expectorated, and she showed improved percutaneous arterial O2 saturation after MI-E. Her fever pattern also gradually improved along with a decrease in the sputum volume. On day 19, her neutrophil count normalized, and the C-reactive protein also decreased to pre-hospitalization levels. The required oxygen level also decreased to 3L from 5L before hospitalization, and her P/F ratio improved from 170 to 320. The patient was discharged at day 22 after MI-E introduction and continued undergoing MI-E at home. Case 2: A 58-year-old man with airway narrowing due to advanced lung cancer was hospitalized after severe dyspnea progression. Subsequently, a Y-type silicon stent was placed in the tracheal bifurcation. The day after stenting, his dyspnea improved significantly; however, his sputum production increased and he experienced expectoration difficulties. Hence, MI-E was introduced. The MI-E pressure was +30/-40 cm H2O; oscillations (10 Hz, ±5cm H2O) were used simultaneously during exhalation. The PCF was about 170 L/min. Sputum was easily expectorated and his dyspnea improved. Once the patient was accustomed to the technique, he began operating the MI-E himself and was able to expectorate his sputum with appropriate timing.

DISCUSSION: The MI-E was shown to be effective in patients with decreased sputum expectoration strength, such as those with neuromuscular disease. However, both patients in our report were able to effectively expectorate sputum at a lower PCF than is recommended in cases with neuromuscular diseases, probably because the CoughAsist E70® device we used had an oscillatory function and improvement in maintenance of a constant airway pressure may have enabled sputum elimination from a more peripheral airway region. In Case 1, the efficacy of home usage was brief, but the patient was elderly and may have therefore found it difficult to comprehend the usage of the MI-E leading to poor implementation.

CONCLUSIONS: This is the first study to report the effectiveness of MI-E in patients with bronchiectasis and airway stenting. MI-E was useful for the removal of large amounts of viscous sputum in patients with bronchiectasis and in those after airway stenting. The results of this study suggest that sputum elimination may lead to improvement in clinical symptoms. Future studies are warranted to conduct prospective investigation on the usefulness of MI-E in patients with various chronic respiratory diseases.

Reference #1: Vianello A, Corrado A, Arcaro G,et al. Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections.Am J Phys Med Rehabil. 2005 ;84 :83-88

Reference #2: Winck JC, Gonçalves MR, Lourenço C,et al. Effects of mechanical insufflation-exsufflation on respiratory parameters for patients with chronic airway secretion encumbrance. Chest. 2004 ;126 :774-780.

Reference #3: Chatwin M, Ross E, Hart N,et al.Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness.Eur Respir J. 2003 ;21 :502-508.

DISCLOSURE: The following authors have nothing to disclose: Hibiki Kanda, Shuichi Yano, Shinichi Iwamoto, Emiko Nishikawa, Toru Kadowaki, Kanako Kobayashi, Masahiro Kimura, Toshikazu Ikeda

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Chest. 2015;148(4_MeetingAbstracts):3A. doi:10.1378/chest.2278232

SESSION TITLE: Airways Global Case Reports I

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Ectopic parathyroid glands can be seen from the front of the bifurcation of carotis to pericardium (1). In this case report an ectopic parathyroid adenoma (EPA) obstructing the tracheal lumen, locating in the distal part of the trachea is presented. It has never been reported in the literature before.

CASE PRESENTATION: 52 year old female patient who was being followed epicentral for 5 years with asthma diagnosis was hospitalized after directing to our center with pre-diagnosis of tracheal mass. Patient’s epicentral thorax CT showed a polypoid lesion with sizes of 22x19 mm in the trachea with a posterior soft tissue extension. In rigid bronchoscopy, a pink mass, which has hipervascular nodular formation on its surface and was obliterating 95 % of distal tracheal lumen was found. The mass was coagulated with argon plasma coagulation (APC) and Nd-YAG laser. Biopsy report idetified the lesion as a EPA which was located abnormally. After this report of EPA, on parathyroid scintigraphy performed with Tecnesium 99m metoksiisobutilisonitril (Tc99-m MIBI); on the early images at 15 minutes a focal increased uptake of 99mTc-MIBI was observed at the right posterolateral wall of trachea . With right posterolateral thoracotomy, right hemithorax was explored. Tumor in size of 2 cm was found in the distal part of trachea, extending from membranous surface to posterior mediastinum. Histopathological examination showed that the mass has pathological parathyroid tissue.The mass was accepted to be adenomatous ectopic parathyroid tissue

DISCUSSION: Besides the rare appearance; EPA are usually seen related with structures embryological developing from third and fourth pharyngeal pouche in different localizations. In our case ectopic parathyroid adenoma was located posterolaterally of trachea passing through intratracheal area and made an almost complete constriction. Benign endobronchial tumors are characterized by a slow growth rate and generally present with dry cough and wheezing. Intermittent, low-grade respiratory symptoms can often be misdiagnosed as asthma. Our patient was being followed with asthma diagnosis for years. The localization and screening works for PA generally used for misdiagnose, unnoticed PA, not being able to find the adenoma in the first surgery because of lack of surgical experience. For this reason ultrasound; Tc99-m MIBI scintigraphy; SPECT and MRI are the most common used metods among the noninvasive tests (2). In our case with a prediagnosis of tracheal mass. After pathological ectopic parathyroid adenoma diagnosis 99mTc-MIBI scintigraphy and SPECT/CT were performed. MIBI uptake was seen at the right posterolateral distal part of the trachea. Endobronchial bronchoscopic resection can be diagnostic as well as curative because of the benign nature of the tumor. Neodymium: yttrium- aliminyumgarnet (Nd:- YAG) lazer fotoresection, chriotherapy, electrocautery and argon plasma coagulation (APC) are used to provide the airway openness (3) . In our case; because of the almost complete obstructing tracheal mass, we used primarily Nd:- YAG lazer and APC afterwards to clean the tumor in order to provide airway openness. The surgical technique decision is related to ademoma’s localization. In our case thoracotomy was performed in order to excise the remaining residual tissue after rigid bronchoscopic parathyroid adenoma resection. With right posterolateral thoracotomy, right hemithorax was explored.

CONCLUSIONS: In conclusion, PA may be seen endotracheally as the ectopic location. Clinicians should be aware of this rare entity, that can clinically mimic other common pulmonary pathology like bronchial asthma

Reference #1: 1. Okuda I, Nakajima Y, Miura D, Maruno H, Kohno T, Hirata K. Diagnostic localization of ectopic parathyroid lesions: develop- mental consideration. Jpn J Radiology 2010;28(10):707-13.

Reference #2: 2. Hindié E, Ugur O, Fuster D, O'Doherty M, Grassetto G, Ureña P, Kettle A, Gulec SA, Pons F, Rubello D; Parathyroid Task Group of the EANM. 2009 EANM parathyroid guidelines. Eur J Nucl Med Mol Imaging. 2009 Jul;36(7):1201-16.

Reference #3: 3. Wahidi MM, Herth FJF, Ernst A. State of the art. Interventional pulmonology. Chest 2007; 131: 261-74.

DISCLOSURE: The following authors have nothing to disclose: Ekrem Seyhan

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Chest. 2015;148(4_MeetingAbstracts):4A. doi:10.1378/chest.2280468

SESSION TITLE: Allergy and Airway Poster Discussions

SESSION TYPE: Original Investigation Poster Discussion

PRESENTED ON: Wednesday, October 28, 2015 at 08:45 AM - 10:00 AM

PURPOSE: To evaluate clinical characteristics, comorbidity and health-related quality of life (QoL) in patients with persistent asthma receiving medium- to high-dose inhaled corticosteroids (ICS) plus a long-acting beta-agonist (LABA).

METHODS: Baseline clinical and patient-reported parameters in a phase 2 dupilumab clinical trial (NCT01854047) were analyzed and included: FEV1, exacerbation history, Asthma Control Questionnaire 5-item version (ACQ-5), Asthma Quality of Life Questionnaire (AQLQ), Sino-Nasal Outcomes Test (SNOT-22), Hospital Anxiety and Depression Scale (HADS), EuroQol 5-dimensions (EQ-5D).

RESULTS: 63% of patients were female and 78% Caucasian; mean age was 49±13.0 years. Patients (N=776) had asthma for 22±15.4 years. FEV1 was 1.8±0.5 L, FEV1%predicted 61±10.7, median ICS dose 1000/640/800mcg for fluticasone+salmeterol/budesonide+formoterol/mometasone+formoterol. Patients had 2.2±2.14 asthma-related exacerbations in the past year; 25% of patients had ≥3 exacerbations. 74% of patients had concomitant atopic conditions. Mean ACQ-5 was 2.74±0.81; over 50% of patients reported ‘moderate’ to ‘maximum’ impairment on 4 out of 5 ACQ-5 items. 63% of patients reported at least ‘moderate’ symptoms upon waking, 70% reported at least ‘moderate’ shortness of breath, and 61% experienced wheezing at least a ‘moderate amount of the time’. 53% of patients reported ‘moderate’ to ‘total’ activity limitation due to asthma on the ACQ-5; likewise, 39% and 43% of patients reported they had ‘moderate problems/unable’ to walk or do usual activities, respectively, on the EQ-5D. Overall AQLQ score was 4.0±1.1, indicating a moderate impact of asthma on QoL. Patients with sino-nasal conditions also reported a moderate effect of these conditions on QoL (SNOT-22: 37.4±18.8). One quarter (25%) of patients scored ≥11 on the HADS, the cutoff for anxiety/depression; over one third (35%) scored ≥8, indicating possible anxiety/depression. Similarly, 31% of patients reported ‘moderate to extreme’ anxiety/depression on the EQ-5D.

CONCLUSIONS: Despite receiving ICS+LABA, patients entering the study had recurrent exacerbations, as well as moderate to severe asthma-related symptoms and daily activity limitations. Concomitant atopic diseases were common and about one third of patients had symptoms of anxiety/depression.

CLINICAL IMPLICATIONS: New treatment options may be warranted for some patients with persistent asthma despite ICS+LABA therapy. Patients may also present with comorbidities requiring medical attention.

DISCLOSURE: Jonathan Corren: Other: Received funding from Sanofi for dupilumab clinical trial Mario Castro: Other: Washington University received funding from Sanofi for participation in dupilumab clinical trial Vijay Joish: Employee: Regeneron Pharmaceuticals, Inc. ‐ employee and shareholder Vera Mastey: Employee: Regeneron Pharmaceuticals, Inc. ‐ employee and shareholder Caroline Amand: Employee: Sanofi employee, may hold stock and/or stock options in the company Christine Taniou: Employee: Sanofi employee, may hold stock and/or stock options in the company Robert Evans: Employee: Regeneron Pharmaceuticals, Inc. ‐ employee and shareholder Mariana Louis Tisserand: Employee: Sanofi employee, may hold stock and/or stock options in the company Ariel Teper: Employee: Sanofi employee, may hold stock and/or stock options in the company Laurent Eckert: Employee: Sanofi employee, may hold stock and/or stock options in the company

Dupilumab is in clinical development and has no marketing authorization yet.

Chest. 2015;148(4_MeetingAbstracts):5A. doi:10.1378/chest.2264349

SESSION TITLE: Allergy and Airway Poster Discussions

SESSION TYPE: Original Investigation Poster Discussion

PRESENTED ON: Wednesday, October 28, 2015 at 08:45 AM - 10:00 AM

PURPOSE: Severe asthma is a heterogenous disease. Current management of severe asthma is moving towards targeted treatment addressing the mechanism of disease including inflammation. This study aims to examine the sputum inflammatory phenotype of severe asthmatics who are exacerbation-prone.

METHODS: Cross sectional study of patients with severe treatment- resistant asthma (on a combination of high-dose inhaled corticosteroids and long-acting beta agonists) and frequent exacerbations (≥2 exacerbations requiring systemic corticosteroids in the past year) was performed. Sputum induction was performed using a validated protocol. Demographic data, sputum inflammatory cell counts, spirometry, methacholine challenge test results and blood eosinophil levels were obtained. Sputum cell counts were read by an investigator blinded to clinical phenotype of the patient. The cell counts were classified into 4 groups: eosinophilic (>3%), neutrophilic (>76%), paucigranulocytic (normal levels of both eosinophils and neutrophils) and mixed (more than 1 predominant cell type present).

RESULTS: 8 Patients were recruited. 3 patients could not expectorate any sputum despite induction. The results of 5 successful patients (3 males, 2 females) are presented. Mean age was 48 ±11.2 years and median number of controllers used was 2 (IQR: 2-4). They had an average of 4 ± 1.5 exacerbations in the past year and the mean post-bronchodilator FEV1 was 2.50 ± 0.65L (85.8±9.9% predicted). The median blood eosinophil count was 0.44 x 109/L (IQR: 0.37-0.67 x 109/L). 3 patients had a predominantly eosinophilic inflammatory phenotype, whilst 2 had a paucigranulocytic inflammatory phenotype. The median eosinophil count from induced sputum was 6.00% (IQR: 0.8- 15.7%) and median neutrophil count was 12.2% (IQR: 4.8-12.7%).

CONCLUSIONS: Preliminary results seem to suggest more eosinophilic inflammation in the sputum of frequent exacerbating severe treatment-resistant asthmatics. None of the patients examined had neutrophilic inflammation in their sputum.

CLINICAL IMPLICATIONS: Treatment targeting eosinophils and the Th2 pathway may be the key to reducing exacerbations amongst some of these patients with frequent exacerbations. Lack of sputum production and paucigranulocytic picture suggest airway inflammation may not be the main mechanism driving exacerbations in the other group of frequent exacerbators. Further studies are underway.

DISCLOSURE: The following authors have nothing to disclose: Shera Tan, Carrie Leong, Angela Takano, Therese Lapperre, Keng Leong Tan, Philine Chan, Kah Ling Lim, Mariko Koh

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Topics: phenotype , asthma , sputum
Chest. 2015;148(4_MeetingAbstracts):6A. doi:10.1378/chest.2263849

SESSION TITLE: Allergy and Airway Poster Discussions

SESSION TYPE: Original Investigation Poster Discussion

PRESENTED ON: Wednesday, October 28, 2015 at 08:45 AM - 10:00 AM

PURPOSE: The assessment of airway inflammation by sputum induction is an essential tool in the evaluation of severe asthmatic patients. Treatment guidance using eosinophil and neutrophil differential cell counts is now well established, but the significance and the interpretation of high macrophages in induced sputum (IS) is still poorly understood. The aim of this study was to assess the clinical and sputum characteristics of a series of asthma patients with inadequate control among whom IS macrophage differential counts were elevated and to compare subgroups based on their inflammometry phenotype.

METHODS: Between January 2010 and Mars 2015, we retrospectively selected all asthma patients treated at our institution with ≥ 70% macrophages in there IS differential cell counts. Subgroups of specimens with and without eosinophilic phenotype (≥ 3% eosinophils) in our population were also compared.

RESULTS: A total of 28 IS specimens (24 asthma patients) were eligible for this study. Sputum showed a mean total cell count of 3.99 ± 3.65 ×106 cells/g, a mean macrophage differential of 78% ± 7%, a mean sputum weight of 0.120 ± 0.044 g, and a mean viability of 46% ± 14%. Our population mean age was 48 years (age range, 22 to 78 years) and 92% were female. The patient characteristics were as follow: 13% and 25% were smokers and ex-smokers respectively; 50% were atopic; the mean FEV1 was 2.57 L (94% predicted); and 89% were treated with a moderate to high dose of inhaled corticosteroids on the day of their IS test. A total of 12 specimens (11 patients) had a high-eosinophils/high-macrophages phenotype (mean eosinophil differential of 8.7% ± 6.8%) and 16 specimens (16 patients) had a low-eosinophils/high-macrophages phenotype (mean eosinophil differential of 0.7% ± 0.6%). Total mean neutrophil differential was 10.3% ± 7.2%. Patients from the low-eosinophils/high-macrophages subgroup were more obstructed compared to the high-eosinophils/high-macrophages subgroup (predicted FEV1 88% vs 102% and FEV1/FVC ratio 71 vs 77 respectively).

CONCLUSIONS: In our population, patients with low-eosinophils/high-macrophages IS differential had a tendency to a more obstructive spirometry (p 0.06) compared to patients with high eosinophils/high macrophages.

CLINICAL IMPLICATIONS: Macrophages seem to play an important role in airways inflammation. Further studies targeting a high macrophages phenotype are certainly needed.

DISCLOSURE: The following authors have nothing to disclose: Philippe Lachapelle, Pascale Rioux, Lyne Despars, Pierre Ernst

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Chest. 2015;148(4_MeetingAbstracts):7A. doi:10.1378/chest.2228495

SESSION TITLE: Allergy and Airway Poster Discussions

SESSION TYPE: Original Investigation Poster Discussion

PRESENTED ON: Wednesday, October 28, 2015 at 08:45 AM - 10:00 AM

PURPOSE: The aim of this study were to assess how much the diagnostic yield is increased in HIV-uninfected patients by implementation of the liquid culture system, to evaluate whether supplemental solid media is necessary to maximize the sensitivity of effusion culture, and to determine the predictors of culture-positive effusion.

METHODS: We retrospectively compared the culture yield, time to positivity, and contamination rate of pleural effusion samples in the BACTEC Mycobacteria Growth Indicator Tube 960 (MGIT) and Ogawa media among patients with tuberculous pleurisy.

RESULTS: Out of 104 effusion samples, 43 (41.3%) were culture positive on either the MGIT or the Ogawa media. The culture yield of MGIT was higher (40.4%, 42/104) than of that of Ogawa media (18.3%, 19/104) (P < 0.001). One of the samples was positive only on the Ogawa medium. The median time to positivity was faster in the MGIT (18 days, range 8-32 days) than in the Ogawa media (37 days, range 20-59 days) (P < 0.001). No contamination or growth of nontuberculous mycobacterium was observed on either of the culture media. The combination of the effusion and sputum cultures contributed to a good diagnostic yield of 66.3% (69/104). The percentage of polymorphonuclear cell in effusion was independent predictors of the culture-positive effusion (aOR 1.026; 95% CI 1.006-1.046).

CONCLUSIONS: The automated liquid culture system could provide approximately twice as high yields and fast results in effusion culture, compared to solid media. Supplemental solid media may have a limited impact on maximizing sensitivity in effusion culture; however, further studies are required.

CLINICAL IMPLICATIONS: With the implementation of a liquid culture method, the sensitivity of effusion culture was much higher than has been previously reported. If TB pleurisy is suspected, the collection of sputum and pleural fluid samples for mycobacterial liquid culture should be encouraged.

DISCLOSURE: The following authors have nothing to disclose: Doosoo Jeon, Seong Hoon Yoon, Hye Ju Yeo, Seung Hyun Lee, Seung Eun Lee, Woo Hyun Cho, Yun Seong Kim

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Chest. 2015;148(4_MeetingAbstracts):8A. doi:10.1378/chest.2281168

SESSION TITLE: Allergy and Airway Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: The objective was to provide a summary of the real-world clinical and health economic outcomes associated with omalizumab in the treatment of moderate to severe allergic asthma.

METHODS: A systematic literature review was conducted to identify studies of omalizumab in patients ≥12 years with moderate to severe allergic asthma. A search of MEDLINE and EMBASE reference databases was conducted for relevant studies published from 2003 to 2014. Outcomes of interest included rescue medication use and pulmonary function assessments (FEV1, FVC, and PEF). Patient-reported outcomes (PROs) were also reviewed for included studies. Study quality was assessed by 2 reviewers using the Newcastle-Ottawa Quality Assessment Scale of Cohort Studies and the International Society of Pharmacoeconomics and Outcomes Research checklist.

RESULTS: A total of 42 studies were included; 20 studies evaluated pulmonary function and 9 evaluated rescue beta-agonist use. Statistically significant improvements in FEV1 were reported in 75% (15/20) of included studies. Improvements in FEV1 ranged from 3.2%-43.6%. Five studies reported changes in FVC or FEV1/FVC. Significant improvements in FVC were observed in 3 studies and in FEV1/FVC in 2 studies. Six studies analyzed PEF with 5 finding significant improvements. Seven studies reported significant reductions in rescue medication use. The percentage of patients with any rescue medication use ranged from 87.0%-97.7% at baseline to 12.5%-49.8% at follow-up. In studies examining change in use from baseline, change at follow-up ranged from 56.1%-78.8%. Among the included studies, 14 utilized patient-reported health-related quality of life (HRQoL) outcomes. The ACT (12 studies) and the AQLQ (4 studies) were the most commonly used surveys to assess asthma control and HRQoL, and improvements were consistently seen after omalizumab was added to therapy.

CONCLUSIONS: While patient populations and outcome definitions are heterogeneous, overall, patients with moderate to severe asthma using omalizumab had improvements in FEV1 and PEF and experienced a decrease in the need for rescue beta-agonist medications. Patient-reported asthma control and HRQoL appears to improve among patients utilizing omalizumab in clinical settings.

CLINICAL IMPLICATIONS: Asthma patients administered omalizumab during routine clinical use experience significant clinical benefits, including an improvement in pulmonary function and decrease in rescue medication usage.

DISCLOSURE: Jonathan Corren: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to Novartis Susan Gabriel: Employee: Novartis Employee Tom Karagiannis: Employee: Novartis employee Kimberly Ruiz: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to Novartis Bethany Sawchyn: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to Novartis Jennifer Colby: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to Novartis Meryl Mendelson: Employee: Novartis employee

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Chest. 2015;148(4_MeetingAbstracts):9A. doi:10.1378/chest.2281115

SESSION TITLE: Allergy and Airway Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: The objective was to provide a summary of the real-world clinical and health economic outcomes associated with omalizumab in the treatment of moderate to severe allergic asthma.

METHODS: A systematic literature review was conducted to identify studies of omalizumab in patients ≥12 years with moderate to severe allergic asthma. A search of MEDLINE and EMBASE reference databases was conducted for relevant studies published from 2003 to 2014. Prospective observational studies, retrospective studies, meta-analyses, and health economic studies were included. Outcomes of interest included the rate or number of severe or clinically significant exacerbations and the rate, number, or costs of emergency room (ER) visits and hospitalizations. Study quality was assessed by 2 reviewers using the Newcastle-Ottawa Quality Assessment Scale of Cohort Studies.

RESULTS: A total of 42 studies were included; 24 studies evaluated asthma exacerbations, 11 evaluated ER visits and costs, and 17 evaluated hospitalizations. Statistically significant reductions in exacerbations were reported in 83% (20/24) of included studies; 18 studies utilized a pre/post design and 2 studies compared omalizumab treatment to standard of care. Significant decreases in the number of ER visits were reported in 82% of studies (9/11) across a variety of patient populations in numerous countries over 12-months. A significant reduction in hospitalizations was reported in 65% of included studies (11/17). The 2 studies that reported hospitalization costs observed a reduction in cost. Over 12 months, mean monthly hospitalization costs decreased from €133.85 to €0 (P<0.01), and the cost per inpatient day was reduced from €14,668 to €4,683 in a 6-month period. Overall, a reduction in clinically significant exacerbations, hospitalizations, including number of visits and percent of patients, and ER utilization occurred in patients utilizing omalizumab add-on therapy.

CONCLUSIONS: While patient populations and outcome definitions in these studies are heterogeneous, results from this systematic literature review suggest that patients with moderate to severe asthma using omalizumab experienced a decrease in the rate of severe exacerbations, ER visits, and hospitalizations.

CLINICAL IMPLICATIONS: Asthma patients administered omalizumab during routine clinical use experience substantial clinical and economic benefits, including a decrease in exacerbation rate, and reductions in ER and hospital utilization.

DISCLOSURE: Jonathan Corren: Consultant fee, speaker bureau, advisory committee, etc.: Novartis consultant Susan Gabriel: Employee: Employee of Novartis Tom Karagiannis: Employee: Novartis employee Kimberly Ruiz: Consultant fee, speaker bureau, advisory committee, etc.: consultant to Novartis Bethany Sawchyn: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to Novartis Jennifer Colby: Consultant fee, speaker bureau, advisory committee, etc.: Consultant to Novartis Meryl Mendelson: Employee: Novartis employee

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Topics: omalizumab
Chest. 2015;148(4_MeetingAbstracts):10A. doi:10.1378/chest.2277279

SESSION TITLE: Allergy and Airway Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: To describe the frequency of recurrent asthma-related and all-cause ED/hospitalization events following an index asthma-related ED/hospitalization event.

METHODS: This was a retrospective cohort study of asthma patients identified in a commercial claims database during 2010-2011. Eligible patients were required to have an asthma medical code (index date), an asthma medication within ± 3 months of the index date, and be aged ≥12 years. The 12-month period preceding the index date was examined to determine GINA treatment step and exacerbation history. The occurrence and reoccurrence of asthma-related and all-cause ED/hospitalizations was ascertained during the 12-month follow-up period. The reoccurrence of an asthma-related and all-cause ED/hospitalization event was examined during the 30-, 60-, and 90-day period following the first asthma-related ED/hospitalization (index event).

RESULTS: A total of 222,817 patients with asthma were identified; however, this analysis was limited to the 5,167 (2.3%) patients who experienced ≥1 asthma-related ED visit or hospitalization during the follow-up period. The mean (SD) age for this subset was 34.1 yrs (15.5) and 66.7% were female. Among the 5,167 patients, 9.2%, 12.5% and 15.5% experienced a reoccurrence of an asthma-related ED/hospitalization event during the 30-, 60-, and 90-days following the index event, respectively. Reoccurrence of an all-cause ED visit or hospitalization following an index event was seen in 22.6%, 37.0%, and 50.0% of subjects during the 30-, 60-, and 90-days following the index event, respectively. Although reoccurrence of asthma-related and all-cause ED/hospitalizations within 30-days of an index event during the study period increased with GINA step and history of exacerbation, it was highest among patients classified as GINA step 5 (14.9%) or with ≥2 exacerbations in the prior year (17.9%).

CONCLUSIONS: Nearly 10% of patients admitted to the ED or hospital for asthma experienced a second asthma-related ED/hospital admission during the subsequent 30-days. The risk for reoccurrence increased with greater GINA steps and a history of ≥2 exacerbations.

CLINICAL IMPLICATIONS: Proper medication and asthma management should be ensured for asthma patients admitted to the ED or hospital for asthma, particularly severe asthmatics given their increased risk of a recurrent ED/hospitalization event. (Funded by GSK; Study WEUSKOP7048)

DISCLOSURE: Robert Suruki: Employee: GlaxoSmithKline, Shareholder: GlaxoSmithKline Jonas Daugherty: Employee: GlaxoSmithKline, Shareholder: GlaxoSmithKline Nittaya Suppapanya: Employee: GlaxoSmithKline, Shareholder: GlaxoSmithKline Frank Albers: Employee: GlaxoSmithKline, Shareholder: GlaxoSmithKline

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Chest. 2015;148(4_MeetingAbstracts):11A. doi:10.1378/chest.2276345

SESSION TITLE: Allergy and Airway Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: In our previous study, we have learned that factors related with acute exacerbations in elderly asthmatics were complex, for example, poor adherence and inhaler technique, depression, and magnesium deficiency. In this prospective study, we aimed to evaluate the role of a multifaceted approach in reducing acute exacerbations in elderly asthmatics.

METHODS: A total of 100 subjects were randomly selected from our prospective cohort of elderly asthmatics aged 65 years or older. Our multifaceted approach included; repeated education on asthma and inhaler technique, provision of an action plan to cope with acute exacerbations, short message service to prevent follow-up losses, and oral replacement of magnesium. The primary outcome was an acute asthma exacerbation which comprised at least one of the followings; use of systemic corticosteroids for at least 3 days, unscheduled visit of outpatient clinic, and hospitalization or emergency room visit. The intervention period was one year and acute asthma exacerbation rate was compared to that of one year prior to this study.

RESULTS: Ninety-two subjects completed this study, although only 58 subjects continued to take magnesium. Compared to one year prior to this study, the acute asthma exacerbation rate showed a significant reduction from 67% to 50% (McNemar’s test; P = 0001). Interestingly, a subgroup analysis revealed that predicted value of forced expiratory volume in one second (FEV1) increased significantly in subjects who continued to take magnesium from 79.9% to 87.1% (P = 0.008).

CONCLUSIONS: To reduce acute exacerbations in elderly asthmatics, a multidimensional approach to increase medical awareness, inhaler technique and adherence is essential. In addition, a continuous oral replacement of magnesium may increase FEV1 in elderly asthmatics.

CLINICAL IMPLICATIONS: As the world is aging, asthma in the elderly is getting more attention. This study provides a useful strategy in managing acute exacerbations in elderly asthmatics.

DISCLOSURE: The following authors have nothing to disclose: Suh-Young Lee, Heung-Woo Park, Woo-Jung Song, Sang-Heon Cho

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Chest. 2015;148(4_MeetingAbstracts):12A. doi:10.1378/chest.2272917

SESSION TITLE: Allergy and Airway Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Postoperative pulmonary complications (PPC) are common and important after noncardiothoracic surgery in the patients with chronic obstructive airway disease. Despite variable risk factors and preoperative management have been described for PPC, there are only a few studies that focused on asthma patients. The aim of the present study is to investigate the incidence and risk factors of PPC after noncardiothoracic surgery with adult asthma patients.

METHODS: The electronic medical records at the Pusan National University Yangsan Hospital (Jan. 2009 ~ Dec. 2012) were retrospectively reviewed to identify asthma patients who had evaluated preoperative risk associated with asthma by respiratory physician before noncardiothoracic surgery. Clinical characteristics, history of previous asthma management and the results of preoperative examination were analyzed for determine their association with the occurrence of PPC.

RESULTS: Total of one hundred and twenty-seven patients was included and thirty-seven (29.1%) experienced PPC. Twelve patients (32.4%) had pneumonia, 9 (24.3%) bronchospasm, 7 (18.9%) atelectasis, 6 (16.2%) prolonged mechanical ventilation and 3 (8.1%) acute respiratory insufficiency. Risk factors for PPC were age, presence of respiratory symptoms and low FEV1. No significant difference between patients with or without PPC was found for gender, O2 saturation, abnormal chest radiologic imaging and preoperative systemic steroid administration. The development of PPC was associated with prolonged hospital stay (p<0.05).

CONCLUSIONS: The incidence of PPC after noncardiothoracic surgery with adult asthma patients was 29.1% and the most common PPC was pneumonia. Risk factors were age, presence of respiratory symptoms and low FEV1.

CLINICAL IMPLICATIONS: There are no recent data for incidence of PPC with asthma patient. We are planning to make randomized controlled trial for risk factors of PPC with asthma patients.

DISCLOSURE: The following authors have nothing to disclose: Seung Eun Lee, Woo Hyun Cho, Seung Hyun Lee, Yun Seong Kim, Hye Ju Yeo

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Chest. 2015;148(4_MeetingAbstracts):13A. doi:10.1378/chest.2259338

SESSION TITLE: Allergy and Airway Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: The aim of this study was to review the results of the treatment of persistant inferior turbinate hyperthropy on lung functions. In this study, effects of RF reduction of IT on nose were evaluated with Acustic Rihinometry on lung functions with spiromety.

METHODS: The study was conducted on 19 patients with sympthoms, signs of nasal obstruction associated with IT hyperthrophy bilaterally for 6 months who failed to respond 3 months medical therapy of steroids. Patients with; Smoking habit, Allergic Rhinitis, COPD, Cardiac Disease, Malignancy, Coagulation Disorder were excluded. Additional excluding criteria included Systemic Corticoteroid, Teophyllin, Anticolinerjic, Antileukotrien, Nedokromil, Anticoagulan use. Subjective Sysmptoms including severity of nasal obstruction measured by a standard 10 cm Visual Analog Scale(VAS). A score of 0 repsetented no obstruction and a score of 10 indicated severe nasal obstruction. Data for each Nasal Cavity by Acoustic Rhinometry(AR) before and 6week after IT RF has been performed. Postop evaluations were made in postop Week6. Checked postop week on 1&6. PFTs including FVC, EV1, PEF, FEV1/FVC values were evaluated according to the ATS criteria, given in persentage. SD, Mean (Avg), Min. , Max. values, median values used.

RESULTS: Ages = 32,6±10,48 in the range of 20-59. Patients =♀5 F (%26,3) / ♂14 M (%73,7) Total 19. 38 L & R IT analysed after RF applied VAS values retrieved by t test. Postop 6 week VAS values compared with Preop values, Significant improvement (p<0,05) was obtained. Comparison of Values Obtained From Postop and Preop Mean Cross-section Area of 1&2 (MCA1, MCA2) and R, LVOLumes and (totVOL)evaluated. Postop LMCA1,RMCA1 and RMCA2 values were increasing significantly (p<0,05), LMCA2 did not. Statistically significant (p<0,05) increase observed in postop values of L/R, 1/2 and total volumes. Preop & Postop PFT comparison of FVC and FEV1 values showed statistically significant increase (p<0,05) as shown Table 3, unlikely FEV1/FVC & PERF increases were not significant (p>0,05)

CONCLUSIONS: Evaluation of RF trubinate ablation with AR measurements showed a significant increase in nasal flow and significant decrease in decongestion effects. Small scale changes in the tribunate provided improvement in the symptoms through increasing of airflow in the nasal valve and resulted in positive PFT changes.

CLINICAL IMPLICATIONS: As historical research results in literature in this area is not adequate so far, a series or additional experimental study required to justify these findings.

DISCLOSURE: The following authors have nothing to disclose: Mufide Ozkarafakili

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Chest. 2015;148(4_MeetingAbstracts):14A. doi:10.1378/chest.2259213

SESSION TITLE: Allergy and Airway Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Flunisolide HFA is a small-particle inhaled corticosteroid with a built-in spacer tested in clinical trials. A 12-week, randomized, multicenter, double-blind, placebo-controlled trial was conducted to evaluate the efficacy and safety of flunisolide HFA in adult and adolescent patients 12 years and older with mild-to-moderate asthma. In addition to the primary analysis (improvement in percent predicted FEV1 over the 12-week treatment period), secondary analysis determined the efficacy of flunisolide HFA at the earliest evaluation points during treatment.

METHODS: Patients with mild-to-moderate asthma using inhaled steroids and meeting all study entry criteria were randomized to treatment with flunisolide HFA 80 mcg (1 puff, n=75), flunisolide HFA 160 mcg (2 puffs, n=100), flunisolide HFA 320 mcg (4 puffs, n=113), or placebo (n=104) each BID for a 12-week double-blind study period. The primary efficacy assessment was change from baseline in percent predicted FEV1 after 12 weeks of treatment. Secondary analyses were performed at week 3 (based on change in percent predicted FEV1) and at weeks 1 and 2 (based on patient diary data) to determine the onset of efficacy.

RESULTS: In the primary analysis, patients treated with flunisolide dosages of 160 mcg and 320 mcg BID had statistically superior (P<.05) improvement in percent predicted FEV1 compared to patients treated with placebo over the 12-week treatment period. In the secondary analyses, flunisolide dosages of 160 and 320 mcg BID were statistically superior (P<.05) to placebo for all efficacy endpoints recorded daily in diaries (prn Albuterol use, PEFR, asthma symptoms, and nocturnal awakenings) at week 2 and in some endpoints at week 1. At week 3, the first post-baseline visit measuring FEV1 changes from baseline in percent predicted FEV1 in both these groups were statistically superior (P<.001) to placebo confirming the early onset of effect. This improvement remained statistically significant through week 12.

CONCLUSIONS: The results of this study demonstrated that flunisolide HFA dosages of 160 and 320 mcg BID, delivered with a built-in spacer, were effective and safe for treatment of patients with mild-to-moderate asthma and demonstrated significant improvement in asthma efficacy endpoints with flunisolide HFA 160 and 320 mcg BID within 2 weeks of start of treatment.

CLINICAL IMPLICATIONS: The flunisolide HFA fine-particle formulation provides effective therapy for patients with asthma, with an early onset of therapeutic effect and a favorable safety profile.

DISCLOSURE: Michael Marcus: Consultant fee, speaker bureau, advisory committee, etc.: Received payment for consulting services from Meda Pharmaceuticals John Karafilidis: Employee: employee meda pharmaceuticals

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Biotechnology

Chest. 2015;148(4_MeetingAbstracts):18A. doi:10.1378/chest.2275382

SESSION TITLE: 21st Century Technology

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 28, 2015 at 08:45 AM - 10:00 AM

PURPOSE: Patients are routinely given written instructions to prepare for surgery. At discharge from hospital further written instructions are given to patients. Less than 40% of patients read those instructions and less than 20% can articulate important information contained within the instructions. We created electronic reminders and web-based modules to improve patient compliance to pre-operative instructions. We wanted to reduce the number of post-operative ER visits and complications by detecting concerns early.

METHODS: All patients received the standard written instructions. A total of 54 patients undergoing thoracic surgery received automated, prescheduled messages via text message (SMS) 2 weeks leading up to surgery. The messages contained reminders for important preoperative instructions and each message was delivered on a specific day before the surgery date. Post-operatively patients were asked to keep a digital log of symptoms. Based on their entries, suggestions would be delivered to their mobile devices that instructions to deal with their symptoms. We tracked pre-operative and post-operative failures defined as deviations from the expected clinical course. The number of failures were compared to a historical control group of 50 patients.

RESULTS: Prior to implementing the digital reminders and log, our team had 6 pre-operative failures (3 patients failed to stop anticoagulation, 2 failed to bring information to pre-operative visit and 1 patient was a "no show") and 4 post-operative failures (2 wound infections that did not seek attention, 1 pneumonia found at first post-operative visit, 2 "unnecessary" ER visits). After implementation of the mobile application, there we 0 pre-operative failures and 0 post-operative failures. Patient satisfaction surveys indicate 100% of users were happy with the product.

CONCLUSIONS: The use of pre-operative SMS reminders as well as having patients log post-operative progress and symptoms significantly reduces the risk of cancellations for procedures and decreases post-operative ER visits. The mobile application significantly improves patient satisfaction by empowering patients with more information about their progress and giving them better access to their surgeon using web-based videos.

CLINICAL IMPLICATIONS: Our mobile application will improve communication with patients, increase patient satisfaction, decrease ER visits and improve patient outcomes following thoracic surgery.

DISCLOSURE: The following authors have nothing to disclose: Carmine Simone, Robert Zeldin, Najib Safieddine, Joshua Liu, Philip Chen

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Chest. 2015;148(4_MeetingAbstracts):19A. doi:10.1378/chest.2271179

SESSION TITLE: 21st Century Technology

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 28, 2015 at 08:45 AM - 10:00 AM

PURPOSE: Self-management is a key component of evidence-based care for patients living with COPD. Mobile-based applications with patient-specific information may support COPD patients in learning self-management skills, including adherence to inhaled medications, proper inhaler device technique, and early identification and response to acute exacerbations. There is currently no application with these features available to COPD patients in Canada.

METHODS: University Health Network’s Centre for Global eHealth Innovation and clinical leads from the University Health Network’s Asthma and Airway Centre worked collaboratively to create an Android application (app) to support self-management in patients with COPD. User-centered design principles were utilized throughout the development process. A technical Working Group (WG) and a clinical WG were engaged to provide input into desired content, features and usability. Patients with COPD were interviewed to gather user requirements and iterative usability testing was performed with patients and clinicians separately.

RESULTS: An app accessible on a smartphone using Android operating system was developed. Features of the app include a tailored list of COPD medications, reminders to aid in adherence to a medication schedule, and links to inhaler technique videos. The app also incorporates daily symptom tracking as a tool for early identification of acute exacerbations of COPD, and prompts users to initiate a customized action plan when an acute exacerbation is identified. Patient-specific data is entered into the app by the clinical team and longitudinal data visualization, including exacerbation history and acute care visits, is available to both patients and clinicians. Usability studies conducted throughout the development of the app validated and strengthened the design, ensuring the development of a usable, useful, and engaging application.

CONCLUSIONS: Mobile information technology has not been widely used to support self-management in COPD patients. This novel app has been designed to help patients with COPD self-manage their condition, and capitalize on “teachable moments” to improve early recognition and response to acute exacerbations.

CLINICAL IMPLICATIONS: Mobile information technology provides an innovative approach to supporting selected patients with COPD. This app could be integrated into clinical work flows to support and enhance existing clinical care. A six-month pilot project of the app is to be completed in 2015.

DISCLOSURE: The following authors have nothing to disclose: Yeung Melanie, Joseph Cafazzo, Emily Seto, Kenneth Chapman, Deborah Casey

The application for COPD self-management that has been developed is still being evaluated for feasibility and impact. The application is currently being piloted in a clinical setting, with plans for larger implementation and evaluation next year. At present, the app is only available through participation in the pilot and is not available to the general public for download or use.

Chest. 2015;148(4_MeetingAbstracts):20A. doi:10.1378/chest.2265508

SESSION TITLE: 21st Century Technology

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 28, 2015 at 08:45 AM - 10:00 AM

PURPOSE: Exercise capacity can be used to determine functional status, prognosis, and for adjustment of therapeutics in heart failure (HF) patients. There are a variety of methods to assess exercise capacity, including six-minute walk (6MW) test, peak VO2, and submaximal exercise measurements. We sought to understand the relationships between exercise modalities and in particular understand the value of patient home collected pedometer step measurement in heart failure patients.

METHODS: To investigate the feasibility of pedometer measured activity and to correlate with known prognostic variables, we enrolled 23 patients with Stage C HF. The patients (15 men, 8 women) aged 37-85 (69 mean) years, NYHA Functional Class 1-3 (2.1) wore a pedometer for 3 days to record home activity; the 3 day results were averaged. Then a 6MW test with simultaneous measurement of oxygen consumption variables was performed.

RESULTS: The mean 6MW distance was 988.9ft, while the mean daily pedometer steps were 2226. The mean peak VO2 was 9.26 ml/kg/min. The data confirms a relationship between functional class and pedometer steps (R=0.62, p=0.002), pedometer steps and 6MW (R=0.68, p=0.0005) and peak VO2 and 6MW distance (multiple R=0.73, p=0.0001). While both relationships between home measured pedometer steps and peak VO2 and VE/VCO2 were suggestive (both R=0.43, p=0.04 the reationships were not as statistically significant..

CONCLUSIONS: We suggest that home measured pedometer steps correlate with other key meausrements of functional status (NYHA FC and 6MW distances) in heart failure patients, and may serve as suitable surrogate markers of potent exercise prognostic indices. However, they may not replace oxygen consumption variables. The pedometer may be further used to motivate HF patients to increase activity and be used as early home predictors of subtle changes in clinical status.

CLINICAL IMPLICATIONS: Average daily steps as measured by a home pedometer provides important surrogate exercise information for heart failure patients. Step measurement correlates well with functional class, 6 minute walk distance but not as well with peak VO2 or VE/VCO2. With increased availability of individual personal health data collection, step measurement might be used as an early warning of sublte changes in clinical status and to better guide heart failure therapies and decisions.

DISCLOSURE: The following authors have nothing to disclose: Marc Silver

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Chest. 2015;148(4_MeetingAbstracts):21A. doi:10.1378/chest.2265321

SESSION TITLE: 21st Century Technology

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 28, 2015 at 08:45 AM - 10:00 AM

PURPOSE: A variety of groups have taken to social media to educate, to market, and to promote causes. The social media platform Twitter has been used as a forum for online discussion at nonmedical and medical conferences. Our goal is to examine trends in social media use by different groups at pulmonary and critical care conferences.

METHODS: We used Symplur metrics to examine the hashtags of three major pulmonary and critical care conferences over the last 2 years: the CHEST Annual Meeting (#CHEST2013 & #CHEST2014), the American Thoracic Society International Conference (#ATS2013 & #ATS2014), and the Society of Critical Care Medicine Congress (#CCC43 & #CCC44).

RESULTS: In the first year, #CHEST2013, #ATS2013 and #CCC43 had an average of 1943 + 800 tweets by 381 + 77 individuals resulting in > 6.6 million views. In the second year, #CHEST2014, #ATS2014 and #CCC44 had a significantly higher average of 4646 + 1423 tweets by 1126 + 803 individuals resulting in > 32.6 million views (p<0.05 for each). Overall, 71% of these tweets were by healthcare providers and 29% were by industry, advocacy groups, organizations or journals in the first year, compared to 65% and 34% respectively in the second year. The mean number of mentions rose significantly between the two years (p<0.05) with healthcare providers increasing from 91 + 54 to 196 + 207 mean mentions and other medical groups increasing from 166 + 88 to 371 + 32 mentions. There were significant differences between conferences in the frequency of tweets by healthcare providers, industry, advocacy groups, organizations and journals. The conference attendance for the three conferences was 21,257 in the first year and 21,064 in the second year.

CONCLUSIONS: There has been substantial growth in Twitter over the last two years at three major pulmonary and critical care conferences with the number of impressions on Twitter far surpassing the number of attendees at each conference. Healthcare providers are a significant contributor and make up significant proportion of tweets, mentions and impressions.

CLINICAL IMPLICATIONS: Conferences should consider making live-tweeting their conferences easier to broaden their reach. Tactics could include meeting app integration with social media, promotion of conference hash tags, showcasing in-session tweets on digital signage, offline tactics such as Twitter user names on name badges, opportunities for in-person meetings, and promotion of social media through traditional communication vehicles before and during the meeting. .

DISCLOSURE: The following authors have nothing to disclose: Christopher Carroll, Kristi Bruno, Gabriel Bosslet, Pradeep Ramachandran

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Chest. 2015;148(4_MeetingAbstracts):22A. doi:10.1378/chest.2251134

SESSION TITLE: 21st Century Technology

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 28, 2015 at 08:45 AM - 10:00 AM

PURPOSE: Although inhaled medications are effective therapies for COPD, many patients and providers use them incorrectly. Inhaler education is critical but effective provider training in correct inhaler technique is lacking. The aim of this study was to improve provider knowledge of correct inhaler technique using a tablet-based multimedia educational tool.

METHODS: Primary Care providers (PCPs) and Pulmonologists who prescribe inhalers or teach inhaler technique were recruited and their use of metered dose inhalers (MDIs), various dry powder inhalers (DPIs) and Respimat® was assessed using predefined checklists. Then, they watched educational videos on a tablet that demonstrated correct inhaler technique by a clinical pharmacist with teach-back from a patient and were re-evaluated. A Student’s t-test was used for statistical analysis.

RESULTS: 13 Pulmonologists and 17 PCPs were tested. For all providers, correct inhaler technique (reported as % correct steps) increased after the video for: MDI without a spacer (76% vs 97%), MDI with a spacer (75% vs 98%), formoterol DPI (54% vs 97%), mometasone DPI (52% vs 98%), tiotropium DPI (82% vs 100%), and Respimat® (41% vs 95%) (p<0.001 for all comparisons). When analyzed separately, both Pulmonary and PC providers improved their inhaler technique for every inhaler (p<0.008 for each inhaler in both groups). There were no differences between PCPs and Pulmonologists in pre- or post-education inhaler technique for any inhaler (p>0.05 for all comparisons). 100% of providers found the videos helpful and the tablet easy to use, 93% found the videos easy to understand, 87% found the sound quality sufficient, 100% found the video quality sufficient and 97% felt the videos to be of appropriate length.

CONCLUSIONS: Both PCPs and Pulmonologists use inhalers incorrectly. A tablet-based multimedia educational tool significantly improved provider inhaler technique. Hopefully, this training will translate into improved inhaler education for patients with COPD. This tablet-based multimedia educational tool is being tested in patients with COPD to determine if there is a durable improvement in inhaler technique that produces symptomatic improvement.

CLINICAL IMPLICATIONS: This tablet-based multimedia educational tool can improve provider inhaler education, hopefully leading to improved patient education, inhaler technique, and respiratory symptoms. Our goal is to offer this educational tool to every provider who prescribes inhalers or teaches inhaler technique at our institution.

DISCLOSURE: The following authors have nothing to disclose: Aaron Mulhall, Muhammad Zafar, Samantha Record, Herman Channell, Ralph Panos

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Cardiothoracic Surgery

Chest. 2015;148(4_MeetingAbstracts):23A. doi:10.1378/chest.2254405

SESSION TITLE: Cardiothoracic Surgery Cases - Student/Resident

SESSION TYPE: Student/Resident Case Report Slide

PRESENTED ON: Sunday, October 25, 2015 at 03:15 PM - 04:15 PM

INTRODUCTION: Patients with an anterior mediastinal mass (AMM) are at high risk for cardiorespiratory collapse (CRC) postoperatively [1]. We present a case of prone positioning (PP) for CRC after mediastinoscopy with biopsy for an AMM. We present this case to demonstrate the use of PP to resolve CRC in patients with AMM and recommend a multidisciplinary preoperative plan (MPP) to decrease this risk in adults.

CASE PRESENTATION: A 23 year old previously healthy Indian male presented to our emergency department c/o 2 months of shortness of breath. ROS was positive for DOE, stridor, positional lightheadedness and morning facial swelling. Physical exam findings were HR 110 and decreased right-sided breath sounds. Imaging (Image 1) revealed an AMM measuring 15x10x16cm, SVC obstruction and compression of the right main pulmonary artery, veins and central airway. He underwent mediastinoscopy with biopsy, failed extubation and was transferred to our ICU. Hours after surgery he became hypotensive, with elevated peak airway pressures and hypercarbia refractory to increased ventilatory support and fluid resuscitation. CXR was unremarkable for pneumothorax, atelectasis or new infiltrate. We initiated PP for CRC with rapid normalization of peak pressures, correction of PaCO2, and resolution of hypotension (Table 1). On POD2 his hemodynamics tolerated supine positioning, on POD3 chemotherapy began and POD6 yielded successful extubation. He was discharged on POD7 with a pathological diagnosis of pure seminoma.

DISCUSSION: Severe symptoms and CT findings placed our patient at high risk and his subsequent clinical decline highlights the need for an MPP. Interventions to correct CRC in this population include avoidance of general anesthesia and maintenance of spontaneous ventilation, "rescue" positioning, placement of a reinforced ETT distal to the obstruction, rigid bronchoscopy, heliox, and cardiopulmonary bypass [2]. "Rescue" positioning in our case was achieved by PP with resolution of immediate threat to life.

CONCLUSIONS: General anesthesia can prompt CRC in patients with an AMM [1]. In children with an AMM, an MPP demonstrated favorable outcomes while minimizing morbidity and anesthetic risks [3]. In adults an MPP should include oncology, anesthesia, cardiothoracic surgery, and intensivist services. Our case demonstrates that PP can be instituted with a good outcome in a patient with an AMM. An MPP may identify those patients that would benefit from early intervention with PP.

Reference #1: Béchard P, Létourneau L, Lacasse Y, Côté, D. et al. Perioperative cardiorespiratory complications in adults with mediastinal mass. Anesthesiology,2004;100(4),826-34

Reference #2: Blank R, Souza D. Anesthetic management of patients with an anterior mediastinal mass: continuing professional development.Canadian Journal of Anesthesia.2011;58(9),853-867

Reference #3: Acker S, Linton J, Tan G. et al. A multidisciplinary approach to the management of anterior mediastinal masses in children. Journal of Pediatric Surgery.2009

DISCLOSURE: The following authors have nothing to disclose: Brian Scheele, Kori Ascher, Carolina De La Cuesta, Mark Csete

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Chest. 2015;148(4_MeetingAbstracts):24A. doi:10.1378/chest.2250093

SESSION TITLE: Cardiothoracic Surgery Cases - Student/Resident

SESSION TYPE: Student/Resident Case Report Slide

PRESENTED ON: Sunday, October 25, 2015 at 03:15 PM - 04:15 PM

INTRODUCTION: Renal cell carcinoma invades the IVC in approximately 10% of patients with further tumor extension into the RA occurring in only 1%. Survival after tumor embolization into the PA is unusual, but successful surgical resection of RCC tumor emboli has been occasionally reported. We describe our management of large bilateral pulmonary tumor emboli after nephrectomy for RCC.

CASE PRESENTATION: A 66 year-old, previously healthy man, presented with gross hematuria. CT revealed a 4.8x4.0x4.6 cm mass in the inferior pole of the right kidney with tumor extension into the right renal vein and intrahepatic IVC. While the patient was undergoing nephrectomy two large pieces of tumor were dislodged, embolizing to the RA and RV (noted on TEE). CT surgery was consulted intraoperatively, but the fragments embolized through the right heart and could no longer be visualized. The patient remained stable, thus the surgery was completed as planned. The patient was extubated in the OR and his immediate postoperative course was uneventful. A postoperative CT scan demonstrated large bilateral tumor emboli in the distal right and left main PA. TEE estimated peak PA systolic pressure at 71 mmHg and showed a mildly enlarged RV with preserved systolic function. The large burden of tumor emboli causing severe pulmonary hypertension prompted us to return the patient to the operating room on POD#2 for PA tumor embolectomy. TEE performed after intubation revealed that the patient’s RV was now severely dilated and its contractile function was profoundly reduced. Median sternotomy was performed and the left and right PA were isolated using blunt dissection during cardiopulmonary bypass. Bilateral arteriotomies were made and the PAs were directly visualized and the tumor extracted. The patient was transferred to the ICU in a stable condition and extubated later that day. The remainder of his hospital course was unremarkable being discharged POD#7.

DISCUSSION: Embolization of RCC to the pulmonary circulation is a rare, often fatal complication (mortality of 60-75%), but successful resection of pulmonary tumor emboli have been reported using either simultaneous or staged approaches with advocates for both. In our patient we observed real-time embolism of two tumor fragments through the right heart during nephrectomy, however he remained hemodynamically stable allowing a CT and ECHO to be obtained to define anatomy and pursue a staged approach in a more elective manner.

CONCLUSIONS: This case illustrates that pulmonary embolectomy can be performed safely as a staged approach following nephrectomy for RCC. However, one must take into account the strain being put on the right heart during this waiting period as evidenced by our patient’s relatively rapid decrease in right heart function.

Reference #1: Shuch B et al. Intraoperative thrombus embolization during nephrectomy and tumor thrombectomy: critical analysis of the University of California-Los Angeles experience. J Urol 2009;181:492-9.

DISCLOSURE: The following authors have nothing to disclose: Elizabeth Colwell, Sweeta Gandhi, Zafar Iqbal, Zahir Rashid, Paul Pagel

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Chest. 2015;148(4_MeetingAbstracts):25A. doi:10.1378/chest.2246367

SESSION TITLE: Cardiothoracic Surgery Cases - Student/Resident

SESSION TYPE: Student/Resident Case Report Slide

PRESENTED ON: Sunday, October 25, 2015 at 03:15 PM - 04:15 PM

INTRODUCTION: Infective endocarditis (IE) of four valves is an extremely uncommon phenomenon and successful surgical repair even is rarer.1 Due to the significant burden of diseased tissue, the prognosis is often poor, and the risks of surgery must be carefully weighed.

CASE PRESENTATION: A 48 year old male with murmur since childhood presented with 6 months of dyspnea and fatigue. He was noted to have severe anemia, acute renal failure and new-onset congestive heart failure. Work-up was significant for enterococcal bacteremia. He was treated with broad spectrum antibiotics, later deescalated to ampicillin and ceftriaxone. Upon transfer to a tertiary care facility, echocardiogram showed regurgitation and vegetations of all four valves, with a 1.5 cm aortic root pseudoaneurysm, thickened pericardium and 6 mm ventricular septal defect (VSD). Chest x-ray demonstrated bilateral pleural effusions. The patient denied injection drug use and colonoscopy was normal, but he had extensive dental caries with root involvement; multiple teeth required extraction. Despite his severe illness, the decision was made to proceed to surgery. After sternotomy, the thickened anterior pericardium was removed. Extensive calcified vegetations were excised from the tricuspid valve, right ventricle and VSD; sparing the tricuspid valve leaflets, which were repaired with an Alfieri stitch. The VSD was closed with a bovine pericardial patch. The damaged pulmonary valve was excised via the main pulmonary artery. Next, the aorta was transected and the non-coronary sinus pseudoaneurysm was excised (later repaired with bovine pericardium). The aortic valve was resected via the aorta and the mitral valve was resected via the intraatrial septum; both were replaced by mechanical valves. Lastly, a bioprosthetic pulmonary valve was placed and the right atriotomy was repaired. After bypass discontinuation, the pericardium was excised and pleural effusions were drained. After surgery, the patient did well: echocardiogram showed an ejection fraction of 50%. He was discharged on post-operative day 8 with a 2 month course of IV ampicillin and gentamicin.

DISCUSSION: Due to severe disease and lack of other source, dental pathology was deemed the probable cause of the patient's infection. Although not a constituent of normal oral flora, enterococcus may colonize the mouth in the case of periodontal disease.2 His history of VSD was postulated as a factor allowing spread of the infection to all 4 valves.

CONCLUSIONS: Despite critical illness, patients with multiple valve infective endocarditis have significant potential for benefit from surgical intervention in obtaining definitive source control.

Reference #1: Kim N, Lazar JM, Cunha BA, Liao W, Minnaganti V. Multivalvular endocarditis. Clin Microbiol Infec. 2000;6:207-212.

Reference #2: McCrary BR, Streckfuss JL, Keene HJ. Oral hygiene and the prevalence of oral group D streptococci in medically-physically compromised and periodontal disease patients. J Periodontol.1989;60(5):255-8.

DISCLOSURE: The following authors have nothing to disclose: Amy Bellinghausen Stewart, Anees Razzouk

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Chest. 2015;148(4_MeetingAbstracts):26A. doi:10.1378/chest.2222173

SESSION TITLE: Cardiothoracic Surgery Cases - Student/Resident

SESSION TYPE: Student/Resident Case Report Slide

PRESENTED ON: Sunday, October 25, 2015 at 03:15 PM - 04:15 PM

INTRODUCTION: Cavernous hemangiomas are extremely rare benign tumor of the heart. Mainstay of treatment is complete surgical resection of the tumor. We report a case of atrial septal cardiac hemangioma, which was enucleated with complete preservation of endocardial wall.

CASE PRESENTATION: A 79 year old female presented to the cardiologist with a complaint of progressive dyspnea. TEE showed an intact interatrial septum with approximately 5 x 4 cm round soft tissue mass in posterior inferior part of interatrial septum, bulging into right atrium and slightly into the left atrium. (Figure 1) In the operating room, after an anterior atriotomy, a large mass protruded from the lower portion of the atrial septum. The mass was located between the orifices of the coronary sinus and the IVC subsequently pushing the coronary sinus medially. The tumor was carefully dissected with the preservation of the endocardium on both sides. Then, enucleation of the soft, jelly like tumor from within the septum was performed. The histopathologic study of the tumor showed a red-brown mass with soft and spongy consistency. (Figure 2) The mass was identified as a cavernous hemangioma. Patient remains asymptomatic and shows no signs of tumor recurrence on repeat echocardiogram on 2 year follow up.

DISCUSSION: Cavernous hemangioma is often an incidental finding in an asymptomatic patient but it may present as dyspnea, syncope, arrhythmias, congestive heart failure, or right ventricular outflow tract occlusion depending on the location of the tumor. [1] Progressive dyspnea was the only presenting symptom for our patient, which happens to be the most frequent clinical presentation in patients with cardiac hemangioma (43%). [1] Total surgical resection of the mass is considered the best way to treat cardiac tumors; however in the past, partial excision of masses has been performed. In a review of 23 cases, 12 patients did not undergo total resection. Outcomes were favorable without complete resection (data unavailable in 5 patients, 6 were alive and well, and 1 patient died postoperative day 1). Spontaneous regression wihtout intervention and recurrent hemangioma with total resection has been reported. [2,3]

CONCLUSIONS: Enucleation was performed without any recurrence or complications. Enucleation rather than resection of a benign cardiac tumor may be considered in selected patients since it may result in less morbidity, such as residual intracardiac defects or conduction abnormalities. To the best of our knowledge, this is the first report of this surgical technique for a cavernous hemangioma.

Reference #1: Brizard C, Latremouille C, Jebara VA, et al. Cardiac hemangiomas. Ann Thorac Surg. 1993 Aug;56(2):390-4. Review.

Reference #2: Palmer TE, Tresch DD, Bonchek LI. Spontaneous resolution of a large, cavernous hemangioma of the heart. Am J Cardiol. 1986 Jul 1;58(1):184-5.

Reference #3: Colli A, Budillon AM, DeCicco G, et al. Recurrence of a right ventricular hemangioma. J Thorac Cardiovasc Surg. 2003 Sep 126(3):881-3.

DISCLOSURE: The following authors have nothing to disclose: Shintaro Chiba, Fatima Janjua, Sathappan Kumar, Eugene Shteerman, Mikhail Vaynblat

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Chest. 2015;148(4_MeetingAbstracts):27A. doi:10.1378/chest.2278364

SESSION TITLE: Cardiothoracic Surgery Global Case Reports

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Originally blank cartridges (BCs) were designed and produced for the training purposes of the Prussian army. Today, these guns or ammunitions are used for military training manoeuvres or funeral honours, in starter pistols to signal the beginning of races and entertainment industries such as in historical re-enactments, theatre and movie special effects. BC describes special type of ammunition that discharge sound and gas flares, but no bullet or shot. Contrary to their production purpose; BCs have become very popular in society and amongst criminals due to their low price, easy to provide, easy convert into firearms and obscure legal status. Therefore, morbidity and mortality affiliated to BCs are increasing. Several cases were represented in the literature since its first described in 1865 by Hamilton [1,2]. Herein, we represent penetrating lung injury due to the firing of a gun with a blank cartridge, with attempted murder.

CASE PRESENTATION: A 17-year-old male was brought to the emergency department with chest injury by gunshot from a blank cartridge. Upon examination, a single entrance wound at the left 4th intercostal space in the midclavicular line without exit wound and subcutaneous emphysema was observed. Any projectile or fragments were seen in radiological examination of the body. CT scans revealed left hemopneumothorax, lacerations and contusion of the left lung. The patient underwent left thoracotomy along with wedge resection of lingular segment of upper lobe. He was discharged on 9th postoperative day without any complaints.

DISCUSSION: In most of the countries as in Turkey; BCs generally are not considered firearms and regarded as harmless or toys. That’s why, they are sold without licensed or with few restrictions and their use is poorly supervised. BCs are generally loaded with black powder or nitrocellulose that detonates rather than burns. The gas pressure that is emerged in an explosion at the muzzle when a BC is fired acts like a bullet in close or contact range. This pressure or invisible bullets can be powerful enough to penetrate the soft tissue and even in bones. They can lead severe and fatal injuries even without any modification [3].

CONCLUSIONS: Chest injuries due to blank cartridges have rarely been reported in literature. The “blank” word gives a false sense of safety to people. Although blank cartridges do not contain a bullet, precautions are still required because of the fatalities and severe injuries have resulted on occasions when blank cartridges have been fired at very close ranges.

Reference #1: Gülşen I, Ak H, Sosuncu E, Bulut MD. Are blank cartridge guns really harmless? Ulus Travma Acil Cerrahi Derg. 2014 May;20(3):214-6.

Reference #2: Berlatzky Y, Katz S, Ayalon A, Abu-Dallo K. Abdominal injuries due to blank cartridges. Injury. 1977 Aug;9(1):77-8.

Reference #3: Demirci S, Dogan KH, Koc S. Fatal injury by an unmodified blank pistol: a case report and review of the literature.J Forensic Leg Med. 2011 Aug;18(6):237-41.

DISCLOSURE: The following authors have nothing to disclose: Mustafa Calik, Mehmet Orkun Sahsivar, Saniye Calik, Hidir Esme

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Chest. 2015;148(4_MeetingAbstracts):28A. doi:10.1378/chest.2278213

SESSION TITLE: Cardiothoracic Surgery Global Case Reports

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary artery dissection is a rare condition which usually occurs in patients with underlying pulmonary arterial hypertension. The condition generally manifests as cardiogenic shock or sudden death because the dissection progresses rapidly and thereby it is usually diagnosed at post-mortem studies[1].We report a case of pulmonary artery dissection developing secondary to trauma.

CASE PRESENTATION: 42-year-old man was admitted with the left chest pain through cause of high falling. On the x-ray, the left hilar enlargement was detected and then contrast-enhanced thoracic CT imaging was performed. Hilar enlargement causing the image was found to be the dilated pulmonary artery. Left lower lobe pulmonary artery dissection revealed. In the echocardiographic evaluation second degree tricuspid insufficiency was detected and pulmonary artery pressure was measured 100 mmHg. Examination in terms of Behcet's disease has resulted in negative and there was also no history of syphilis in the history of the patient. General condition of the patient was well and had no symptoms so conservative approach has been done.

DISCUSSION: Pulmonary artery dissection is an extremely rare and fatal disease which is usually diagnosed on post-mortem examination. It usually occurs as a complication of chronic pulmonary arterial hypertension. Other rare causes include chronic inflammation of the pulmonary arteries, right heart endocarditis, amyloidosis, trauma and severe atherosclerosis [2].Pulmonary artery dissections usually occur in patients with medial degeneration and pulmonary arterial dilatation due to chronic increases in pulmonary arterial pressures [3-4].

CONCLUSIONS: In our case, there was pulmonary hypertension and we believe that trauma caused the pulmonary artery dissection. This condition is extremely rare in the literature.

Reference #1: Türkvatan, Aysel, et al. "Pulmonary Artery Dissection Diagnosed by Multidetector Computed Tomographic Angiography: Case Report." Turkiye Klinikleri Cardiovascular Sciences 21.2 (2009): 292-296.

Reference #2: Bhatia, Vikas, et al. "Role of Multi-Detector Computed Tomography (MDCT) in Diagnosis of Pulmonary Artery Dissection: A Rare but Fatal Entity." Annals of the Academy of Medicine, Singapore 43.1 (2014): 64

Reference #3: Inayama Y, Nakatani Y, Kitamura H. Pulmonary artery dissection in patients without underlying pulmonary hypertension. Histopathology 2001; 38: 435-442

DISCLOSURE: The following authors have nothing to disclose: Atilla Can, Hidir Esme, Mustafa Calik, Saniye Calik

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Chest. 2015;148(4_MeetingAbstracts):29A. doi:10.1378/chest.2277709

SESSION TITLE: Cardiothoracic Surgery Global Case Reports

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Aortic dissection (AD) was first described in 1761, by Morgagni and occurs with the separation of the layers of the aortic wall.The intima and inner media are separated from the outer media and adventitia of the aorta to create a false lumen. AD whose incidence ranges from 5 to 30 cases per million people per year normally represents with acute thoracic or abdominal pain and concomitant cardiovascular symptoms.Even though pain and hypotension most frequently encountered clinical symptoms are wide and extremely variable. Neurological symptoms emerge due to hypotension, brain vessels occlusion and perfusion deficit [1, 2]. For 250 years after being notified by Morgagni AD is still associated with high mortality. Here in; we report a rare case of Stanford Type A Aortic Dissection (STAAD) onset with neurological symptoms.

CASE PRESENTATION: A 71-year-old male, who was transported to our emergency department by ambulance complaint of inability to recognize the environment, suddenly became non-verbal and had back pain. He was mild distress and confused at the admission. Physical examination was substantially unremarkable, with the exception of thready peripheral pulses and cold extremities. Initial computed tomography (CT) of the head showed no hemorrhage or areas of hypodensity. It was regarded as a normal by the attending radiologist. Acute stroke was determined in diffusion magnetic resonance imaging (MRI) but we thought that these complaints were not likely due to the stroke. The history and physical examination may strongly suggest AD that was suspected. Chest CT was performed and defined STAAD in the anterior arch of the aorta. He was taken immediately to operating room. Patient died because of ventricular fibrillation on second postoperative day.

DISCUSSION: AD occurs due to tearing in the inner wall of the aorta, which then causes blood to flow between layers of the muscular wall. Stroke occurs in one in twenty of patients with aortic dissection was associated with increased morbidity and in-hospital mortality, but not higher long-term mortality among survivors [3]. Neurological symptoms at the onset of AD are not only frequent (17-40%), but often dramatic and may mask underlying conditions [2].

CONCLUSIONS: Making the correct diagnosis could be difficult due to the rarity, wide range of symptoms and the similarity of other disease in emergency departments. Here, the essences of diagnosis are high level of suspicion in the patient with atypical signs and symptoms. Even though, relatively uncommon cause of stroke, AD should be kept in mind.

Reference #1: Karthikesalingam A, Holt PJ, Hinchliffe RJ, Thompson MM, Loftus IM. The diagnosis and management of aortic dissection. Vasc Endovascular Surg. 2010 Apr;44(3):165-9.

Reference #2: Gaul C, Dietrich W, Friedrich I, Sirch J, Erbguth FJ. Neurological Symptoms in Type A Aortic Dissections. Stroke. 2007 Feb;38(2):292-7.

Reference #3: Bossone E, Corteville DC, Harris KM, Suzuki T, Fattori R, Hutchison S, Ehrlich MP, Pyeritz RE, Steg PG, Greason K, Evangelista A, Kline-Rogers E,Montgomery DG, Isselbacher EM, Nienaber CA, Eagle KA Stroke and outcomes in patients with acute type A aortic dissection. Circulation. 2013 Sep 10;128(11 Suppl 1):S175-9.

DISCLOSURE: The following authors have nothing to disclose: Saniye Calik, Ismail Aktas, Mustafa Calik, Basar Cander

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Chest. 2015;148(4_MeetingAbstracts):30A. doi:10.1378/chest.2225168

SESSION TITLE: Cardiothoracic Surgery Global Case Reports

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Bronchopleural fistula (BPF) following lung resection is a devastating complication, associated with significant morbidity and mortality. The usual therapy for BPF includes prolonged courses of antibiotics, pleural drainage and surgical repair. Several endobronchial techniques such as the application of ethanol, tissue sealants ,fibrin glue, or coils have also been used with different degrees of success. Recently, the use of one-way endobronchial valves (EBVs) is emerging as a powerful and minimally invasive procedure to facilitate BPF closure in patients who had not responded to standard therapy. In this report we describe our first experience with this novel procedure in one patient with persistent air leak after lung resection.

CASE PRESENTATION: The patient was a 74-year-old man who underwent a left lower lobectomy due to epidermoid lung cancer. There were not complications in the inmediate postoperative course and BPF was not observed. He recovered from his surgery uneventfully; however, he presented 2 months postoperatively with left lower-lobe pneumonia, empyema and central BPF owing to a stump leak visibly seen as a hole via bronchoscopy. Unfortunately, the medical condition of the patient was not optimal to attempt surgical closure of the BPF. He was treated with antibiotics for 4 weeks, and no pleural drainage was placed. Following the antibiotic therapy, a bronchoscopy was performed and after therapeutic aspiration of the purulent secretions from the cavity of the left lower lobectomy, the BPF was identified. A guidewire was placed under direct vision, and a small-sized endobronchial valve EBV Zephyr® 4.0 (Pulmonx) was loaded, inserted, and deployed into the fistula with an excellent fit and position. No complications related to the procedure were observed. The patient tolerated the procedure and was transferred to the recovery room. Hospital admission was not needed. Four months after the valve placement, the patient is doing well, with no infection and the fistula is completely closed.

DISCUSSION: BPF leads to significant morbidity for patients, and complications have prompted the need for a nonsurgical, minimally invasive approach to treat these patients. The use of EBVs has been recently described as a novel alternative treatment for BPF. By preventing air flow back through the affected airway, the airleak is minimized and the fistula may eventually close. EBVs placement has been demonstrated to be well tolerated with few complications reported.

CONCLUSIONS: Despite our limited experience, we hold that EBVs placement in central BPF after lung resection is a safe, cost-effective and minimally invasive intervention.

Reference #1: Berkowitz D. Management of Bronchopleural Fistulas. En: Ernst A, Herth F. Principles and Practice of Interventional Pulmonology. Springer Science+Business Media New York; 2013. p. 435-48.

Reference #2: Travaline JM, McKenna Jr RJ, De Giacomo T, Venuta F, Hazelrigg SR, Boomer M, et al. Endobronchial Valve for Persistent Air Leak Group. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest. 2009;136:355-60.

DISCLOSURE: The following authors have nothing to disclose: M.J. Bernabé Barrios, G. Rodríguez Trigo, C. Pinedo Sierra, M. Calderón Alcalá, A.M. Gómez Martínez, J.R. Jarabo Sarceda, F. Hernando Trancho, J.L. Álvarez-Sala Walther

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Chest. 2015;148(4_MeetingAbstracts):31A. doi:10.1378/chest.2275046

SESSION TITLE: Cardiothoracic Surgery Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: To describe introduction of hTEE into a tertiary care Cardiac Surgery Intensive Care Unit (CSICU) and define the clinical impact on critically-ill patients.

METHODS: Case series of 38 cardiac surgery patients who received hTEE imaging performed by multiple providers, including Medical Intensivists, Physician Assistants and Cardiac Surgeons. Each received standardized training by cardiac sonographers, including simulation, image interpretation and image acquisition on live patients. Guidelines for usage were developed, but individual providers determined actual use. The hTEE probes can remain indwelling for 72 hours allowing multiple imaging sessions. The three images that can be obtained are Mid-Esophageal Super Vena Cava View, the 4 chamber view and the Transgastric Short Axis. The clinical findings and therapeutic decisions for each case were recorded in a secure database.

RESULTS: In 27/38 patients all three imaging planes were obtained. In 37/38 patients clinically useful information was obtained. Hemodynamic management categorized as alteration in intravascular fluid given 15/38 patients, vasopressor or inotrope titration in 15/38 patients, inhaled Nitric Oxide titration occurred in 4/5 patients. 2/38 patients did not require an after hours or weekend echocardiography to be done. 2/38 patients did not have to go back to the operating room for re-exploration. 2/38 patients had minor bleeding from probe placement, but did not require blood transfusions.

CONCLUSIONS: The hTEE probe can successfully be introduced into a tertiary-care CSICU with multidisciplinary providers. HTEE impacted the management of 26/38 patients with minor risk to them. The hTEE probe can save the need for emergency re-exploration and the need for after hours echocardiography in this population. Further review is necessary to see if these changes impact patient length of stay, ventilator weaning and or mortality.

CLINICAL IMPLICATIONS: Htee can be introduced successfully with standardized training to multidisciplinary providers who have no formalized training in echocardiography. The technology is safe and can reduce the need for emergency post-operative echocardiograms, unnecessary reexplorations and decrease the duration of use of inhaled vasodilators. It is an alternative way to assess hemodynamics and cardiac function in critically-ill patients.

DISCLOSURE: The following authors have nothing to disclose: Jason Vourlekis, Osman Malik, Ramesh Singh, Nitin Puri, Megan Terek, Ashok Cattamanchi, Chris King

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Chest. 2015;148(4_MeetingAbstracts):32A. doi:10.1378/chest.2250571

SESSION TITLE: Cardiothoracic Surgery Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Fever and leukocytosis are commonly observed after ECMO decannulation, and it is difficult to differentiate the SIRS phenomenon from an infectious process. This study was performed to investigate the SIRS phenomenon after ECMO decannulation.

METHODS: An IRB approved review of 62 patients who survived ECMO between 2010-2014 was done to identify patients who exhibited the post-ECMO SIRS phenomenon. The SIRS phenomenon was defined as having 2 out of the 3 following criteria after ECMO decannulation: fever, leukocytosis, and/or escalation of vasopressors. Patients with the SIRS phenomenon were divided into 2 groups: those with true SIRS (Group TS) vs. infection (Group I). Infection was defined as any positive culture after decannulation. Pre-, intra-, and post-ECMO variables were compared between the two groups to identify risk factors.

RESULTS: 37 (60%) patients fit the criteria for the SIRS phenomenon (29 male, mean age of 48.5 ± 13.4 years, 24 venoarterial (VA) ECMO, 13 venovenous (VV) ECMO, mean ECMO length 10.1 ± 5.1 days). Group TS consisted of 15 patients without any identified source of infection (11 male, mean age of 45.2 ± 13.0 years, 9 VA ECMO, 6 VV ECMO, mean ECMO length 10.7 ± 5.8 days). Group I consisted of 22 patients with various infections, including bacteremia in 7 (32%), pneumonia in 12 (56%), surgical site infection in 3 (14%), and Clostridium difficile infection in 1 (4.5%); infection sites may be overlapped among the patients. Risk factor analysis did not identify pre- or intra-ECMO variables related to the development of true SIRS vs. infection. The post-decannulation duration of vasopressor use was shorter in Group TS (3.7 ± 2.5 days) vs. Group I (6.1 ± 2.9 days), p=0.015. Post-decannulation 30-day survival rate was greater in Group TS (100%) vs. Group I (77%), p=0.047. Post-decannulation leukocytosis, fever, and days on antibiotics were similar between Group TS and Group I.

CONCLUSIONS: True SIRS and infection are common after ECMO decannulation. Compared to those who developed true SIRS, patients who developed infection post-decannulation were found to require a longer course of vasopressors and their post-decannulation 30-day survival rate was found to be decreased. Risk factor analysis did not demonstrate variables to distinguish between post-ECMO true SIRS vs. infection.

CLINICAL IMPLICATIONS: The post-ECMO SIRS phenomenon is common. The differentiation of infection from true SIRS is important in order to potentially improve hospital survival after ECMO decannulation.

DISCLOSURE: The following authors have nothing to disclose: Karthik Thangappan, Nicholas Cavarocchi, Michael Baram, Brandi Thoma, Hitoshi Hirose

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Chest. 2015;148(4_MeetingAbstracts):33A. doi:10.1378/chest.2280176

SESSION TITLE: Cardiothoracic Surgery Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Thromboembolism is a known complication after orthopedic surgery but rarely occurs intraoperatively. Cement embolism during the procedure is less common but can be fatal. While the diagnosis is readily made, management may be controversial as there is no current consensus regarding optimal treatment. We present such a case requiring emergent embolectomy assisted by cardiopulmonary bypass.

CASE PRESENTATION: A 64-year old man with a history of COPD and alcohol abuse presented with streptococcus pneumonia and a complex fracture of the hip, necessitating total artificial hip replacement. After initial medical management and conservative treatment of the fracture the patient was scheduled for elective surgery. During that procedure, at the time of bone cement injection, the patient abruptly developed hemodynamic instability and PEA. CPR was initiated, while thromboembolism was confirmed by TEE. An emergency sternotomy was performed and the patient was placed on cardiopulmonary bypass for removal of massive clot extending from the IVC through the RV into the pulmonary arteries (Fig. 1). An IVC filter was also placed to prevent further thromboembolism.

DISCUSSION: Massive thromboembolism was provoked by cement leak into circulation in this patient who had other risk factors including a recent infection and prolonged immobilization. Particles of bone cement were found in the removed clot on surgical pathology.

CONCLUSIONS: The incident of massive and fatal thromboembolism in perioperative patients is reported as 0.1-2% after most procedures, but as high as 13% after hip replacement[1]. This case illustrates diagnosis and treatment, including emergent pulmonary embolectomy, in patients presenting with major intraoperative thromboembolism, which is a rare but often fatal complication during surgery. Patients undergoing bone cement injection are particularly at risk for this entity.

Reference #1: Geerts WH, Bergqvist D, Pineo GF, et al. American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133(6 Suppl):381S-453S.

DISCLOSURE: The following authors have nothing to disclose: Moritz Wyler Von Ballmoos, G Almassi, Sweeta Gandhi

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Chest. 2015;148(4_MeetingAbstracts):34A. doi:10.1378/chest.2278764

SESSION TITLE: Cardiothoracic Surgery Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Arthroscopic shoulder surgery is a common orthopedic procedure, with 5.8-9.5% risk of complications. Respiratory complications are rare, and are mostly attributed to anesthesia or surgical technique. We present a case of spontaneous pneumothorax with extensive subcutaneous emphysema, presenting within 1-hour of shoulder arthroscopy.

CASE PRESENTATION: 51-year-old female without any co-morbid conditions, presented to the ER with sudden onset shortness of breath, dysphagia and dysphonia. She has no history of smoking or underlying lung problems. Patient underwent a right arthroscopy and rotator cuff repair for rotator cuff tear under general anesthesia as outpatient. Her symptoms started just 30 minutes after discharge. Vital signs were stable with oxygen saturation of 97% at room air. Physical examination showed no respiratory distress. There was decreased air entry with diminshed tactile vocal fremitus on the right chest wall. There were skin crepitations on palpation on the right side. CT chest and head & neck showed a large right pneumothorax and pneumomediastinum. There was extensive subcutaneous emphysema involving the right hemithorax extending into bilateral supraclavicular regions, neck, and anteromedial aspect of right arm. There was also an evidence of residual air in right shoulder joint. A right side chest tube was placed with good lung expansion. Patient continued to have an air leak during her hospital stay, hence was discharged home with Heimlich valve.

DISCUSSION: Spontaneous pneumothorax and subcutaneous and mediastinal emphysema are significant complications following shoulder arthroscopy. Mechanisms responsible for pneumothorax may include, rupture of parietal pleura by an external trauma to the chest wall; rupture of visceral pleura; or alveolar rupture, which can commonly occur by a rupture of bulla or bleb secondary to positive pressure ventilation. A direct injury to the trachea or esophagus from endotracheal intubation can also be a cause. Infusion pump system used in arthroscopy; intermittently pumps fluid into the cavity with simultaneous removal of fluid by suction, thus maintaining a constant pressure. Understanding of fluid dynamics suggests, a Bernoulli effect can potentially occur during surgery, which may create conditions favoring air entry into subacromial space. Our patient did not have any history of smoking or underlying lung pathology. Presence of air on CT in right shoulder communicating with subcutaneous pneumothorax along with large pneumothorax favors this to be likely cause of pneumothorax.

CONCLUSIONS: Heavy smoking and pulmonary comorbidities are important predisposing conditions to spontaneous pneumothorax following shoulder arthroscopy under general anesthesia. Both anesthesia-and surgery-related variables can be inferred as a cause of subcutaneous emphysema and pneumomediastinum.

Reference #1: Dietzel DP, Ciullo JV (1996) Spontaneous pneumothorax after shoulder arthroscopy: a report of four cases. Arthroscopy 12:99-102

DISCLOSURE: The following authors have nothing to disclose: Sarah Asghar, Muhammad Azam, Rudin Gjeka, Alexander Adams, Arham Barakzai, Alaeddin Maeza, Sarwan Kumar

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Chest. 2015;148(4_MeetingAbstracts):35A. doi:10.1378/chest.2260749

SESSION TITLE: Cardiothoracic Surgery Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Extragonadal germ cell tumors are rare, representing 1-3% of all germ cell tumors. The most common location of extragonadal germ cell tumors is in the anterior mediastinum. Of all types of anterior mediastinal neoplasms in adults, mediastinal germ cell tumors represent about 15% of cases and are usually benign teratomas.[1]

CASE PRESENTATION: A 36-year-old Columbian man with no past medical history presented with right (R.) shoulder and R.-sided chest pain for two days. The pain was sharp, constant, pleuritic, and non-radiating. He denied fever, night sweats, weight loss, dyspnea, cough, hemoptysis, palpitations, or any other symptoms. CT Chest showed a well-circumscribed mass along the R. heart border. Further imaging with cardiac MRI delineated a large R. anterior mediastinal mass measuring 8.2 x 9.0 x 6.1 cm arising from the R. pericardium (Fig. 1), without intracardiac extension, imposing on the SVC and R. atrium (Fig. 2). The mass enhanced heterogeneously, showing calcification and fat signal consistent with a teratoma. CT Abdomen/Pelvis, testicular ultrasonography, alpha-fetoprotein and beta-HCG levels were normal. The patient underwent median sternotomy; pericardial and pleural spaces were both entered, revealing tumor arising from the fibrous pericardium without invasion of the serous pericardial surface. Adhesions between the tumor and right lung were present. The excised mass grossly appeared solid and cystic, tan-pink with fragments of hair and histology revealed a benign mature teratoma with margins free of tumor. Post-operative course was uncomplicated and patient was seen in follow-up 2 months later doing well.

DISCUSSION: Mediastinal germ cell tumors of cardiac origin are exceedingly rare, with reported incidence of cardiac teratomas less than 1%. Cardiac teratomas predominantly occur in children and young adults and peak incidence is in the second and third decades of life. The majority of cardiac teratomas arise from the pericardium and are usually R.-sided masses. Generally, mediastinal teratomas are asymptomatic and found incidentally due to the nature of their slow growth, although large tumors may cause symptoms such as chest pain related to mechanical effect. MRI is sensitive in defining the spatial relationship of mediastinal teratomas to structures such as the pericardium and great vessels. Surgical resection of these tumors is usually through median sternotomy or posterolateral thoracotomy with careful surgical technique so as not to injure vital mediastinal structures.[2]

CONCLUSIONS: This case reports a very rare occurrence of a pericardial mature teratoma in a patient of adult age and although uncommon, complete surgical resection is curative with good prognosis.

Reference #1: Shameem, M. et al. Mature mediastinal teratoma in adult. Respiratory Medicine CME. 2010; 3:116-117.

Reference #2: Cohen, R. et al. Mature cardiac teratoma in an adult. Cardiology Research. 2012; 3(3):97-99.

DISCLOSURE: The following authors have nothing to disclose: Larysa Sanchez, Narjust Duma, Martin Gutierrez

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Chest. 2015;148(4_MeetingAbstracts):36A. doi:10.1378/chest.2258663

SESSION TITLE: Cardiothoracic Surgery Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Neurofibromatosis is a genetic condition of neurofibromas with only 32 cases of spontaneous aneurysmal ruptures from intrathoracic neurofibromatosis tumors managed by thoracotomy, video-assisted thoracoscopic surgery or coil embolization. We discuss a case of a 35-year-old female presenting with hemothorax from a ruptured right subclavian artery secondary to tumor involvement.

CASE PRESENTATION: We present a case of a previously healthy 35-year-old female with neurofibromatosis presenting with worsening chest pain and shortness of breath over one day. On examination, there was decreased breath sound on the right chest with dullness to percussion. An initial chest x-ray showed a large right pleural effusion and a chest tube was placed which drained one liter of sanguineous fluid. A CT chest with IV contrast raised suspicion for an aneurysmal right subclavian artery with active contrast extravasation. The patient’s hemodynamic condition deteriorated with worsening respiratory distress. The decision was made to operate emergently. An extended right posterolateral thoracotomy approach revealed a large hemothorax. After temporary control of active bleeding, she was found to have large rupture of distal right subclavian aneurysm. The aneurismal bleeding was controlled by pressure and the ruptured artery was oversewn incorporating pleural tissue followed by pledgeted sutures. Postoperative CT chest demonstrated complete resolution of the hemothorax and no evidence of bleeding. The patient was discharged home in stable condition on postoperative day 7.

DISCUSSION: Neurofibromatosis (NF) is a tumor disorder that rarely presents in the thoracic cavity with a suggesed incidence of 3.6%. In the literature, there are 32 cases of spontaneous hemothorax involving the subclavian, intercostal, thyrocervical trunk, and internal thoracic artery. Studies have attributed mesodermal dysplasia as the case for NF vascular weakness, while others suggest that direct tumor invasion causes ischemic wall weakness and aneurysmal dilatation. There have been cases of a subclavian artery rupture repaired with collagen fleece and direct ligation with video-assisted thoracoscopic surgery and ruptured costo-cervical arteries in more stable patient successful coil embolized. In our case, we used open thoracotomy to successfully control the aneurismal bleed and emergently save the patient’s life.

CONCLUSIONS: There are various ways to manage an intrathoracic arterial rupture from a NF tumor. Depending on the patient’s hemodynamic stability and the surgeon’s expertise, the ruptured aneurysm can be repair primarily via open thoracotomy and VATS or coil embolized.

Reference #1: Miyazaki T, Tsuchiya T, Tagawa T, Yamasaki N, Nagayasu T. Spontaneous hemothorax associated with von Recklinghausen's disease. Ann Thorac Cardiovasc Surg. 2011;17(3).

Reference #2: Hoonjan B, Thayur N, Abu-Own A. Aneurysmal rupture of the costo-cervical trunk in a patient with neurofibromatosis type 1. Int J Surg Case Rep. 2014;5(2).

DISCLOSURE: The following authors have nothing to disclose: Bo Gu, Sean Kwon

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Chest. 2015;148(4_MeetingAbstracts):37A. doi:10.1378/chest.2251480

SESSION TITLE: Cardiothoracic Surgery Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) accounts for less than 0.5% of all congenital cardiac anomalies and is associated with a 90% mortality rate in the first year of life. ALCAPA causes myocardial ischemia due to a coronary steal phenomenon leading to congestive heart failure and even sudden cardiac death. Diagnosis of this anomaly in adulthood is extremely rare. Herein, we present a case of ALCAPA diagnosed in an adult female eleven years after a successful pregnancy.

CASE PRESENTATION: A 33-year-old female presented with worsening angina since her successful pregnancy at age 22. Physical exam and vitals were within normal limits. EKG had non-specific ST changes. She underwent a coronary angiography after having a positive stress test. It showed retrograde filling of the left coronary artery system via collaterals from the dilated right coronary artery and eventually draining into the pulmonary artery. The diagnosis of ALCAPA was confirmed with a computerized tomography angiogram. Transthoracic echocardiography showed moderate mitral regurgitation and moderate to severe global hypokinesis. The patient eventually underwent reimplantation of the left coronary system to the aortic root without any complications. Over the next 4 years she continues to have normal routine follow up ever since the reimplantation.

DISCUSSION: ALCAPA is a rare life-threatening anomaly. Without surgery, the mortality rate is 90% in the first year of life. In extremely rare cases, patients make it to adulthood, even through pregnancy as illustrated in this case, due to adequate collateral blood supply from the right coronary artery to the left coronary system. The diagnosis is often made due to the development of persistent angina caused by myocardial ischemia. This ischemia is due to a coronary steal phenomenon from a left to right shunt via the collateral vessels resulting in decreased perfusion pressure as seen on our patient’s coronary angiogram. Overtime, myocardial ischemia leads to the development of congestive heart failure, mitral insufficiency, malignant arrhythmias, and even sudden cardiac death, therefore surgical correction to reimplant the coronary artery to the aorta is crucial.

CONCLUSIONS: The presentation of ALCAPA in adulthood even after pregnancy, though extremely rare, is possible with persistent symptoms of angina usually leading to the diagnosis; this in turn allows early surgical correction to provide excellent long-term prognosis as seen in our presented patient.

Reference #1: Dodge-Khatami A, et al. Anomalous origin of the left coronary artery from the pulmonary artery: collective review of surgical therapy. Ann Thorac Surg. 2002;74:946-955.

Reference #2: Wollenek G D, et al. Anomalous origin of the left coronary artery: a review of surgical management in 13 patients. J Cardiovasc Surg 1993;34:399-405.

Reference #3: Edwards JE. Anomalous coronary arteries with special reference to arteriovenous-like communications. Circulation.1958;17:1001-1006.

DISCLOSURE: The following authors have nothing to disclose: Hiren Patel, Brian Swirsky

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Chest. 2015;148(4_MeetingAbstracts):38A. doi:10.1378/chest.2275576

SESSION TITLE: Thoracic Surgery

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 28, 2015 at 04:30 PM - 05:30 PM

PURPOSE: Postoperative airleak may occur following 30-50% of lung resections, with up to 15% being classified as prolonged. Patients with prolonged airleak are at increased risk for infectious and other complications, increased hospital costs and lengths of stay. Efforts to reduce airleak have led to development of various sealants which have been used as an adjunct to standard closure techniques with sutures or staples. This study aims to test the performance of different sealants without sutures in mechanically ventilated explanted pig lungs with standardized pleural defects.

METHODS: Explanted pig lungs were evaluated for airleak after creation of 1 cm circular defects in the visceral pleura. Airleak was confirmed by submerging in PBS. Pleural defects were sealed using Evicel (fibrin-based), Bioglue (two-part hydrogel glue consisting of bovine serum albumin and glutaraldehyde), Progel (two-part hydrogel glue consisting of human serum albumin and polyethylene glycol), or sutures (2 layered running horizontal mattress and simple closure). Lobes were then selectively ventilated for 2 minutes at an airway pressure of 10 cmH2O, PEEP of 0, and respiratory rate of 12. Airway pressure was increased by 5 cmH2O at 2-minutes intervals. Lungs were submerged in a water bath containing PBS at 37˚C to test for airleak at each interval. This process was continued till airleak was observed or a maximum airway pressure of 50 cmH2O was reached. Our primary endpoint was bursting pressure (BP), defined as the minimal peak pressure at which gas bubbles were observed. One-way ANOVA and post-hoc Tukey tests were used to compare groups.

RESULTS: A total of 12 lungs were evaluated and 20 lobes were selected. Bioglue demonstrated the highest sealing efficacy, with no bursting in any samples after reaching peak pressures of 50cmH2 O (n=3, p<0.0001). There were no significant differences in BP between sutures, Progel and Evicel.

CONCLUSIONS: Our study suggests that Bioglue had the highest sealing efficacy, although it is not currently approved as a pleural sealant. Progel, the only approved pleural sealant on market, had similar sealing efficacy to sutures.

CLINICAL IMPLICATIONS: To our knowledge, this is the first study to evaluate the performance of lung sealants as alternatives to sutures in an ex vivo airleak model. In vivo animal models are needed to further explore these findings.

DISCLOSURE: The following authors have nothing to disclose: Sebastian Ochoa, Bijan Dehghani, George Cheng, Jennifer Wilson, Adnan Majid, Nasim Annabi, Ali Khademhosseini, Sidhu Ganghadaran

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Chest. 2015;148(4_MeetingAbstracts):39A. doi:10.1378/chest.2230958

SESSION TITLE: Thoracic Surgery

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 28, 2015 at 04:30 PM - 05:30 PM

PURPOSE: The optimal management for patients with T1 esophageal carcinoma is still under debate. We developed a nomogram to predict lymph node status in T1 esophageal squamous carcinoma and adenocarcinoma and stratify patients who need further treatment.

METHODS: Patients diagonosed with pT1NxM0 esophageal squamous cell carcinoma and adenocarcinoma between 1988-2010 were selected from the Surveillance, Epidemiology, and End Result(SEER) database. All patients underwent primary tumor resection and regional lymphadenectomy. A multivariate logistic model was created from preoperative clinicopathologic data of the patients between 1988-2008,and a nomogram to predict lymph node metastasis was constructed. A cohort of patients diagonosed between 2009-2010 was used for external validation.

RESULTS: The final model presented as a nomogram included T stage, grade, age and tumor size. The nomogram incorporating these four predictors demonstrated good discrimination (concordance index 0.69). In the validation cohort, the discrimination accuracy was 0.74 . After 200 repetitions, the bootstrap corrected concordance index of the model was 0.68 in the model-development cohort.

CONCLUSIONS: A nomogram predicting lymph node status in T1 esophageal squamous cell carcinoma and adenocarcinoma was developed. This model will help physicians to assess the risk of lymph node metastasis and decide whether lymphadenectomy should be performed.

CLINICAL IMPLICATIONS: Clinical physician can calculate a total score according to the parameters of the nomogram. This score could then be used to value the probability of LN metastasis for individual patient corresponding to the scale at the bottom of the nomogram.

DISCLOSURE: The following authors have nothing to disclose: Su Yang

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Chest. 2015;148(4_MeetingAbstracts):40A. doi:10.1378/chest.2215910

SESSION TITLE: Thoracic Surgery

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 28, 2015 at 04:30 PM - 05:30 PM

PURPOSE: The role of extrapleural pneumonectomy (EPP) in malignant pleural mesothelioma (MPM) is controversial. For patients presenting with limited disease, trimodality therapy consisting of induction chemotherapy, EPP and post-operative radiation may be offered at some institutions. The benefit of EPP remains questionable after a randomized feasibility trial failed to complete, but suggested no benefit. We completed a case-matched chart review to determine the frequency and outcomes of EPP at The Ottawa Hospital.

METHODS: All MPM patients from 1991 to June 2012 were identified. Data collected included age, gender, performance status (PS), histology, stage, laboratory values and therapies received. The primary outcome was overall survival. A case-control analysis involving EPP and comparable patients not undergoing surgery was subsequently performed. Matches were chosen by age, PS, histology and stage.

RESULTS: From 245 patients with MPM, only 20 (8%) underwent EPP. The mean age of EPP patients was of 60 years (range 21 to 68). Of these, 90% were men, 90% had a PS ECOG 0-1, and 75% were of epithelial histology. 19 patients had chemotherapy, and 11 received trimodality therapy. Median overall survival of patients having undergone EPP was 24.7 months versus 9.1 months in non-EPP patients (p=0.0001). The benefit of EPP was not statistically significant after multivariate analysis; HR 1.57, 95% CI 0.80-3.08 (p=0.19). 19/20 EPP patients had a suitable match. From the case-match analysis, there was also no statistically significant benefit from EPP, median overall survival of 23.9 months in EPP patients versus 20.8 months in matched subjects; HR 0.68, 95% CI 0.34-1.37 (p=0.28).

CONCLUSIONS: We did not find a statistically significant improvement in outcomes associated with EPP at our institution, suggesting that the longer overall survival seen in patients undergoing this procedure is mainly due to the selection of those with better baseline characteristics.

CLINICAL IMPLICATIONS: Conducting randomized clinical trials is difficult due to the relatively low incidence of MPM. Most patients have advanced disease at the time of diagnosis, but some do present at an earlier stage. In these patients, surgical resection may be considered although there is debate as to the role of EPP. Our analysis would suggest that EPP does not improve overall survival.

DISCLOSURE: The following authors have nothing to disclose: Mathieu Saint-Pierre, Tinghua Zhang, Garth Nicholas, Scott Laurie, Paul Wheatley-Price

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Chest. 2015;148(4_MeetingAbstracts):41A. doi:10.1378/chest.2278997

SESSION TITLE: Thoracic Surgery Cases

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 27, 2015 at 07:30 AM - 08:30 AM

INTRODUCTION: Lung herniation occurs infrequently. Transdiaphragmatic Intercostal Herniation (TIH) of abdominal contents has rarely been reported. We present a complex case of lung, liver and colon herniation through the same intercostal space.

CASE PRESENTATION: A 47 year-old man with a history of COPD and seizures, presented after a fall with dyspnea and right chest wall pain. Physical exam showed large ecchymosis over the right flank. Thoracic CT demonstrated herniation of the lung and a portion of the liver through the 8th rib space. Cardiothoracic surgery (CTS) recommended elective repair of the defect after optimization of pulmonary status. He was subsequently discharged home. A week later, he was readmitted with worsening dyspnea and a soft, reducible mass over the right posterior chest wall that decreased and increased in size with inspiration and expiration respectively. Thoracic CT revealed pleural effusion contiguous to the herniated lung with new airspace disease. Thoracentesis yielded a large amount of serosanguinous fluid. He was treated for HCAP and discharged with a chest brace. Two weeks later, he presented to the ER with severe abdominal pain. CT scan revealed interval enlargement of the above hernia, TIH of mesenteric fat and ascending colon with evidence of incarceration. He was emergently taken to the OR and underwent successful reduction and repair of the incarcerated hernia. He is now awaiting evaluation for the intercostal defect repair.

DISCUSSION: Fewer than 300 cases and 40 cases of lung herniation and TIH have been reported in literature respectively.1 The majority of cases are acquired and occur after a blunt trauma. While diaphragmatic injury should be suspected in all cases of intercostal herniation,2 prompt and precise diagnosis can be made by CT scan. Although, small hernias seldom regress spontaneously,3 management can be complex. Definitive treatment can be achieved through surgical repair.1

CONCLUSIONS: Intercostal lung herniation is rare and even rarer in conjunction with TIH of abdominal contents. We present an intricate case with unexpected complications of pneumonia, pleural effusion and incarceration with the management challange of this rare entity.

Reference #1: Sharma OP, et al. “TIH: review of the world literature and presentation of a case,” Journal of Trauma, vol. 50, no. 6, pp. 1140-1143, 2001

Reference #2: Sarkar D, et al. “TIH following Blunt Trauma,” Case Reports in Radiology, vol. 2012, Article ID 502765, 4 pages, 2012

Reference #3: Weissberg D. Lung hernia - a review. Adv Clin Exp Med 22: 611-613; 2013

DISCLOSURE: The following authors have nothing to disclose: Brijesh Patel, Umar Sofi

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Topics: lung , hernias , colon , liver
Chest. 2015;148(4_MeetingAbstracts):42A. doi:10.1378/chest.2271662

SESSION TITLE: Thoracic Surgery Cases

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 27, 2015 at 07:30 AM - 08:30 AM

INTRODUCTION: Blunt traumatic rupture of the pericardium (BTRP) with associated cardiac herniation is an unusual and often fatal condition. Despite being a recognized complication of blunt chest trauma, the majority of cases have been identified postmortem. We present a patient who suffered high-energy blunt force thoracic trauma leading to pericardial rupture with cardiac herniation.

CASE PRESENTATION: A 22 year-old man with no previous history sustained a fall from the top of a 7-story building. On arrival the patient was comatose with bilateral chest subcutaneous emphysema. Chest radiography revealed multiple rib fractures with bilateral pneumothoraces, pneumopericardium and complete right-sided deviation of the cardiac silhouette. (Figure 1). Several cervical, pelvic and long bone fractures were identified. Bilateral chest tubes were placed. A chest tomography revealed persistent pneumothoraces and pneumopericardium with displacement of the cardiac structures to the right (Figure 2). The patient became hemodynamically unstable and was taken to the operating room. A median sternotomy revealed a 10cm vertical defect on the right pericardium at the level of the phrenic nerve with displacement of the entire heart into the right pleural space. The heart was mobilized back to its normal anatomic position. No great vessel or cardiac injury was identified. The pericardial defect was repaired with a Gore-Tex patch. Hemodynamic stability was recovered soon after. The patient survived surgery and is recovering from his injuries.

DISCUSSION: Pericardial rupture after blunt chest trauma has a reported incidence of 0.4% to 3%. If the heart herniates through the rupture, only approximately one third of patients will survive. Death occurs from torsion at the atrial level, which results in inflow occlusion with consecutive cardiac arrest, or compression of the coronary arteries. In this case there was delay in the diagnosis due to the abundance of other extrathoracic injuries. Nevertheless after prompt surgical repair his condition improved significantly. BTRP's high mortality is thought to be not only due to cardiac injury and herniation, but also due to associated injuries and delays in diagnosis.

CONCLUSIONS: BTRP with associated cardiac herniation is rare and difficult to diagnose. It should be suspected in every case of severe blunt chest trauma, particularly if there is hemodynamic instability.

Reference #1: Lindenmann J, Matzi V, et al. Traumatic pericardial rupture with cardiac herniation. Ann Thorac Surg. 2010; 89(6):2028-30.

DISCLOSURE: The following authors have nothing to disclose: Juan Biguria, Diego Maselli, Julian Salas Millan

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Chest. 2015;148(4_MeetingAbstracts):43A. doi:10.1378/chest.2262209

SESSION TITLE: Thoracic Surgery Cases

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 27, 2015 at 07:30 AM - 08:30 AM

INTRODUCTION: Pulmonary artery sarcomas are rare tumors with less than 300 cases reported in the literature. They arise from the pulmonary vasculature and can extend proximally and distally, rapidly resulting in right heart failure and death. Although most interventions are considered palliative, surgical excision can prolong survival. Here we present a case of pulmonary artery angiosarcoma with right ventricular failure that was treated with PTE.

CASE PRESENTATION: A 28 year-old Malaysian male was referred for evaluation of CTEPH and possible PTE. Until 8 months prior to presentation he had been very active, but at that time he started developing significant and progressive dyspnea on exertion which culminated to syncope. On initially work-up in he was thought to have a “saddle” PE with extension into the proximal branches of the ascending and descending PA based on CT pulmonary angiography. He received alteplase without improvement, and after two months on anticoagulation and persisting symptoms he underwent pulmonary embolectomy. Histopathology from the surgical specimen at the time demonstrated thrombus without neoplasia, but the clot was noted to be adherent to the vessel wall and difficult to remove. After some initial relief, his symptoms recurred and were compounded by anorexia and severe lower extremity edema. Follow up echocardiography showed elevated PA pressures and a mass within the the right ventricular outflow tract (RVOT). Right heart catheterization and PA angiogram showed mean PA pressure of 44mmHg, cardiac output of 2.4 and significant bilateral filling defects. He underwent bilateral PTE, RVOT mass resection and pulmonary valve replacement. His pathology was consistent with PA sarcoma, and despite developing acute renal, liver and respiratory failure, DIC and cardiogenic shock post-operatively, he improved and was eventually discharged home.

DISCUSSION: Pulmonary artery sarcoma is a rare and aggressive tumor, often misdiagnosed for pulmonary emboli and is usually confirmed on surgical and autopsy specimens. The disease is highly fatal even if treated, with studies demonstrating an average survival of 17 months after surgical resection and chemotherapy with or without radiation.

CONCLUSIONS: Although there are case reports of surgical cure this is rare, and surgical excision with PTE surgery or with pneumonectomy remains the best option for prolonging survival and providing some symptom relief.

Reference #1: Devendra G et al. Pulmonary artery sarcomas: the UCSD experience. Am J Respir Crit Care Med 2002;165:A24.

DISCLOSURE: The following authors have nothing to disclose: Alexandra Perry, Nick Kim, William Auger, David Poch, Gert Pretorius, Demosthenes Papmatheakis

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Chest. 2015;148(4_MeetingAbstracts):44A. doi:10.1378/chest.2230121

SESSION TITLE: Thoracic Surgery Cases

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 27, 2015 at 07:30 AM - 08:30 AM

INTRODUCTION: Chyloptysis is the clinical entity of sputum laced with chyle. We present a case of chyloptysis due to fibrosing mediastinitis that presented with recurrent airway obstruction and respiratory failure.

CASE PRESENTATION: A 57 year-old man was referred with a 9-year history of frequent episodes of dyspnea and a cough productive of copious white mucus that worsened after eating fatty meals. Five years prior to referral, he was treated for cryptococcal pneumonia and had recurrent episodes of respiratory failure related to tracheobronchial stenosis that improved with bronchoscopic dilations and aspiration of airway secretions. Physical examination was remarkable for bilateral rhonchi and fullness of the right axilla and chest wall. Bronchoscopy revealed thick, white, mucoid secretions, and stenosis of the trachea and bilateral main bronchi with white plaques on the mucosa (Image 1). Triglycerides, cholesterol, and chylomicrons were detected in the bronchial washings and endobronchial biopsies demonstrated abundant lipid-filled macrophages with dilated CD31+ and D2-40+ lymphatic channels. An MRI lymphangiogram showed mediastinal lymphangiectasis communicating with a malformation involving the right chest and axilla. The patient underwent ultrasound-guided doxycycline sclerosis of the lymphatic malformation.

DISCUSSION: A history of cough productive of copious white sputum following fatty meals should raise the specter of chyloptysis. It can develop from dilated bronchopulmonary lymphatics or a bronchopleural fistula communicating with a chylous effusion. This case is an unusual presentation of chyloptysis that resulted from lympangiectasis and obstruction associated with fibrosing mediastinitis and airway narrowing following cryptococcal bronchopneumonia. Upon sclerosis of the lymphatic malformation and adoption of a strict low fat diet, the patient has remained symptom-free at 18 months and has had dramatic improvements pulmonary function (Table 1).

CONCLUSIONS: Chyloptysis is confirmed by the presence of triglycerides, cholesterol, and chylomicrons in sputum or bronchial washings. Multiple diagnostic modalities may be required to identify the etiology. Here, we used bronchial washings with endobronchial biopsies and MRI lymphangiography to confirm the diagnosis. This case highlights the diagnostic utility of MRI as a noninvasive alternative to traditional lymphangiography and the therapeutic efficacy of dietary fat restriction for chyloptysis.

Reference #1: Lim KG, et al. Chyloptysis in adults. Chest. 2004;125:336-40

DISCLOSURE: The following authors have nothing to disclose: Allen Burks, Derek Byers, Chad Witt, Constantine Raptis

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Cardiovascular Disease

Chest. 2015;148(4_MeetingAbstracts):45A. doi:10.1378/chest.2281141

SESSION TITLE: Advances in Cardiac Disease

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Monday, October 26, 2015 at 04:30 PM - 05:30 PM

PURPOSE: Pentraxin-3 (PTX3) is a member of pentraxin superfamily that is structurally and functionally similar to C- reactive protein. PTX3 is suspected to be a specific marker of vascular inflammation. It is produced in response to proinflammatory cytokines (Interleukin 1 and tumor necrosis factor) by cells in atherosclerotic lesions including smooth muscle cells, vascular endothelial cells and macrophages. It is suggested that PTX3 may precisely reflect the inflammatory status of the vascular wall. The association between PTX3 and coronary artery disease (CAD) remains obscure. We conducted a meta-analysis to evaluate the relationship between serum PTX3 levels and coronary artery disease (CAD).

METHODS: We searched MEDLINE, CINHAL and COCHRANE databases for studies reporting serum PTX3 levels in the CAD and non-CAD study population. We included case controls, cohort and cross-sectional studies. We calculated the weighted standardized mean difference (SMD) in serum PTX3 levels between the CAD and control groups

RESULTS: Our search strategy yielded 177 articles and we included 17 studies enrolling 5550 participants. The median age of the CAD group was 65 yrs. (IQR 54.8 - 67.4) compared to 58.5 yrs. (IQR 49 - 64) in the control group. The median body mass index of the CAD group was 25.9 kg/m2 (IQR 25 - 27.4) compared to 26.9 kg/m2 (IQR 24.5 - 27.2) in control group. The median percentage of female population in the CAD group was 35.4% (IQR 18.4 - 40.7) compared to 40.8% (IQR 31.7 - 51.3) in the control group. The unweighted median serum PTX3 levels in the CAD group were 3 ng/ml (IQR 1.7 - 4.1) compared to 1.9 ng/ml (IQR 1 - 2.9) in the control group. The SMD of PTX3 level was 0.959 (95% CI 0.646 - 1.272) p<0.001 comparing those in the CAD group and control group.

CONCLUSIONS: Elevated serum PTX3 levels are significantly associated with CAD. However further studies are required to test this association after adjusting for traditional risk factors.

CLINICAL IMPLICATIONS: PTX3 is a promising novel biomarker of vascular inflammation and CAD which could potentially be used in early diagnosis of CAD and help determine the severity coronary atherosclerosis.

DISCLOSURE: The following authors have nothing to disclose: Pradyumna Agasthi, Sivakanth Aloor, Vivek Menon, Avantika Chenna , Anekwe Onwuanyi

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Chest. 2015;148(4_MeetingAbstracts):46A. doi:10.1378/chest.2278853

SESSION TITLE: Advances in Cardiac Disease

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Monday, October 26, 2015 at 04:30 PM - 05:30 PM

PURPOSE: VA ECMO has been described in the resuscitation of patients in sudden cardiac arrest. Limiting its use is the needed expertise to place large bore cannulae for vascular access to ensure adequate blood flow. Decreased cannulae size results in higher pressures needed to generate equivalent flows which in turn induce vessel collapse as pressures increase. We hypothesize that the state of cardiac contraction influences maximum obtainable withdrawal rates and that higher withdrawal rates are obtainable during cardiac arrest.

METHODS: Three 50 kg adult pigs were intubated and sedated with inhaled isoflurane. Pressure in the aortic arch and right atrium was measured with Millar catheters with coronary perfusion pressure calculated as the difference. A 15 Fr 18 cm long Medtronic arterial cannula was inserted into the femoral artery of each pig. A 15 Fr, 17 Fr, or 21 Fr 50 cm long Medtronic venous cannula was placed in the femoral vein to the level of the diaphragm in each pig. ECMO was initiated with a Medtronic centrifugal pump and Maquet Quadrox adult oxygenator. Flow measurements performed at a series of pump speeds until suction events resulted in flow cessation. A pacing wire was inserted into the right ventricle. Measurements were performed with the animals in three different cardiac states: (1) normal sinus rhythm; (2) paced at a rate of 240 beats per min; (3) cardiac arrest secondary to hypoxemia induced by ventilation with 100% nitrogen gas.

RESULTS: Rapid pacing resulted in minimal cardiac output as demonstrated by the lack of aortic pressure deflections and was used to simulate a rapidly reversible state in which the heart did not work against the ECMO circuit. The 15 Fr withdrawal cannula experienced suction events at low pump speeds during sinus rhythm but was able to support flow rates of 40 to 70 ml/kg/min during both rapid pacing and cardiac arrest. The 17 Fr and 21 Fr venous withdrawal cannulae were able to support a flow rate of 40 ml/kg/min during sinus rhythm until experiencing suction events at higher pump speeds. The larger cannulae supported flows comparable to the smaller cannula during paced and arrest states.

CONCLUSIONS: Smaller ECMO venous cannulae are able to sustain adequate venous withdrawal to maintain flow rates of 50 to 70 ml/kg/min in a porcine model of cardiac arrest but can supply only minimal support during normal cardiac function.

CLINICAL IMPLICATIONS: The successful use of smaller vascular cannulae may lead to wider use of ECMO for use in supporting patients in cardiac arrest.

DISCLOSURE: The following authors have nothing to disclose: Steven Keller, Sarah Fink, Henry Halperin, Muz Zviman

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Chest. 2015;148(4_MeetingAbstracts):47A. doi:10.1378/chest.2273229

SESSION TITLE: Advances in Cardiac Disease

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Monday, October 26, 2015 at 04:30 PM - 05:30 PM

PURPOSE: Although sepsis is a known risk factor for cardiac arrhythmias, data on incidence and outcomes of atrial and ventricular arrhythmias in severe sepsis are limited. We examine the association of severe sepsis with cardiac arrhythmias and their impact on outcome in this patient population.

METHODS: We used hospital discharge data from the Nationwide Inpatient Sample (NIS) from 2012. All patients 18 and older were included in the study. The International Classification of Diseases-Clinical Modification, 9th revision (ICD-9-CM) code was used to identify patients with discharge diagnosis of severe sepsis, atrial fibrillation, atrial flutter, ventricular fibrillation (VF) arrest and non-ventricular fibrillation (non-VF) arrest. To study the association of arrhythmias with severe sepsis, we defined two groups; a group with severe sepsis was compared to a group without severe sepsis. We used univariate and multivariate logistic regression methods to adjust for potential confounding factors and determined variables associated with cardiac arrhythmias.

RESULTS: A total of 30,712,524 NIS hospital discharges (weighted for national estimate) were included in our study, of which 1,756,965 (5.7%) had severe sepsis. On multivariate analysis, after adjusting for potential confounders, severe sepsis was associated with higher prevalence of atrial fibrillation (OR 1.23; 95% CI 1.21-1.24), atrial flutter (OR 1.34; CI 1.30-1.40), VF arrest (OR 2.58; CI 2.38-2.79) (OR 3.31; CI 3.07-3.57) and non-VF arrest (OR 4.91; 4.74-5.07). In the severe sepsis group cardiac arrhythmia was associated with higher in-hospital mortality (OR 1.41; 95% CI 1.37-1.45), length of stay >75% quartile (OR 1.50; CI 1.46-1.53) and total hospital charges >75% quartile (OR 1.37; CI 1.34-1.41). Advanced age, male sex, ischemic heart disease, diabetes mellitus, congestive heart failure, valvular heart disease, respiratory failure, mechanical ventilation and use of vasopressors were independently associated with cardiac arrhythmias.

CONCLUSIONS: Patients with severe sepsis are at high risk of atrial and life-threatening ventricular arrhythmias. Despite adjustment for potential confounding factors, patients hospitalized with severe sepsis carry significantly higher risk for cardiac arrest and increased mortality.

CLINICAL IMPLICATIONS: Increased risk of life-threatening ventricular arrhythmias associated with severe sepsis warrants closer monitoring and highlights a need for developing preventive strategies, which could lead to better outcomes in this population.

DISCLOSURE: The following authors have nothing to disclose: Krishna Thandra, Jawad Hussain, Muhammad Shahreyar, Sanjay Bhandari, Atul Thakur, Geetanjali Dang, Arshad Jahangir

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Chest. 2015;148(4_MeetingAbstracts):48A. doi:10.1378/chest.2259459

SESSION TITLE: Advances in Cardiac Disease

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Monday, October 26, 2015 at 04:30 PM - 05:30 PM

PURPOSE: Heart failure (HF) often worsens clinical outcomes in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) despite appropriate in-hospital therapy.

METHODS: This is a 5-year retrospective study on patients admitted with AECOPD. Patients were divided in left (LHF) vs right (RHF) vs biventricular HF (BiHF). Pre-morbid conditions such as obstructive sleep apnea (OSA), coronary artery disease (CAD) and use of pre-hospital angiotensin-converting-enzyme inhibitor (ACE-i)/angiotensin-receptor blocker (ARB), beta-blockers (BB) and 3-hydroxy-3-methylglutaryl CoA reductase inhibitors (statins) was analyzed. Outcomes included need and duration of non-invasive ventilation (NIV) and mechanical ventilation (MV), intensive care unit (ICU) length of stay (LOS) and total LOS (days). The data was assessed using chi-square test and Fisher’s exact test. Two-tailed p-value <0.05 was considered statistically significant.

RESULTS: A total of 735 patients met our inclusion criteria and were included in this study. HF was noted in 419 (57.0%) patients - LHF 165 (39.4%), RHF 154 (36.8%) and BiHF 100 (23.8%) (Mean left ventricular ejection fraction 52.4±15%). OSA increased ICU LOS in BiHF (5.1±0.4 vs 1.6±0.6, p=0.003), LHF (4.2±0.3 vs 2.6±0.5, p=0.03), RHF (4.3±0.6 vs 2.6±0.3, p=0.007) and no HF (5.6±0.6 vs 3.2±0.2, p<0.0001). MV days were increased in CAD+BiHF (9.5±1.5 vs 5.4±0.6, p=0.005), CAD+LHF (4.6±0.6 vs 2.6±0.5, p=0.01), OSA+LHF (4.4±0.5 vs 0.9±0.5, p=0.004) and OSA+no HF (6.2±1.0 vs 2.8±0.3, p<0.0001). Pre-hospital BB use decreased (a) MV in LHF (17.5% vs 5.6%); (b) MV days in BiHF (6.9±0.6 vs 2.0±0.9) and no HF (4.9±0.7 vs 2.7±0.3); (c) ICU LOS in LHF (5.3±0.5 vs 3.3±0.3), BiHF (5.2±0.4 vs 2.1±0.6) and no HF (5.1±0.5 vs 3.2±0.3); and (d) total LOS in LHF (7.1±0.7 vs 5.3±0.4) and no HF (6.0±0.5 vs. 4.8±0.2) (all p<0.05). In LHF, statins reduced NIV use (41.9% vs 26.6%, p=0.03), MV days (4.6±0.6 vs 2.5±0.5, p=0.01) and ICU LOS (4.4±0.4 vs 3.3±0.4, p=0.04). ACE-i/ARB reduced MV days and ICU LOS for BiHF (7.7±0.8 vs 3.4±0.7; 6.0±0.5 vs 3.0±0.4) and RHF (3.3±0.6 vs 1.4±0.5; 3.6±0.4 vs 2.5±0.3) (all p<0.05).

CONCLUSIONS: In this hypothesis-generating study on patients with AECOPD, pre-hospital cardiac medications predict better outcomes in concomitant HF. CAD with coexisting LHF/BiHF portends a worse prognosis while OSA is associated with worse outcomes independent of HF.

CLINICAL IMPLICATIONS: Pre-hospital factors influence outcomes in AECOPD patients with HF and merit further study in prospective trials.

DISCLOSURE: The following authors have nothing to disclose: Saraschandra Vallabhajosyula, Pranathi Sundaragiri, Anas Ahmed, Hamza Rayes, Toufik Mahfood Haddad, Haitam Buaisha, Anila Khan, Gene Pershwitz, Muhammad Sarfraz Nawaz, Dustin McCann, Christopher Wichman, Mark Holmberg, Lee Morrow

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Chest. 2015;148(4_MeetingAbstracts):49A. doi:10.1378/chest.2281581

SESSION TITLE: Cardiovascular Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Herniation of the lung through a defect in the intercostal muscles is a rare condition which is usually associated with either chest trauma or thoracic surgery. There are a few reports of lung hernia following vigorous cough in the absence of trauma or surgery. SAM is a rare non inflammatory vasculopathy characterized by vacuolar degeneration of smooth muscle cells of the medial layer of arteries. It usually affects abdominal visceral arteries. We report a case of intercostal lung herniation after vigorous cough in a patient with a history of celiac artery aneurysm due to SAM.

CASE PRESENTATION: A 42-yr-old male with history of ruptured celiac artery aneurysm 10 months prior presented with severe, sharp left lateral chest pain and mild shortness of breath. He had severe non-productive cough for a week. No history of chest trauma or surgery. Chest examination revealed decreased air entry on the left side with tenderness and subcutaneous emphysema over the left lower ribs laterally. A chest radiograph showed subcutaneous gas along the left lower chest wall. A computerized tomography (CT) scan of the chest revealed rupture of the intercostal muscles between the left lateral 7th and 8th ribs with herniation of the lung through the defect and a small left pneumothorax. Complete blood count and basic metabolic panel were unremarkable. Acid fast stain from sputum and bronchial washings were negative whereas Quantiferon-TB test was indeterminate. The sputum culture grew Mycobacterium mucogenicum. A left thoracotomy with repair of intercostal muscle defect was performed.

DISCUSSION: Acquired lung hernias are usually posttrauma or postsurgery. Spontaneous lung hernias occur in association with increased intra-thoracic pressure usually from vigorous cough, valsalva maneuver and heavy weight lifting. Our patient had vigorous cough which may explain the spontaneous lung herniation. There are no reports of association with SAM; however, a similar process may have predisposed the patient to a defect in intercostal muscles and subsequent lung herniation precipitated by cough.

CONCLUSIONS: Lung herniation should be considered in the differential diagnosis of patients who present with localized pain and subcutaneous emphysema after vigorous cough.

Reference #1: Tack, D et al Spontaneous lung herniation after a single cough. European Radiology 2000, 10:500-502

Reference #2: Jastrow KM, et al. Posterior lung herniation after a coughing spell: a case report. Cases journal. 2009;2(1):86.

DISCLOSURE: The following authors have nothing to disclose: Jilalu Kelbe, Gene Schwartz, Jayshil Patel

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Chest. 2015;148(4_MeetingAbstracts):50A. doi:10.1378/chest.2278648

SESSION TITLE: Cardiovascular Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: The presentation of a post pneumonectomy space (PPS) infection may be very subtle. Late empyema is rare and usually occurs more than three months post-surgery; however, it has been reported several decades following surgery.

CASE PRESENTATION: A 66 year-old man with hypertension, COPD, coronary artery disease and pneumonectomy for pulmonary tuberculosis in 1968 presented with pleuritic chest pain, fever, chills and night sweats for two weeks. He had tachycardia and absent breath sounds in the left hemithorax. Chest images revealed air-fluid level in the left cavity. Acid fast bacilli were present on AFB stain of two sputum samples and fluid aspirated from the left cavity. The fluid cultures only grew MRSA. A bronchoscopy evaluation did not reveal a bronchopleural fistula. He received broad spectrum antibiotics and anti-tuberculous for suspected mycobacteria tuberculosis infection and empyema of the PPS. He underwent VATS with debridement, rib resection and chest tubes placement. A closed Clagget procedure with continuous irrigation of the cavity with antibiotics (DAB solution) and saline for 10 days rendered cultures negative. Later a polymicrobial infection ensued with persistent purulence drainage from the site of the removed chest tubes. An Eloesser flap was created and fluid continues to drain to an ostomy bag. Dakin’s soaked Kerlix is used to pack the chest cavity.

DISCUSSION: We report a rare case of reactivation tuberculosis presenting as PPS empyema 45 years after pneumonectomy. The presence of a new air-fluid level in the space raised the suspicion of this serious complication. His initial treatment with ciprofloxacin rendered cultures negative for MTB. In very ill patients with PPS empyema open chest wall thoracostomy (OWT) allow time for rehabilitation in preparation for a definitive therapy.

CONCLUSIONS: Drainage remains the main step of therapy for this condition with high morbidity and mortality. Although closed irrigation was initially successful, the creation of an OWT controlled the recurrent infection. The obliteration of the cavity by thoracoplasty or muscle flap transposition is the standard treatment, but a good open drainage can give long lasting control.

Reference #1: McNulty N. Reactivation Mycobacterium Tuberculosis Presenting as Empyema Necessitans 55 Years Following Thoracoplasty. Radiology Case Reports. [Online] 2008;3:183.

Reference #2: Thourani VH, Lancaster RT, Mansour KA, Miller JI Jr. Twenty-six years of experience with the modified Eloesser flap. Ann Thorac Surg. 2003 Aug; 76(2):401-5; discussion 405-6.

DISCLOSURE: The following authors have nothing to disclose: Domingo Franco-Palacios, Darryl Weiman, Ganpat Valaulikar

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Chest. 2015;148(4_MeetingAbstracts):51A. doi:10.1378/chest.2263884

SESSION TITLE: Cardiovascular Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Single ventricle abnormality represents approximately 1% of all congenital cardiac defects, with an incidence of 0.05-0.1:10’000 live births [1]. With current medical and surgical advances, more patients are surviving to adulthood. Acute decompensation in adults is a common cause of death. New corrective approaches should be entertained to support the failing single ventricular hearts [2, 3]

CASE PRESENTATION: We present a case of a 61 year old female with unrepaired cyanotic congenital heart disease. Her defect is significant for double inlet single ventricle with left looping and transposition of great arteries and situs inversus with dextrocardia, with somewhat “protected” pulmonary bed secondary to pulmonary stenosis (PS). The patient has done well, despite developing atrial fibrillation and worsening atrioventricular valve regurgitation and complete heart block. TEE confirmed well preserved systolic function with EF 54%, severe PS and severe biatrial enlargement. Right and Left catheterization notable for within normal limits coronary flow and high normal pulmonary artery pressures. Cardiopulmonary testing is significant for abnormal cardiovascular response - inability to augment stroke volume and increased oxygen consumption with submaximal exercise response. Multidisciplinary decision was made to proceed with epicardial pacemaker (EPM). After uneventful minimal inferior medial sternotomy approach for placement and uncomplicated CTICU recovery our patient is undergoing evaluation for orthotopic heart transplant

DISCUSSION: The goal of EPM placement was to improve the patient’s choronotropic incompetence and respectively functional capacity. After initial post-operative recovery, patient noted improved functional status and oxygen saturation in high to low 70s

CONCLUSIONS: The uncorrected complex adult cyanotic cardiac pathology offers multifactorial array of challenges to the treating team. Understanding of the anatomy and pathological complications, as well as the physiological adaptation of each patient’s condition, is essential for the optimum management of these intricate disorders

Reference #1: EK Steinberger,C Ferencz,CA Loffredo.Infants With Single Ventricle:A Population-Based Epidemiological Study.Teratology.2002;65:103-115

Reference #2: Rossano JW,Chang AC.Perioperative management of patients with poorly functioning ventricles in the setting of the functionally univentricular heart.Cardiol Young.2006;16 (S1):47-54

Reference #3: H Vyas, DJ Hagler.Double Inlet Left Ventricle.Cur Treat Opt Card Med.2007;9:391-398

DISCLOSURE: The following authors have nothing to disclose: Ntesi Asimi, Jane Wilcox, Sherif Afifi

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Chest. 2015;148(4_MeetingAbstracts):52A. doi:10.1378/chest.2217303

SESSION TITLE: Cardiovascular Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Incidence of bronchopleural fistula (BPF) after pneumonectomy is reported to be 1-5% for cancer resections, with a reported mortality of 30-50%. It is more common after right-sided pneumonectomy secondary to various considerations including lack of local tissue coverage. Other risk factors include completion pneumonectomy, previous mediastinal/hilar radiation, prolonged mechanical ventilation, post-pneumonectomy empyema, residual tumor at the bronchial stump, and technical factors including devascularization, incomplete bronchial stump closure, or failure to provide supplemental tissue coverage of the bronchial stump. When the bronchial stump remains elongated, this leads to pooling of airway secretions and resultant BPF development.

CASE PRESENTATION: 72 year old female who presented with low grade fevers and shortness of breath one and a half weeks after undergoing an open right lobectomy converted to completion pneumonectomy for bronchogenic adenocarcinoma. Intraoperatively it was noted that the bronchial stump was difficult to manage, requiring oversewing and application of tissue adhesive. One month later, the patient was transferred for definitive treatment which included debridement of the right pleural space, resection of the elongated bronchial stump, and intrathoracic transposition of a pedicled right serratus anterior muscle flap. Following serial operative packing exchanges, the modified Clagett procedure was completed with chest closure 8 days after re-exploration.

DISCUSSION: Treatment of BPF is divided into acute and chronic phases. If BPF develops early after surgery (within 2 weeks) it is likely related to technical failure of the bronchial stump closure. Clinically it may present as a persistent or continuous air leak, progressive subcutaneous emphysema, and/or respiratory insufficiency/failure. If the BPF develops later in the postoperative course, it is likely due to inadequate healing or rupture of the bronchial stump. These patients usually present with fevers and/or productive coughs and are in danger of aspiration though the bronchial stump into the contralateral lung.

CONCLUSIONS: At the time of reoperation, the bronchial stump should be covered with a vascularized pedicle of tissue including either muscle, pericardial fat pad, or omentum. If the pleural space appears clean, it may be closed using the Clagett procedure.

Reference #1: Liberman M. and Cassivi SD. Bronchial Stump Dehiscence: Update on Prevention and Management. Seminar of Thoracic and Cardiovascular Surgery. 2007: 19:366-373.

DISCLOSURE: The following authors have nothing to disclose: Lawrence Greiten, Stephen Cassivi

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Chest. 2015;148(4_MeetingAbstracts):53A. doi:10.1378/chest.2275702

SESSION TITLE: Cardiovascular Disease Global Case Reports

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Penetrating aortic ulcer may lead to aortic hematoma, aortic dissection or rupture, as well as distal embolization. This variant of classic aortic dissection is a severe condition that demands accurate diagnosis and treatment. Since the patients are usually elderly and have comorbidities that would increase the complication rates of traditional surgery, endovascular management using endoprosthesis is an important alternative treatment.

CASE PRESENTATION: An 86-year-old female patient, with history of hypertensive cardiovascular disease presented to the emergency department complaining of recurrent substernal chest pain radiating to her back. She was admitted to the Intensive Care Unit (ICU) for blood pressure and pain control. No electrocardiogram or cardiac enzyme abnormalities were noted. A chest computerized tomography (CT) scan demonstrated a Type A aortic wall intramural hematoma (IMH) involving the ascending aorta, from two penetrating ulcers located on its anterolateral and posterior walls. No dissection flap was identified. Those findings were corroborated by both transthoracic echocardiogram exam and aortic angiography. After all treatment options were given to the patient and her family, she was taken to the cardiac catheterization laboratory where an aortic angiography was performed to deploy a 38 x 65mm ascending CMD endoprosthesis device (COOK Medical), just proximal to the brachiocephalic trunk. Angiography was subsequently performed to ensure placement of the endograft. The patient tolerated the procedure, with no major complications in clinical follow-up.

DISCUSSION: Aortic ulcer is a potential source of massive hemorrhage or even chronic chest pain. Shennan first described it in 1934. It occurs most commonly in the descending aorta. Diagnosis is suggested if focal ulcer with adjacent subintimal hematoma is found on CT scan. There is a tendency of Type A IMH to progress to aortic dissection, rupture, or aneurysm formation and an increased mortality. The management of a Type A IMH lacks consensus but, taking into account the profile of patients, endoprosthesis implantation via the femoral artery may be a considerable treatment. Considering her poor clinical condition, that was the choice in our patient.

CONCLUSIONS: Endovascular stent-graft placement is a more conservative and possibly definitive treatment option for Type A IMH when an ascending aortic ulcer can be identified.

Reference #1: Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection. Harris KM1, Braverman AC, Eagle KA, Woznicki EM, Pyeritz RE, Myrmel T, Peterson MD, Voehringer M, Fattori R, Januzzi JL, Gilon D, Montgomery DG,Nienaber CA, Trimarchi S, Isselbacher EM, Evangelista A. Circulation. 2012 Sep 11;126(11 Suppl 1):S91-6.

Reference #2: Endovascular treatment of an acute ascending aortic intramural hematoma. White C, Lapietra A, Santana O, Burke W 3rd, Beasley R, Conde C, Lamelas J. Int J Surg Case Rep. 2014;5(3):126-8. doi: 10.1016/j.ijscr.2013.12.001. Epub 2014 Jan 8.

Reference #3: Percutaneous Management of Penetrating Aortic Ulcer. Carvalho G, Machado MN, Carvalho RB, Neto AC. Arq Bras Cardiol. 2005 Oct;85(4):279-82. Epub 2005 Nov 7.

DISCLOSURE: The following authors have nothing to disclose: Gilberto Franco, Carlos Alves, Pamela Bianchet, Alberto Najjar, Sidney Munhoz, José Alfredo Sejólopes, Samuel Moreira, Paulo Ruiz Lima

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Chest. 2015;148(4_MeetingAbstracts):54A. doi:10.1378/chest.2220390

SESSION TITLE: Cardiovascular Disease Global Case Reports

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Epidermal nevus syndrome is a rare congenital sporadic neuro-ectodermic disorder, characterized by the presence of epidermal nevi in association with various developmental abnormalities of the skin, eyes, nervous, skeletal, cardiovascular and urogenital systems. In the literature, the outcomes of percutaneous transluminal angioplasty is known to be poor in other neuro-ectodermic diseases such as neurofibromatosis,

CASE PRESENTATION: We describe a 5-year-old boy with conjunctival lipodermoid, cervical and facial sebaceous nevi who presented at 3 years of age with hypertension due to bilateral renal artery stenosis together with multiple vascular anomalies (aorta, celiac trunk, superior mesenteric artery) as shown by magnetic resonance angiography. Systemic arterial hypertension was difficult to control despite combined anti-hypertensive drugs and the surgical repair of the aortic coarctation.

DISCUSSION: Bilateral renal artery stenosis is an unusual vascular malformation associated with epidermal nevus syndrome. A percutaneous transluminal angioplasty was not attempted because of known poor results in other neuro-ectodermic diseases such as neurofibromatosis, and also because of bilateral involvement with a risk of thrombosis and further renal damage compared with acceptable control of blood pressure by medical therapy. The overall therapeutic attitude was made with the motto “primum non nocere” as long as the situation is stable for several years. The optimal treatment strategy for renal artery stenosis remains unclear. There are no randomized clinical trials comparing the effects of angioplasty stenting versus medical therapy alone in such patients

CONCLUSIONS: we need randomized clinical trials comparing the effects of angioplasty stenting versus medical therapy alone in patients with renal artery stenosis.

Reference #1: Solomon LM, Fretzin DF, Dewald RL. The epidermal nevus syndrome. Arch Dermatol. 1968;97:273-285. doi: 10.1001/archderm.97.3.273

Reference #2: Grebe TA, Rimsza ME, Richter SF, Hansen RC, Hoyme HE. Further delineation of the epidermal nevus syndrome: two cases with new findings and literature review. Am J Med Genet. 1993;47:24-30. doi: 10.1002/ajmg.1320470106

Reference #3: Booth TN, Rollins NK. MR imaging of the spine in epidermal nevus syndrome. AJNR Am J Neuroradiol. 2002;23:1607-1610

DISCLOSURE: The following authors have nothing to disclose: Fahad Alsohime

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Chest. 2015;148(4_MeetingAbstracts):55A. doi:10.1378/chest.2278932

SESSION TITLE: Cardiovascular Disease Posters I

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Patients in cardiac arrest with an initial rhythm of asystole or pulseless electrical activity (PEA) have a poor rate of survival to hospital discharge despite adequate CPR. Manual chest compressions are estimated to provide 30% of normal cardiac output. Support with veno-arterial extracorporeal membrane oxygenation (VA ECMO) has been successfully used in patients experiencing sudden cardiac arrest. VA ECMO is performed with large bore cannulae in the venous and arterial vasculature with targeted flows of 50 to 70 ml/kg/min. We hypothesized that lower flow rates provide coronary perfusion pressure (CPP) comparable to CPR in a porcine model of minimal cardiac output which may then allow for the use of smaller cannulae resulting in wider access to ECMO support.

METHODS: Five 50 kg adult pigs were intubated and sedated with inhaled isoflurane. A 21 Fr 50 cm long Medtronic cannula was inserted via the femoral vein into the inferior vena cava to the level of the diaphragm. A 15 Fr 18 cm long Medtronic arterial cannula was inserted into the femoral artery. Pressures in the aortic arch and right atrium were measured with Millar catheters with coronary perfusion pressure (CPP) calculated as the difference. Rapid pacing was triggered via a transcutaneous pacing wire inserted into the right ventricle. After onset of rapid pacing, ECMO was initiated with a Medtronic 550 Console and Maquet adult oxygenator with pump speeds gradually increased from 1500 rpm to higher speeds until vessel collapse was encountered with simultaneous measurement of flow and CPP.

RESULTS: Rapid pacing was performed at a rate of 240 bpm which induced minimal cardiac output as evidenced by the lack of deflections in the aortic pressure tracing. ECMO mechanical support was started with an initial pump speed of 1500 bpm and a flow rate of 25 ml/kg/min and maintenance of a CPP of 40 mm Hg. The pump speed was gradually increased until suction events at 4000 rpm resulted in reduced flow rates. Prior to vessel collapse, peak flow of 80 ml/kg/min was produced. Calculated CPP gradually increased as flow increased from 40 ml/kg/min to 60 ml/kg/min and then remained roughly constant even as flow rates further increased.

CONCLUSIONS: Low flow VA ECMO support is able to provide comparable CPPs to CPR which may permit the use of smaller access cannulae resulting in wider access to ECMO support during cardiac arrest.

CLINICAL IMPLICATIONS: Increased use of ECMO utilizing smaller vascular cannulae may lead to increased survival from sudden cardiac arrest.

DISCLOSURE: The following authors have nothing to disclose: Steven Keller, Sarah Fink, Henry Halperin, Muz Zviman

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Chest. 2015;148(4_MeetingAbstracts):56A. doi:10.1378/chest.2278832

SESSION TITLE: Cardiovascular Disease Posters I

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Peak expiratory flow rate (PEFR) has been shown to be an effective tool in assessing heart failure (HF) status and its course of recovery in patients with acute decompensated HF. However, the role of PEFR in patients with chronic stable HF in the outpatient setting has not been studied. We sought to investigate this relationship.

METHODS: We prospectively enrolled fifty patients with chronic stable HF, stage C, NYHA functional class I-III, from our outpatient HF clinic. Patients with HF hospitalization and those with cardiac surgery or myocardial infarction within 3 months were excluded. PEFR was measured for each subject in triplicate. Averaged PEFR values were compared to predicted averages (adjusted for age, sex, and height) and expressed as percentages. Data related to patient demographics, hemodynamics, laboratory values, clinical signs and symptoms and functional capacity were collected.

RESULTS: Mean age was 69 years, 68% were Caucasian and 68% were males. All patients had NYHA class II-III chronic stable HF with average HF duration of six years. Majority of the patients had ischemic HF (68%) and HF with reduced ejection fraction (80%). Overall mean percentage of predicted PEFR was 81% + 28%. Subjects with brain-natriuretic peptide (BNP) levels above 100 pg/ml had significantly lower PEFR compared to those with BNP less than 100 pg/ml (59% + 20%, p= 0.001). PEFR also tended to be lower in patients with positive physical findings for HF compared to those without physical findings (62% + 17% vs 84% + 28%, p=0.06). There was no significant difference in PEFR between patients with NYHA class III and NYHA class II HF (82% + 26% vs 74% + 21, p=0.3).

CONCLUSIONS: PEFR reflects large airway flow, muscular strength and patient effort and is associated with known indicators of HF status. Our study suggests that there is great variability in normalized PEFR ratios even in stable HF outpatients. Additionally we observed relationships with key HF biomarkers but not between NYHA classes.

CLINICAL IMPLICATIONS: The ease of performance along with its limited cost and portability suggest that the repeated PEFR testing may be an additive simple clinical tool that distinguishes patients with overlapping clinical scenarios and residual risk for adverse HF outcomes. We are currently evaluating the predictability of PEFR as a biomarker for HF outcomes. The simplicity, repeatability, and portability emphasize reconsideration of PEFR in chronic disease management of HF patients.

DISCLOSURE: The following authors have nothing to disclose: Hesam Keshmiri, Jeffrey Ziffra, Fadi Abou Obeid, Luay Rifai, Marc Silver

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Chest. 2015;148(4_MeetingAbstracts):57A. doi:10.1378/chest.2278740

SESSION TITLE: Cardiovascular Disease Posters I

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Survival to discharge from cardiac arrest in patients with an initial rhythm of pulseless electrical activity or asystole remains dismal despite adequate cardiopulmonary resuscitation (CPR) efforts. Successful use of extracorporeal membrane oxygenation (ECMO) in the management of out-of-hospital sudden cardiac arrest has been reported and has generated interest in its use as an adjunct therapy to traditional CPR. We tested the hypothesis that cardiopulmonary support via ECMO may result in return of spontaneous circulation (ROSC) in a porcine model of hypoxic cardiac arrest.

METHODS: Utilizing a porcine model of cardiac arrest, five 50 kg adult pigs were intubated and sedated with inhaled isoflurane. A 21 Fr 50 cm long Medtronic Bio-Medicus venous cannula was inserted via the femoral vein into the inferior vena cava to the level of the diaphragm. A 15 Fr 18 cm long Medtronic Bio-Medicus arterial cannula was inserted into the femoral artery. Pressure in the aortic arch and right atrium was measured with Millar catheters with coronary perfusion pressure (CPP) calculated as the difference between the two measured pressures. Hypoxemia was induced by ventilation with 100% nitrogen gas. Fifteen minutes after onset of arrest, ECMO was initiated with a Medtronic Bio-Console 550 and MaquetQuadrox adult oxygenator with pump speeds set for a mean flow of 40 ml/kg/min.

RESULTS: After a mean average of one minute of ECMO support, organized cardiac electrical activity resumed evidenced by deflections in right atrial pressure tracings. Ventricular fibrillation became evident after a mean average of three minutes of ECMO support which was then successfully defibrillated into sinus rhythm after an additional 5 minutes of ECMO support in all five pigs. Prior to defibrillation, the mean CPP provided by ECMO was 32 mm Hg at a pump speed of 2000 RPM. Two minutes after return of spontaneous circulation (ROSC), the ECMO pump was turned off with maintenance of sinus rhythm, with mean peak aortic pressures of 70 mm Hg, and mean CPP of 40 mm Hg.

CONCLUSIONS: Low to moderate flow ECMO support can successfully produce ROSC in a porcine model of hypoxemic asystole cardiac arrest without any additional resuscitative support. ECMO deserves further investigation as an adjunct support technology for the resuscitation of PEA and asystolic cardiac arrest.

CLINICAL IMPLICATIONS: Maintenance of cardiac blood flow via ECMO can maintain cardiac viabillity in a PEA model of arrest even in the abscence of oxygen support.

DISCLOSURE: The following authors have nothing to disclose: Steven Keller, Sarah Fink, Henry Halperin, Muz Zviman

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Chest. 2015;148(4_MeetingAbstracts):58A. doi:10.1378/chest.2271618

SESSION TITLE: Cardiovascular Disease Posters I

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: This study investigates whether heart sound frequency analysis (HSFA) differentiates hypertrophic cardiomyopathy (HCM) from hypertensive heart disease. In addition, this study compares the HSFA to ECG testing for identifying HCM.

METHODS: Subjects with HCM (n=9), hypertensive heart disease (HHD, n=9) and normals (n=9) underwent heart sound frequency analysis (HSFA) and electrocardiography (ECG). An electronic stethoscope was used to record heart sounds for 6 seconds in the lying down (LD), standing (S) positions and post exercise (E). Fast Fourier analysis of the heart sound recordings was performed and frequency peaks were analyzed using MATLAB software. Change in frequencies from LD to S and LD to E were evaluated. The data was statistically analyzed using t-test. The results of the frequency analysis were compared to the results of the ECG.

RESULTS: Widening of the frequency spectrum of heart sounds upon standing identified the majority of subjects with HCM. 88.9% of HCM subjects showed an increase in the range of frequencies from LD to S (average change = +57.74 Hz). In comparison, 88.9% of normal subjects displayed a significant decrease in the range of frequencies (average change = - 27.2 Hz, p-value = 0.01). 88.9% of subjects with HHD also showed a significant decrease in the range of frequencies upon standing (average change = -38.62 Hz, p-value=0.008). No significant differences were found between the normal and HHD group (p-value=0.64). HSFA had a high specificity and sensitivity of 88.9% each. ECG with a 100% specificity and 38.9% specificity was unable to identify the majority HCM subjects (false negative rate 61.1%). At a cut off of 20 Hz the estimated accuracy of HSFA is 99.93%.

CONCLUSIONS: The heart sound frequency analysis differentiates HCM from both normals and hypertensive heart disease and outperforms ECG testing.

CLINICAL IMPLICATIONS: AHA/ACC acknowledges the limited public health benefit of universal ECG screening in HCM on account of its high false positive and negative rates. Early detection of HCM is key to preventing sudden cardiac death. Heart sound frequency analysis is inexpensive, easy to perform in a public health setting and has the attributes of an ideal screening test.

DISCLOSURE: The following authors have nothing to disclose: Medha Krishen, Mary Zaremba, Ajay Krishen, Sivaji Gundlapalli, Ramesh Reddy, Sridhar Reddy

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Chest. 2015;148(4_MeetingAbstracts):59A. doi:10.1378/chest.2267528

SESSION TITLE: Cardiovascular Disease Posters I

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: The heart failure (HF) syndrome includes global and cerebral hypoperfusion. We reported that HF patients have low resting cerebral oxygen saturation (SctO2) and have a decline in SctO2 approaching the anaerobic threshold (AT). We sought to study peripheral (SpO2) and cerebral (SctO2) changes in oxygenation at rest and during 6 minute walk (6MW) and to study the impact of oxygen supplementation.

METHODS: We conducted a prospective cohort study in 30 patients with HF with 21 patients being male, average age of 66 and average HF duration of 48 months. LVEF ranged from 12-60% (32.1%) with only 4 pts > 55%. Average BNP was 353 pg/ml. During a non-urgent visit to our HF clinic, patients performed a 6MW without additional oxygen followed by a second 6MW with oxygen (3L/min nasal cannula) within 60 minutes or starting the 6MW with oxygen followed by a second 6MW without oxygen within 60 minutes. SctO2 and SpO2 were continuously monitored.

RESULTS: 30 patients safely completed both 6MW. Walk distances with or without supplemental oxygen (785 vs 814 feet, respectively) were not significantly different. Similarly, SpO2-rest (96.7% vs 97.9%), SpO2-6min (95.2% vs 95.5%), SctO2-rest (64.5% vs 62.7%) or SctO2-6 min (62.3 vs 61.3) did not significantly differ either with or without supplemental O2, respectively.

CONCLUSIONS: During 6MW in HF patients, oxygen supplementation did not alter walk distances, baseline or post walk SpO2 or SctO2, nor modest exercise declines observed in SpO2 and SctO2. This study underscores the complexity of peripheral/cerebral oxygen delivery in HF patients. It also suggests that 6MW, even in symptomatic HF patients, may not approximate AT in most patients. Given concern that repetitive episodes of cerebral hypoxia may contribute to cognitive dysfunction, a better understanding of this physiology is needed.

CLINICAL IMPLICATIONS: Both peripheral (SpO2) and cerebral (SctO2) oxygenation are important biomarkers in HF patients. We have observed abnormal SctO2, despite normal SpO2, in HF patients that decline at AT. The current study demonstrated the lack of these observations with 6MW and the lack of effect of oxygen supplementation.

DISCLOSURE: The following authors have nothing to disclose: Jeffrey Ziffra, Hesam Keshmiri, Luay Rifai, Tariq Yousuf, Jalal Vargha, Marc Silver

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Chest. 2015;148(4_MeetingAbstracts):60A. doi:10.1378/chest.2220355

SESSION TITLE: Cardiovascular Disease Posters I

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Hemorrhage is the most frequent complication occurring in patients who are on venoarterial or venovenous extracorporeal membrane oxygenation (ECMO). Recombinant activated factor VIIa (rFVIIa), a potent procoagulant has been used in these patients with conflicting results. We describe our experience in pediatric patients on ECMO who received rFVIIa for refractory bleeding.

METHODS: We reviewed the medical charts of all the patients who underwent ECMO in our PICU between January 1999 to July 2014 and received FVII for refractory bleeding. Clinical characteristics, demographics, type of congenital heart disease, surgical correction, bleeding, thrombotic complications, mortality, and rFVIIa dose were all documented.

RESULTS: 123 patients underwent ECMO in our unit since 1999, and five of them received rFVIIa for persistent refractory bleeding during venoarterial ECMO. All of these patients were postoperative cardiac surgery for congenital defects prior to the initiation of ECMO. Transfusion requirements dramatically decreased in 4 patients, without a major thrombotic event. In one patient bleeding remained significant and a left pulmonary artery thrombosus was confirmed by cardiac catheterisation. 4 patients survived at 48 hour after withdrawal from ECMO.

CONCLUSIONS: rFVIIa use for refractory bleeding in patients on ECMO was efficacious in stopping bleeding without major thrombotic events. While the use of rFVIIa seems effective, indications for its use, modalities of administration and precautions to be taken need to be better defined.

CLINICAL IMPLICATIONS: to outweight the benifices over the risks of using rFVIIa for patients on ECMO with severe refractory bleeding

DISCLOSURE: The following authors have nothing to disclose: Fahad Alsohime

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Chest. 2015;148(4_MeetingAbstracts):61A. doi:10.1378/chest.2281628

SESSION TITLE: Cardiovascular Disease Posters II

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Radiofrequency and cryoballoon ablation techniques have become more widely used in patients with difficult to manage atrial fibrillation. A significant number of patients have persistent symptoms despite appropriate medical management, necessitating an invasive, nonpharmacologic approach. Multiple energy sources can be used for ablation of atrial fibrillation, and it is unclear whether clinical outcomes are affected by different techniques.

METHODS: All patients undergoing ablation for atrial fibrillation within the past 3 years were assessed. Clinical, laboratory, and electrocardiographic data were evaluated. Patients were divided into subsets based on the type of ablative procedure (radiofrequency, cryoballoon, or hybrid approach using both cryoballoon and radiofrequency energy). Success rates in maintenance of sinus rhythm immediately post-ablation and at the latest follow-up were compared.

RESULTS: A total of 276 patients met inclusion criteria, of which 107 underwent radiofrequency ablation, 93 cryoballoon ablation, and 76 a combined cryoballoon and radiofrequency ablation approach. A similar number of patients were noted to be in normal sinus rhythm both immediately following ablation (p=0.922) and at follow-up (p=0.589). Fewer patients in the cryoablation subset (p=0.003) required anti-arrhythmic medications or additional cardiac procedures such as repeat ablation or cardioversion. Patients in the radiofrequency subset were more likely to have periand post- procedure bleeding complications (n=19, 17.8%) compared to the combined (n=7, 9.2%) and cryoballoon (n=6, 6.5%) approaches (p=0.023).

CONCLUSIONS: Cryoballoon ablation may offer both safety and outcome benefits in the treatment of atrial fibrillation when compared with either a radiofrequency or a combined hybrid approach.

CLINICAL IMPLICATIONS: Providers should be aware of the efficacy and complication rates when deciding on which procedure to use in the ablation of atrial fibrillation.

DISCLOSURE: The following authors have nothing to disclose: David Snipelisky, Jordan Ray, Ryan Ung, Melissa Duart, Christine Kauffman, Fred Kusumoto

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Chest. 2015;148(4_MeetingAbstracts):62A. doi:10.1378/chest.2278908

SESSION TITLE: Cardiovascular Disease Posters II

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Aortic stenosis (AS) resulting in left ventricular hypertrophy with resultant dysfunctional lusitropy leads to pulmonary vascular remodeling (Group 2 pulmonary hypertension). The aim of this study is to examine the effect of pulmonary hypertension (PH) in patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS: We conducted a retrospective post-hoc analysis of 59 patients who underwent TAVR from June 2011 to February 2015 at a single tertiary care facility. Moderate/severe PH was defined as pulmonary artery systolic pressure greater than or equal to 50 mmHg versus mild PH (systolic PAP less than 50 mmHg) at time of TAVR as based on right heart catheterization (RHC). Moderate/severe PH (n = 19, 32.2%) None/mild PH (n = 40, 67.8%)

RESULTS: Pre TAVR acute kidney injury (AKI) was significant for moderate/severe PH (22.2% vs 5%; p = 0.0463). There was a tendency for development of post TAVR AKI (33.33% vs 12.5%, p = 0.0612). AKI was defined by The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines. Post TAVR incidence of heart block (11.11% vs 0%; p = 0.0319) and permanent pacemaker placement (16.67% vs 2.5%; p = 0.0489) were also significant for the moderate/severe PH patients. Significant increases in mortality were seen at 60 days (26.32% vs 5%; p = 0.018), 90 days (31.58% vs 5%; p = 0.0053), and 120 days (31.58% vs 5%; p = 0.0053) for the moderate/severe PH patients.

CONCLUSIONS: Our study finds that PH has a significant deleterious impact in patients undergoing TAVR. Increased short-term mortality, up to three months post TAVR and AKI highlights how right ventricular dysfunction complicates outcomes in this very frail patient population.

CLINICAL IMPLICATIONS: The development of PH is a poor prognostic indicator in aortic stenosis patients who are undergoing TAVR. Pre-operative optimization of PH with pulmonary vasodilators and inotropes with maintenance of euvolemia may play a pivotal role in long-term outcomes post-TAVR.

DISCLOSURE: The following authors have nothing to disclose: Raj Parikh, Benson Varghese, Huma Khatoon, Clifford Kavinsky, Rajive Tandon

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Chest. 2015;148(4_MeetingAbstracts):63A. doi:10.1378/chest.2271760

SESSION TITLE: Cardiovascular Disease Posters II

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Thromboembolism due to atrial fibrillation (AF) is a frequent cause of stroke. More than 90% of thrombi in AF form in the left atrial appendage (LAA). It has been suggested in a few studies that certain types of LAA morphology are at heightened risk for thromboembolism in AF patients. We aimed to systematically anlyze all the existing literature for association between LAA morphology and stroke risk.

METHODS: PubMed, EMBASE and Google Scholar databases were searched to identify all studies describing the different LAA morphologies and their association with stroke. Data from identified studies was extracted and meta-analysis was carried out using Revman 5.2 software. Pooled Odds ratios (OR) were calculated using Mantel-Haenszel random effects model. Between studies heterogeneity was assessed using the I2 statistic.

RESULTS: A total of 3 studies with 1690 subjects met our inclusion and exclusion criteria and were included in the final analysis. The Chicken wing, Cactus, Windsock and Cauliflower type of LAA morphology was seen in 45%, 24%, 23% and 7% of the patients, respectively. The Chicken wing type LAA was associated with low risk of stroke (OR 0.47, 95% CI0.28 -0.80) compared to non-chicken wing LAA. Further, the Cauliflower type increased stroke risk compared to other types (OR 2.45, 95% CI 1.48-4.06) and Cactus type also was associated with increased risk of stroke (OR 1.76, 95% CI 1.22-2.54). The Windsock type of LAA did not increase the risk of stroke compared to other LAA types (OR 0.83, 95% CI 0.42-1.63).

CONCLUSIONS: The non-Chicken wing type of LAA morphologies increases the risk of thromboembolism in AF.

CLINICAL IMPLICATIONS: Assessment of LAA morphology may aid in risk stratifying the patients at heightened risk for thromboembolism in AF.

DISCLOSURE: The following authors have nothing to disclose: Vivek Yarlagadda, Parinita Dherange, Arun Kanmathareddy, Pradyumna Agasthi, Sampath Gunda, Dhanunjaya Lakkireddy, Madhu Reddy

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Chest. 2015;148(4_MeetingAbstracts):64A. doi:10.1378/chest.2259208

SESSION TITLE: Cardiovascular Disease Posters II

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: To investigate warfarin management and clinical outcomes associated with time-in-therapeutic range (TTR) in patients with non-valvular atrial fibrillation (NVAF).

METHODS: A retrospective cohort study was conducted among NVAF patients. Adult patients diagnosed with NVAF and ≥1 warfarin prescription were identified between 01/01/2006-12/31/2011 within Kaiser Permanente Southern California, and followed until 12/31/2013. Clinical outcomes included stroke/systemic embolism (SE), and major bleed. Descriptive statistics and multivariable Cox proportional hazard models were used to determine association between TTR and outcomes.

RESULTS: A total of 34,382 NVAF patients on warfarin treatment were identified and followed for a median of 3.8 years. About half (49%) of patients were newly initiating warfarin therapy. International normalized ratio (INR) monitoring and pharmacist interventions were conducted roughly every 3 weeks [mean (SD) days for INR monitoring was 20.8 (38.2) days, and 21.5 (15.8) days for intervention]. 63% of the study population had ≥1 warfarin dose adjustment during the first 6 months with a median of 5 annual dose adjustments. Warfarin dose adjustment occurred on a median of 1 day after the INR measurement. Median TTR was 61% with 27% of interquartile range. Stroke/SE rates (per 100 person-years) were 1.30 and major bleed rates were 9.01. TTR below median (< 61%) was associated with a higher risk of stroke/SE [hazard ratio (HR) (95% CI) = 1.96 (1.75-2.21)] as well as a higher risk of bleed [HR = 1.56 (1.49-1.64)] compared to TTR above median (≥ 61%). A linear association was found between the stroke/SE rates and TTR quartiles; 0.89, 0.94, 1.27, 2.76 (TTR ≥73%, 61-72%, 46-60%, <46%, respectively), but not between the major bleed rates and TTR; 7.81, 6.76, 8.52, 15.91 (TTR ≥73%, 61-72%, 46-60%, <46%, respectively). The high rates of stroke/SE and major bleed were driven by the lowest TTR quartiles.

CONCLUSIONS: Close monitoring with timely warfarin dose adjustments were found in patients with NVAF managed by pharmacist-led anticoagulation clinics. However, there were still substantial number of patients whose TTR was suboptimal and eventually experienced more stroke/SE and bleeding events.

CLINICAL IMPLICATIONS: Maintaining an appropriate level of TTR is important to maximize stroke/SE prevention benefits from warfarin therapy while minimizing bleed events. New treatment strategies for patients who are not able to reach optimal therapeutic ranges are necessary to improve outcomes.

DISCLOSURE: JaeJin An: Grant monies (from industry related sources): Bristol Myers Squibb/Pfizer, Grant monies (from industry related sources): Genentech Robert Mendes: Employee: Pfizer Diana Dills: Employee: Pfizer Lien Vo: Employee: BMS Prianka Singh: Employee: BMS Amanda Bruno: Employee: BMS Gustavus Aranda: Employee: BMS The following authors have nothing to disclose: Fang Niu, Chengyi Zheng, Nazia Rashid, Daniel Lang, Paul Le, Kristin Jazdzewski

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Chest. 2015;148(4_MeetingAbstracts):65A. doi:10.1378/chest.2253437

SESSION TITLE: Cardiovascular Disease Posters II

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: To compare health care utilization and costs for major bleeding after initiation of oral anticoagulants (OACs) among treatment-naïve non-valvular atrial fibrillation (NVAF) patients.

METHODS: Adult patients in the Medicare advantage population who were prescribed apixaban, rivaroxaban, dabigatran or warfarin were selected from the Optum Research Database between 01JAN2013 through 31DEC2014. The first OAC prescription date was designated as the index date. Patients were required to have an NVAF diagnosis before the index date, continuous health plan enrollment for 6 months pre-index date, and no OAC claims during the baseline period. Patients were categorized into four cohorts based on their index prescription: apixaban, dabigatran, rivaroxaban and warfarin. Major bleeding event claims within 90 days of the index date were captured and associated health care utilizations and costs were calculated per patient per month (PPPM). Major bleeding-related health care resource utilization and costs were compared using propensity score-weighted generalized linear models.

RESULTS: There were 25,847 patients included in the study, of which 1,778 were prescribed apixaban. The major bleeding incidence rate within 90 days of the index date was significantly lower in apixaban patients (12.0 per 100 person-years) compared to rivaroxaban (23.5 per 100 person-years, p<0.001) and warfarin (25.6 per 100 person-years, p<0.001) patients and trended towards numerically lower major bleeding incidence compared to dabigatran patients. After adjusting for baseline characteristics and demographics, patients treated with apixaban were significantly less likely to have a major bleeding-related inpatient stay (1.4%) compared to those treated with dabigatran (2.4%, p=0.017), rivaroxaban (3.2%, p<0.001) or warfarin (3.2%, p<0.001). Apixaban patients had significantly lower major bleeding-related medical costs PPPM within 90 days ($38) compared to rivaroxaban ($109, p<0.001) and warfarin ($114, p<0.001) patients and numerically lower major bleeding-related costs compared to dabigatran ($40, p=0.870) patients.

CONCLUSIONS: Treatment-naïve NVAF patients prescribed apixaban were significantly less likely to have a major bleeding event within 90 days of treatment initiation compared to those prescribed rivaroxaban or warfarin.

CLINICAL IMPLICATIONS: Apixaban patients incurred significantly lower major bleeding-related costs compared to those prescribed rivaroxaban and warfarin.

DISCLOSURE: Alpesh Amin: Consultant fee, speaker bureau, advisory committee, etc.: Alpesh Amin is a paid consultant for Pfizer Inc. Allison Keshishian: Consultant fee, speaker bureau, advisory committee, etc.: Allison Keshishian is an employee of STATinMED Research, which is a paid consultant for Pfizer Inc. and Bristol-Myers Squibb. Lin Xie: Consultant fee, speaker bureau, advisory committee, etc.: Lin Xie is an employee of STATinMED Research, which is a paid consultant to Pfizer Inc. and Bristol-Myers Squibb. Onur Baser: Consultant fee, speaker bureau, advisory committee, etc.: Onur Baser is an employee of STATinMED Research, which is a paid consultant for Pfizer Inc. and Bristol-Myers Squibb. Kwanza Price: Employee: Kwanza Price is an employee of Pfizer Inc. Lien Vo: Employee: Lien Vo is an employee of Bristol-Myers Squibb. Prianka Singh: Employee: Prianka Singh is an employee of Bristol-Myers Squibb. Amanda Bruno: Employee: Amanda Bruno is an employee of Bristol-Myers Squibb. Jack Mardekian: Employee: Jack Mardekian is an employee of Pfizer Inc. Wilson Tan: Employee: Wilson Tan is an employee of Pfizer Inc. Shalabh Singhal: Employee: Shalabh Singhal is an employee of Bristol-Myers Squibb. Chad Patel: Employee: Chad Patel is an employee of Bristol-Myers Squibb. Kevin Odell: Employee: Kevin Odell is an employee of Pfizer Inc. Jeffrey Trocio: Employee: Jeffrey Trocio is an employee of Pfizer Inc.

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Chest. 2015;148(4_MeetingAbstracts):66A. doi:10.1378/chest.2250462

SESSION TITLE: Cardiovascular Disease Posters II

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Using administrative claims data for commercial and Medicare Advantage enrollees linked to hospital electronic health records (EHR) and social security administration’s (SSA) death master file, we describe the inpatient oral anticoagulant (OAC) treatment, discharge location status, and post-discharge OAC treatment for patients hospitalized with NVAF.

METHODS: We identified 2,932 patients that were hospitalized with a primary (38%) or secondary (62%) diagnosis of AF without evidence of rheumatic mitral valvular heart disease or a valve replacement procedure between 01 Jan 2009 and 30 Sep 2013. Inpatient OAC treatment was identified from the EHR data, while discharge status (deceased, long term care, home health care, and home self-care) and OAC treatment in the 30-days post discharge were obtained from claims data and SSA death master file.

RESULTS: The mean age was 72.5 years, 61.3% were male, 70.6% enrolled in a Medicare Advantage plan, and 51 (1.7%) patients died while hospitalized. Of the 2,932 hospitalized patients, 6.5% received a target-specific OAC (TSOAC) (apixaban, rivaroxaban or dabigatran), 37.5% warfarin, and 56% no OAC. Patients receiving a TSOAC were younger (69.1 years) and more likely to be male (69.0%). Of the surviving patients, 71.4% were discharged to home health-care, 12.7% home self-care, and 5.3% long term care (discharge status was unknown for 10.7%). In the 30-days post discharge, 40% of patients initiated on warfarin therapy in the hospital filled a warfarin prescription in the retail setting whereas 52% of patients initiated on a TSOAC prescription in the hospital filled a TSOAC prescription. Very few patients in either cohort filled an outpatient prescription for a different medication; however 19% of NVAF patients who were not initiated on an OAC during their hospitalization did fill a prescription for warfarin (17.6%) or a TSOAC (1.8%) in the first 30 days post discharge.

CONCLUSIONS: The majority of patients hospitalized for NVAF were discharged to home with home health support and a large proportion received no OAC treatment during their hospitalization or in the 30-days post-discharge. More patients initiated on a TSOAC while hospitalized filled a prescription in the first 30 days than patients initiated on warfarin. Additional investigation should be conducted into whether these trends persist beyond 30 days.

CLINICAL IMPLICATIONS: Implications of these treatment patterns on real-world outcomes will require further evaluation.

DISCLOSURE: Jeffrey Trocio: Employee: Employee of Pfizer, a sponsor of this research. Amanda Bruno: Employee: Employee BMS Kenneth Tuell; Employee: Employee BMS Kwanza Price: Employee: Employee Pfizer Prianka Singh: Employee: Employee BMS Jack Mardekian: Employee: Employee Pfizer Kevin Odell: Employee: Employee Pfizer Chad Patel: Employee: Employee BMS Wilson Tan: Employee: Employee Pfizer Henry Henk: Consultant fee, speaker bureau, advisory committee, etc.: Henry Henk is an employee of Optum, a consulting firm retained to conduct research on which this submission is based. Lien Vo: Employee: Employee BMS

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Chest. 2015;148(4_MeetingAbstracts):67A. doi:10.1378/chest.2220367

SESSION TITLE: Cardiovascular Disease Posters II

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: The objective of this study was to report experience with levosimendan in hemodynamically compromised children.

METHODS: all patients aged < 18years with severe myocardial dysfunction and dependent on inotrope support, who received levosimendan infusion, were reviewed for clinical, biological and echocardiographic (LV diameters, shortening fraction, sub-aortic Velocity Time Integral) data. Levosimendan was administered as a continuous intravenous infusion over 24 hours, starting 0.1 micrograms per kg per mn and increased up to 0.2micrograms per kg per mn. Blood pressure and heart rate were continuously monitored, ECG and Echocardiography recorded before, 3 and 5 days after starting levosimendan.

RESULTS: From 2007 to 2011, 8 patients aged 3.5 months to 13years (mean 41months) received 10 courses of levosimendan. All were on milrinone support (mean dose 0.63 mcg/kg/mn) and 3 on associated dobutamine. All achieved the 24-hour course of levosimendan without any complication. Catecholamines were successfully discontinued in 5 cases (3 weaned off at 24th hour and 2 at 5th day). Average milrinone dose dropped to 0.3 mcg/kg/mn at day-5, p=0.028). mean shortening fraction increased from 10.8%±1.8 before to 12.7± 2.3 at day-3 (p= 0.67), mean Velocity Time Integral from 6±0.6 to 8.7±1.2 cm at day-3 (p= 0.04). Five patients (62.5%) were successfully discharged from CICU: 2 are doing well at 1 and 4.5 years follow-up, 1 died from metabolic disease and 2 were readmitted at 1.5 - and 2-month interval and received a second course of levosimendan. The latter 2 patients did not improve and needed mechanical ventricular assistance (1 died and 1 underwent successful heart transplantation). For the remaining 3 patients, first course levosimendan failed and heart transplantation was performed in an emergency setting (pretransplant mechanical ventricular support in 2).

CONCLUSIONS: This small size sample study shows encouraging results of levosimendan in children with uncontrolled myocardial dysfunction. Further studies are needed to assess monitoring, timing and indications for repeated dose infusion during follow-up.

CLINICAL IMPLICATIONS: The role of Levosimendant in treating patients who are inotropes dependents should be widely investigated

DISCLOSURE: The following authors have nothing to disclose: Fahad Alsohime

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Chest. 2015;148(4_MeetingAbstracts):68A. doi:10.1378/chest.2281754

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Spasm of the left main coronary artery (LMCA) is a very rare cause of acute coronary syndrome, with a reported incidence of 1%. We report 2 cases of severe left main spasm during coronary angiography, one successfully managed with medical therapy and a second requiring coronary artery bypass surgery (CABG) .

CASE PRESENTATION: Case #1. A 49 year old man with history of diabetes, hypercholesterolemia, tobacco use and percutaneous coronary intervention (PCI) with implantation of drug-eluting stent (DES) in proximal left anterior descending (LAD) artery, presented with one month history of worsening angina. Nuclear stress test showed moderate size reversible ischemia in the anterior wall with a left ventricular ejection fraction (EF) of 60%. Diagnostic left heart catheterization (LHC) showed severe 95% stenosis of the LMCA. Intracoronary nitroglycerin was administered with an improvement of the LMCA stenosis to 30% stenosis. Patient remained asymptomatic during and after the procedure and was discharged on oral nitrates and calcium channel blockers (CCB) in addition to aspirin and atorvastatin. Case #2. A 66 year old man with history of hypertension, hypercholesterolemia, peripheral artery disease, bilateral renal artery stenting and known non-flow limiting obstructive disease of proximal LAD presented with a non-ST elevation myocardial infarction (NSTEMI). LHC showed significant spasm of the LMCA (95%), which improved after intracoronary nitroglycerin with 30% residual stenosis. LV angiogram showed an EF of 35-40% with new akinesis and ballooning of the anterior wall and the apical segments. He was started on oral nitrates, CCB and ranolazine drug therapy. He continued to have recurrent chest pain with ischemic T-wave inversions in anterolateral leads despite maximum vasodilator therapy. He was taken for CABG where he received a left internal mammary artery (LIMA) graft to the LAD and a saphenous venous (SV) graft to the D1. His perioperative course was complicated with episodes of profound hypotension requiring re-exploration of the LIMA graft, IV nitroglycerin, counter pulsation with intra-aortic balloon pump and inotropic support. He ultimately recovered over the next few days.

DISCUSSION: PCI has been used effectively to treat vasospastic angina refractory to maximal medical therapy in cases where there is moderate to significant obstructive atherosclerotic disease. CABG is also a therapeutic option but still remains controversial. Some advocates report its effectiveness in persistent angina despite medical therapy, while other series report unfavorable results.

CONCLUSIONS: Given the large area of myocardium at risk when the LMCA is involved intervention should be considered early when spasm persists despite maximal medical therapy.

Reference #1: Ali, F., Faraz, H. A., & Siddiqui, M. U. (2013). Left main coronary artery spasm--a rare entity as a cause of myocardial infarction in a patient. The Journal of Invasive Cardiology, 25(2), E36-38.

DISCLOSURE: The following authors have nothing to disclose: Yulanka Castro Dominguez, Atish Mathur, Pranaychandra Vaidya

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Topics: spasm
Chest. 2015;148(4_MeetingAbstracts):69A. doi:10.1378/chest.2280900

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Prosthetic valve thrombosis is a serious and potentially life threatening phenomenon. The usual presentation is with acute heart failure or embolism. A high clinical suspicion and imaging, including echocardiography and Doppler, fluoroscopy, and cine Computed Topography (CT), are required to allow timely intervention.

CASE PRESENTATION: An 84 year old woman, with a history of St. Jude mechanical aortic valve replacement 13 years prior presented with syncope, effort intolerance, and melena. On admission, blood pressure was 98/40, pulse 65, with a grade II/VI systolic murmur radiating to the carotids. Her hemoglobin was 6.3g/dL, PT INR was 3.5, and INR values for the prior 3 months were 2.9, 3.5, and 3.0. After transfusion she underwent upper and lower endoscopies. Hemoglobin dropped as low as 4.6g/dL. Angiography was performed and underwent coiling of an abnormal vessel. Bleeding recurred upon re-initiation of warfarin. Double balloon enteroscopy was performed and a single bleeding point in the jejunum was treated with argon plasma coagulation. Von Willebrand factor multimer analysis revealed loss of the highest molecular weight multimers and increased low molecular weight multimer (figure 1, arrow), which with the history of bleeding defines acquired von Willebrand syndrome. Transthoracic and transesophageal echocardiography revealed a peak aortic velocity of 4.5 m/sec, but the valve leaflets were not well seen. Abnormal motion of the prosthesis was suspected by fluoroscopy. CT angiography confirmed the presence of impaired motion of one leaflet of the mechanical prosthesis (figure 2A). She underwent redo aortic prosthetic valve replacement with resolution of her dyspnea and bleeding. On replacement the etiology of the valve dysfunction was confirmed to be subacute thrombus formation (Figure 2B).

DISCUSSION: Prosthetic valve thrombosis is a serious complication following valve replacement surgery. Acquired von Willebrand syndrome may be present in 20% of patients with severe aortic stenosis. Our patient with prosthetic valve thrombosis presented with severe gastrointestinal bleeding from acquired von Willebrand syndrome due to recurrent aortic stenosis. Imaging played a key role in making the diagnosis, and the laboratory in establishing the etiology.

CONCLUSIONS: Acquired von Willebrand syndrome should be considered in patients with cardiac prostheses and new hemorrhage. Laboratory confirmation of acquired von Willebrand syndrome requires multimer analysis. Cine CT may be useful to confirm prosthetic valve thrombosis when the leaflets are not well seen on echocardiography or fluoroscopy.

Reference #1: Vincentelli, A., S. Susen, et al. (2003). "Acquired von Willebrand Syndrome in Aortic Stenosis." New England Journal of Medicine349(4): 343-349.

DISCLOSURE: The following authors have nothing to disclose: Jordan Ray, Brian Shapiro, Joseph Blackshear

No Product/Research Disclosure Information

Chest. 2015;148(4_MeetingAbstracts):70A. doi:10.1378/chest.2277541

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: SCAD is a very rare cause of acute coronary syndrome in young otherwise healthy patients with striking predilection for female gender. Several conditions have been associated with SCAD such as atherosclerosis, connective tissue disorder and during the peripartum period.

CASE PRESENTATION: 27-year-old female with a history of HIV by birth on therapy, panic attacks, asthma, marijuana use and history of cocaine use presented with sharp, non pleuritic chest pain. Patient was found to be in hypertensive emergency with systolic BP>200,first set of troponins I elevated to 4.75 and urine toxicology significant for cannabis. Initial EKG was significant for non specific changes. Physical examination was unremarkable except for oral thrush. Subendocardial Infarction was suspected and an echocardiogram was performed that was significant for normal ejection fraction and no wall motion abnormality. Patient later on had another episode of chest pain with new EKG significant for anterior STEMI. Coronary angiography showed completely occluded LAD and 90% occlusion of the diagonal and coronary intravascular ultrasound was significant for chronic dissection all the way up to mid LAD. Patient received drug-eluting stents to both LAD and Diagonal and was started on standard medication therapy.

DISCUSSION: SCAD has an incidence of 0.1% for patients who are referred for coronary angiography. Mean age of presentation is between 35-40 years and more than 70% of cases are women. Patients are often divided into three groups: peripartum, atheroscleortic and idiopathic A third of cases occur in peripartum period with peak incidence in the second week after delivery. High level of estrogens can change normal arterial wall architecture resulting in spontaneous dissections. In addition there is also an increase in cardiac output, total blood volume and straining and shearing forces during labor which can result in increased stress on arterial wall. Atherosclerosis account for about 30% of cases. Atherosclerotic plaque formation may lead to the dissection. HIV and HAART may contribute to an increased risk of cardiovascular diseases by directtly affecting the pathogenesis of atherosclerosis through inflammation and endothelial dysfunction. HIV and HAART therapy can increase the occurance of risk factors such as hyperlipidemia, insulin resistance, diabetes, fat redistribution and hypertension.

CONCLUSIONS: Recognition of dissection is quite difficult and may require multiple angiographies or intravascular ultrasounds. HIV can promote inflammation and damage endothelium, including infectionof endothelial cells, secretion of proinflammatory cytokines and secretion of viral proteins and oxidative stress.

Reference #1: Spontaneous coronary artery dissection: current insights and therapy, W. Tanis, P.R. Stella, J.H. Kirkels, A.H. Pijlman, R.H.J. Peters, and F.H. de Man

Reference #2: Myocardial infarction risk in HIV-infected patients,Calza, Leonardo; Manfredi, Roberto; Verucchi, Gabriella 2010, Mar

DISCLOSURE: The following authors have nothing to disclose: Umair Tariq

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Chest. 2015;148(4_MeetingAbstracts):71A. doi:10.1378/chest.2275633

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: The human-immunodeficiency virus is increasingly being recognized as an important cause of cardiomyopathy. While the exact mechanism remains unclear, effects from direct viral burden may play a key role. We present a case of severe HIV-associated cardiomyopathy in a man with a normal CD4, but a high viral load.

CASE PRESENTATION: A 40 year-old male with HIV presented with bilateral lower-extremity swelling and right-calf pain. He was admitted with cellulitis, with course complicated by septic shock, requiring massive fluid resuscitation and broad-spectrum antibiotics. While the infection resolved, he developed severe dyspnea and worsening extremity edema. Chest x-ray showed pulmonary congestion and echocardiogram revealed severe 4-chamber dilated cardiomyopathy with ejection fraction of 27%. Cardiac catheterization revealed non-obstructive coronary arteries and cardiac MRI displayed findings consistent with prior myocarditis. CD4 count on admission was 604 cells/mm3, unchanged from 3 months prior, at which time he had a viral load of 100,000 RNA copies/mL. He was started on heart failure therapy and discharged. 6 months later, he remained off anti-retroviral therapy, with repeat viral load over 220,000 RNA copies/mL. Follow-up echocardiogram revealed worsening heart failure, with ejection fraction below 20%, requiring ICD placement.

DISCUSSION: HIV-associated cardiomyopathy presents a diagnostic challenge, as etiologies can range from co-infections by cardiotropic viruses, dysregulated inflammatory processes induced by HIV, or direct cardiomyocyte invasion by the virus itself. Expression of gp120 and other viral proteins from infected T-cells or marcophages have been shown to induce apoptosis in cardiac myocytes, while increased inflammatory cytokines like TNFα have been reported in the myocardium of patients with HIV cardiomyopathy (1). HIV may also cause defects in antigen-specific immunoglobulin production through poor B-cell activation from infected effector T-cells, further leading to immune dysfunction (2).

CONCLUSIONS: Our case highlights the importance of HAART therapy, both in maintaining appropriate CD4 counts but also in the suppression of high viral loads. We highlight the unique risk present in the HIV population, where immune dysfunction may be present beyond the threat of just opportunistic infections. We illustrate the need to firmly contain viral replication, as high viral loads may be a key player in HIV-associated cardiomyopathy.

Reference #1: Fiala et al. HIV-1 induces cardiomyopathy by cardiomyocyte invasion and gp120, Tat, and cytokine apoptotic signaling. Cardiovascular Toxicology. 2004; 4(2): 97.

Reference #2: Kelly et al. Diastolic dysfunction is associated with myocardial viral load in simian immunodeficiency virus-infected macaques. AIDS 2012, 26(815-823).

DISCLOSURE: The following authors have nothing to disclose: Marjan Islam, Belinda Velasquez

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Topics: hiv , cardiomyopathy
Chest. 2015;148(4_MeetingAbstracts):72A. doi:10.1378/chest.2269978

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Acute onset congestive heart failure is a rare event in a young patient with minimal cardiac risk factors. We present an uncommon cause of heart failure in an otherwise healthy young female.

CASE PRESENTATION: A 27 year-old Asian American female with a history of hypertension presented with generalized edema that began a week prior to admission. She reported worsening dyspnea on exertion, but denied chest pain, palpitations, light-headedness or dizziness. She was adopted and did not know her biological parents’ medical history. Physical examination revealed a blood pressure of 155/120 mmHg, jugular venous distention, rhonchi in right middle and lower lung field and evidence of ascites. Her lower extremities were notable for significant edema with serous weeping. Laboratory findings were significant for BNP of 4128, and troponin of 0.24. A transthoracic echocardiogram showed an ejection fraction of less than 20%. There was also evidence of right-sided heart failure, severe tricuspid regurgitation, an apical thrombus in the left ventricle, and anatomy suggestive of non-compaction syndrome. A cardiac MRI was obtained which showed pericardial effusion with increased trabeculae in the lateral wall, which are also consistent with mild non-compaction. She was diuresed and started on anticoagulation. A loculated right pleural effusion, requiring video-assisted thoracotomy and decortication, complicated her hospital course. She had an uncomplicated recovery and was discharged twelve days postoperatively.

DISCUSSION: Left ventricular noncompaction is a rare condition with an incidence of less than 0.3%. It can be genetically sporadic or familial. There is an arrest of the normal compaction process in the myocardium during embryogenesis. It is characterized by abnormal two-layered myocardium (compacted and non compacted) and thickened myocardial wall with prominent trabeculae. Although this condition may be asymptomatic, it can present as heart failure, fatal arrhythmias, thromboembolic events, or even sudden cardiac death. Between studies, prognosis is variable with mortality at follow-up from 2% to 47%.

CONCLUSIONS: Left ventricular noncompaction should be considered in the differential diagnosis in young patients without cardiac risk factors with decompensated congestive heart failure. Making the correct diagnosis is important for the long-term management of patients, as well as screening of their relatives when necessary.

Reference #1: Stanton C, Bruce C, Connolly H MD, Brady P, Syed I, Hodge D, Asirvatham S, Friedman P. Isolated Left Ventricular Noncompaction Syndrome. Am J Cardiol. 2009;104:1135-1138).

Reference #2: Oechslin EN, Attenhofer Jost CH, Rojas JR, Kaufmann PA, Jenni R. Long-Term Follow-up of 34 Adults With Isolated Left Ventricular Noncompaction: A Distinct Cardiomyopathy With Poor Prognosis. JACC. 2000. 36(2):493-500.

DISCLOSURE: The following authors have nothing to disclose: Weyman Lam, Gbolahan Ogunbayo, David Lobo

No Product/Research Disclosure Information

Chest. 2015;148(4_MeetingAbstracts):73A. doi:10.1378/chest.2268913

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Robotic ablation of atrial fibrillation is an emerging technique in the field of electrophysiology. Though robotic ablation (RA) has been increasingly used for the treatment of atrial fibrillation, its efficacy and safety compared to manual ablation (MA) are not clear.

CASE PRESENTATION: We searched Pubmed, EBSCO and Cochrane databases for randomized studies in English language with terms “robotic navigation system”, “robotic ablation”, “manual ablation”, “conventional ablation”, “atrial fibrillation” and their combinations. The fixed-effects model was used for analysis of homogenous end points, and the random-effects model for heterogeneous end points. Cochrane’s Q statistics were calculated and used to determine the heterogeneity of included studies for each end point. P<0.05 was considered significant.

DISCUSSION: Compared to MA, RA was associated with significant reduction in total fluoroscopic time (mean difference (MD): -0.927, 95% CI: -1.345 to -0.510; P<.00001). No significant differences were noted between the two groups for the total procedure time (MD: -0.019, 95% CI: -0.275 to 0.238; P=0.88), immediate success rate (odds ratio (OR): 0.883, 95% CI: 0.419 to 1.863; P=0.74) or immediate major complication rate (OR: 1.428, 95% CI: 0.655 to 3.113, P=0.37).

CONCLUSIONS: Robotic ablation is a novel technique being used more frequently nowadays due to excellent catheter stability, easy learning curve and good operator comfort1. With recent studies reporting increasing incidence of cataracts, brain and neck tumors in interventional cardiologists2,3, it is essential to reduce the total fluoroscopic exposure time for physicians. Robotic ablation was associated with significantly lower fluoroscopic exposure time when compared to manual ablation for the treatment of atrial fibrillation. This has great significance for practising clinicians. The total procedure time, immediate success and major complication rates were similar in the two groups.

Reference #1: Schmidt B, Tilz RR, Neven K, Julian Chun KR, Furnkranz A, Ouyang F. Remote robotic navigation and electroanatomical mapping for ablation of atrial fibrillation: Considerations for navigation and impact on procedural outcome. Circ Arrhythm Electrophysiol. 2009;2(2):120-128.

Reference #2: Jacob S, Boveda S, Bar O, et al. Interventional cardiologists and risk of radiation-induced cataract: Results of a french multicenter observational study. Int J Cardiol. 2013;167(5):1843-1847.

Reference #3: Roguin A, Goldstein J, Bar O, Goldstein JA. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol. 2013;111(9):1368-1372.

DISCLOSURE: The following authors have nothing to disclose: Mahesh Anantha Narayanan, Saurabh Aggarwal, Rohit Loomba, Navdeep Gupta, Venkata Alla, Hussam Abuissa, Aryan Mooss

No Product/Research Disclosure Information

Chest. 2015;148(4_MeetingAbstracts):74A. doi:10.1378/chest.2266587

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Partial anomalous pulmonary venous return (PAPVR) is a congenital cardiovascular anomaly caused by abnormal return of one or more pulmonary veins to the right side of the heart. It might occur isolated or combined with atrial septal defect. All PAPVRs are left-to-right shunts, and the shunt is usually hemodynamically insignificant. We report a unique case where localized pulmonary edema in a single lobe of lung was found to be secondary to PAPVR.

CASE PRESENTATION: A 47-year-old African American man with history of hypertension, coronary artery disease with bypass grafting and angioplasty, diastolic congestive heart failure (CHF) and end-stage-renal disease on hemodialysis was admitted for worsening dyspnea and chest pain of two-days duration with impression of decompensated heart failure and fluid overload. Chest X-ray (CXR) showed severe cardiomegaly with interstitial pulmonary infiltrates more pronounced in the LUL. Chest computerized tomography (CT) confirmed the CXR findings and further revealed PAPVR in the same lobe. The anomaly was further investigated with multislice CT angiography of the heart and vessels with three-dimensional reconstruction images demonstrating LUL anomalous pulmonary vein draining into the left innominate vein thus creating left-to-right shunt. There was no associated pulmonary hypertension on echocardiography. The edema resolved after fluid removal with hemodialysis and CHF optimization. The remainder of the patient's hospital course was uneventful.

DISCUSSION: Pulmonary veins bring oxygenated blood from lungs to the left atrium. Anomalous pulmonary veins can cause total or partial return of the blood to the right side, thus creating left-to-right shunt. PAPVR is a rare congenital anomaly with incidence of about 0.7% of the population. Asymptomatic mostly, it is often an incidental finding. Echocardiography is the initial diagnostic test of choice. If echocardiography is inconclusive, CT angiography serves as a rapid, safe and non-invasive modality to confirm the diagnosis, with three-dimensional reconstruction images providing more details on vascular anatomy. Surgery is the definitive treatment for PAPVR, but asymptomatic patients with insignificant left-to-right shunt do not require intervention. Localized pulmonary edema is even rarer that may respond to fluid removal with diuretics or dialysis as in our case.

CONCLUSIONS: PAPVR commonly manifests in children, and rarely in adults with pulmonary hypertension secondary to left to right shunt. Absence of pulmonary hypertension and presence of localized lobar edema, makes our case unique.

Reference #1: Demos TC, Posniak HV, et al. Venous Anomalies of the Thorax. American Journal of Roentgenology. 2004;182:1139-1150.

Reference #2: Lakshminrusimha S, Wynn RJ, et al. Use of CT angiography in the diagnosis of total anomalous venous return. J Perinatol. 2009;29(6):458-61.

Reference #3: Agarwal R, Aggarwal AN, Gupta D. Other causes of unilateral pulmonary edema. Am J Emerg Med 2007;25:129-31.

DISCLOSURE: The following authors have nothing to disclose: Lakshya Chandra, Ahmar Malik, Fatima Khan, Anjum Anwar, Wayne Davis, Vishal Poddar

No Product/Research Disclosure Information

Chest. 2015;148(4_MeetingAbstracts):75A. doi:10.1378/chest.2255850

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Myocardial wall rupture is a rare, but often lethal complication of myocardial infarction (MI). It occurs within two weeks in over 90% of cases (1). Hemodynamic stabilization and immediate surgery should be performed to make survival possible.

CASE PRESENTATION: A 63-year-old man with a history of hypertension and diabetes mellitus, but no prior history of cardiac disease or chest pain presented with severe abdominal pain that started one hour earlier. The pain was periumbilical, radiating to the back, associated with diaphoresis and shortness of breath. His blood pressure was 60/30 mmHg, heart rate was 89 bpm, and oxygen saturation was 83% on room air. On exam the patient was in severe distress, lying supine, aggravated by any movement. Cardiovascular exam revealed regular rate and rhythm, no murmurs, faint peripheral pulses. Abdomen was soft and non-distended, with significant tenderness to palpation in both lower quadrants. Laboratory studies yielded hemoglobin of 14.8 mg/dL and troponin T of 0.79 ng/ml. EKG suggested inferior and lateral subendocardial injury. CTA of the chest showed no aortic dissection. Echocardiogram showed moderate circumferential pericardial effusion. Norepinephrine was required for pressure support. Emergent cardiac catheterization showed coronary disease, however not sufficient to explain the presentation. Left ventriculogram revealed a contained myocardial rupture. A pericardial window was created and 500 ml of blood was removed from the pericardium. The patient was managed on ECMO postoperatively.

DISCUSSION: Myocardial rupture and cardiogenic shock are serious and often lethal complications of MI. Left ventricular wall rupture leads to hemopericardium and death from cardiac tamponade. Transthoracic echocardiography can facilitate the diagnosis. Emergent pericardiocentesis may help confirm the diagnosis and transiently relieve the tamponade. Risk factors for developing ventricular rupture after an MI include absence of history of angina or prior MI, presence of ST-segment elevation or Q wave development on the initial electrocardiogram, which result from the lack of collateral blood flow. Larger size MI such as transmural MI increases the likelihood of myocardial rupture. Ventricular rupture is rarely seen in a hypertrophied ventricle or in an area of extensive collateral circulation.

CONCLUSIONS: Patients with signs and symptoms of the left ventricular wall rupture require an immediate bedside echocardiogram and pericardiocentesis followed by emergent surgery, if confirmed. Rapid recognition and treatment can lead to survival. In one study, 25 of 33 patients (76%) with subacute ventricular rupture survived the surgical procedure; 16 patients (48%) were long-term survivors (2).

Reference #1: Batts KP et al. Postinfarction rupture of the left ventricular free wall. Hum Pathol 1990; 21:530.

Reference #2: López-Sendón J, et al. Diagnosis of subacute ventricular wall rupture after acute myocardial infarction. J Am Coll Cardiol 1992; 19:1145.

DISCLOSURE: The following authors have nothing to disclose: Mohamad Zetir

No Product/Research Disclosure Information

Chest. 2015;148(4_MeetingAbstracts):76A. doi:10.1378/chest.2251362

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Sinus of Valsalva Aneurysms are rare entities with an incidence of 0.14-0.23%. Unruptured aneurysms are usually innocuous and are usually incidental findings on imaging. We report a case of unruptured SVA causing pseudo tricuspid stenosis whose initial presentation mimicked acute cholecystitis.

CASE PRESENTATION: A 36-year-old male presented to the emergency department with a 12-day history of progressively worsening abdominal pain and shortness of breath with associated sweats, chest heaviness, nausea, vomiting and diarrhea. He denied fevers, chills, rigors or sick contacts. Eleven days before presentation he was admitted for similar symptoms and treated for possible cholecystitis. Physical examination revealed a middle-aged man in respiratory distress with stable vital signs. Significant findings included an elevated JVD, a II/VI systolic and II/VI diastolic murmur, with tender hepatomegaly and guarding over the right upper quadrant. He also had pitting pedal edema. Laboratory tests revealed transaminitis, hyperbilirubinemia, elevated INR, acute kidney injury and elevated lactate. His electrocardiogram was suggestive of right atrial enlargement. A transesophageal echocardiogram confirmed a large saccular aneurysm measuring approximately 4 cm in diameter that impinged on the tricuspid valve causing tricuspid stenosis. Intraoperatively, a cyst was found in the right atrium with a connecting fistula arising from the non-coronary cusp of the aorta that was excised and repaired. The patient had an uneventful post-operative recovery and was discharged seven days after surgery.

DISCUSSION: Although unruptured sinus of valsalva aneurysms are usually asymptomatic, they may present with symptoms of right ventricular outflow tract obstruction. This may cause congestive hepatopathy and mimic a primary hepatobiliary disease as in our patient. A systolic-diastolic thrill, right upper quadrant tenderness and evidence of synthetic liver dysfunction were clues to this uncommon diagnosis.

CONCLUSIONS: Unruptured sinus of valsalva aneurysms may present with signs and symptoms of extra-cardiac disease. A detailed medical history and thorough physical examination is crucial to early diagnosis and appropriate management.

Reference #1: Goldberg N, Krasnow N. Sinus of valsalva aneurysms. Clin Cardiol. 1990;13(12):831-836. doi:10.1002/clc.4960131204.

Reference #2: John S-H. A rare case of unruptured sinus of valsalva aneurysm obstructing the right ventricular outflow tract. J Cardiovasc Ultrasound. 2010;18(2):55-57. doi:10.4250/jcu.2010.18.2.55.

Reference #3: Bricker AO, Avutu B, Mohammed T-LH, et al. Valsalva Sinus Aneurysms: Findings at CT and MR Imaging1. 2010. http://pubs.rsna.org/doi/full/10.1148/rg.301095719. Accessed December 30, 2014.

DISCLOSURE: The following authors have nothing to disclose: Gbolahan Ogunbayo, Shanchiya Ravindradas, David Lobo, Dipekka Soni, Seth Jacobson

No Product/Research Disclosure Information

Chest. 2015;148(4_MeetingAbstracts):77A. doi:10.1378/chest.2246289

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Theophylline is a methylxanthine bronchodilator that has been used for several decades in the treatment of reversible airway obstruction. However, due to its narrow therapeutic index, its use is declining. In addition to seizures, arrhythmias and hypotension, some case reports also describe a connection between theophylline and dilated cardiomyopathies. We present the first case of Takotsubo secondary to theophylline toxicity.

CASE PRESENTATION: 72 year old female with past medical history of Stage III Non-Small cell lung cancer status post chemotherapy and COPD on theophylline presented with altered mental status after having a seizure. She was intubated for airway protection. Computed tomography (CT) of the head showed no acute intracranial abnormalities. On physical exam, she was afebrile, hypotensive and tachycardic. Electrocardiogram (ECG) was consistent with a supraventricular tachycardia. CT angiography of the chest showed no evidence of pulmonary emboli. Echocardiogram showed an ejection fraction (EF) of 20-25% with severe global left ventricular dysfunction, preserved basal function with severe mid and apical hypokinesis. On admission, laboratory values included elevated theophylline level, negative drug and toxicology screen. Complete metabolic panel showed a low potassium level, hyperglycemia and acute kidney injury. Her blood gas showed a pH 7.26 due to a lactic acidosis. Her complete blood count was within normal limits. Troponin T, Creatinine kinase (CK) and CK-MB levels were elevated. Despite fluid resuscitation, the patient required continuous phenylephrine infusion as well as phenobarbital and activated charcoal for theophylline toxicity. Patient was also started on medical management for non-ST elevation myocardial infarction. As the theophylline levels continued to trend down, her ECG then demonstrated a right bundle branch block with T wave inversion in II, III, AvF and V2-V6. She recovered and was successfully extubated. She underwent a left heart catheterization, which showed normal coronary arteries and confirmed the diagnosis of Takotsubo. A repeat echocardiogram prior to discharge showed an improvement in EF to 40-45% with mild residual apex hypokinesis.

DISCUSSION: A catecholamine surge from theophylline toxicity and apical-basal ventricular gradients of catecholamine responsiveness to β2-adrenergic receptors is the proposed mechanism leading to Takotsubo. Supportive management is the main approach for the management of Takotsubo, arrhythmias and hypotension related to Theophylline.

CONCLUSIONS: Although the use of theophylline for the management of COPD is declining, theophylline toxicity is of persistent concern due to its narrow therapeutic range, especially in the elderly. Thus, review of home medications and rapid discontinuation of the drug with hemodynamic support are imperative.

Reference #1: Shannon M (1999) Life-threatening events after theophylline overdose: a 10-year prospective analysis. Arch Intern Med 159: 989-994

DISCLOSURE: The following authors have nothing to disclose: Melissa Dakkak, Amit Gupta, Patrick Antoun, Alan Miller

No Product/Research Disclosure Information

Chest Infections

Chest. 2015;148(4_MeetingAbstracts):78A. doi:10.1378/chest.2277759

SESSION TITLE: Chest Infections

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Sunday, October 25, 2015 at 01:30 PM - 03:00 PM

PURPOSE: Macrolides are sometimes used in monotherapy but more often with a cephalosporin for CABP. Pneumococcal macrolide resistance is now at >40% (US). We report the results of an outpatient Phase 3 study with oral solithromycin (soli) a 4th generation macrolide that had sufficient potency to be tested in monotherapy in comparison to moxifloxacin (moxi) in CABP.

METHODS: Patients with CABP, PORT Risk II-IV (NCT#01756339) were double-blind randomized (1:1) to oral soli (5 days) or oral moxi (7 days). Evaluations were performed on Day 4 for early clinical response (ECR), Day 7, Day 12-17 short term follow up (SFU) visit, and Day 28. ECR was defined as improvement in at least 2 of 4 cardinal symptoms (cough, chest pain, dyspnea, sputum production) without worsening in any. Investigators assessed success at SFU. Primary objectives were demonstration of non-inferiority (10% NI margin) in ECR (intent-to-treat (ITT) population) and in success at SFU (ITT and clinically evaluable (CE) populations).

RESULTS: 860 patients from 16 countries were randomized (ITT population), 90% met key protocol criteria (CE population). 50.7% of soli patients had PORT III/IV disease (11.3% PORT IV), vs. 48.6% of moxi patients (8.8% PORT IV). Soli was non-inferior to moxi in the ITT population in ECR (78.2% vs. 77.9%) and SFU success (84.5% vs. 86.6%) and in the CE-SFU population (88.1% vs. 91.3%). ECR success was higher among soli patients ≧ age 75 (83.9% vs 69.8%, n=125). Soli had safety comparable to moxi in occurrence of adverse events (AEs) (36.6% vs 35.6%), study-drug related AEs (10.1% vs 12.5%), Serious AEs (6.6% vs 6.3%; none attributed to study drug) and deaths (1.4% vs 1.4%). Grade 4 ALTs (>8xULN) were observed in 5 moxi patients and 2 soli patients (without symptoms or bilirubin elevation). Two episodes of C. difficile diarrhea were diagnosed in moxi recipients. 15 patients had S. pneumoniae (Spn) bacteremia; treatment was successful in the majority, with equal success rates (soli vs moxi). Among all Spn patients, treatment was successful at SFU in 85.3 % (soli) and 87.3 % (moxi) of patients. 100% success at SFU was observed in all soli patients with macrolide-resistant Spn at SFU.

CONCLUSIONS: Oral soli was non-inferior to moxi for treatment of CABP. Safety outcomes were comparable, although moxi was associated with more Grade 4 ALT elevation and C. difficile diarrhea.

CLINICAL IMPLICATIONS: Solithromycin, a potent new macrolide, has potential for use as monotherapy in moderate to moderately severe CABP, even on the outpatient basis.

DISCLOSURE: David Oldach: Employee: Employee of Cempra, which is developing solithromycin Carlos Barrera: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Brian Rowe: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Floarea Mimi Nitu: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Analia Mykietiuk: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Hristo Metev: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Jessica Laabs: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Ismail Mitha: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Cristina Mihaela Tanaseanu: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Joseph McDermott Molina: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Yuri Antonovsky: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Dirkie Johanna Van Rensburg: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Jose Flores: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Barbara Sokolowska: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Alexis Doreski: Other: As part of IRB and ethics committee approved trial sponsored by Cempra, Inc., institution received compensation for execution of trial protocol Anita Das: Consultant fee, speaker bureau, advisory committee, etc.: Statistical consultant to Cempra, which is developing solithormycin Kay Clark: Employee: Employee of Cempra, which is developing solithromycin Brian Jamieson: Employee: Employee of Cempra, which is developing solithromycin Amanda Sheets: Employee: Employee of Cempra, which is developing solithromycin Kara Keedy: Employee: Employee of Cempra, which is developing solithromycin Prabhavathi Fernandes: Employee: CEO of Cempra, Inc., which is developing solithromycin

Solithromycin is an antibiotic in clinical development for the treatment of community-acquired bacterial pneumonia.

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