Monday , July 26 2021

A patient with heart failure actually spit out this blood clot in the form of a lung passage



A near-perfect cast of a right bronchial tree spit out by a patient with internal bleeding related to anticoagulants given during the treatment of heart failure.
Photo: Gavitt A. Woodard, M.D., and Georg M. Wieselthaler, M.D. (New England Journal of Medicine)

Although it resembles a coral, root system or some other type of growth, the picture above describes a six-inch wide clot in the near-perfect form of the right bronchial tree of a human lung, Atlantic said on Thursday. . Even more uncomfortable is the revelation that she was not removed by the medical staff, but was actually expelled by a patient suffering from heart failure.

The photo was released in late November as part of the Imaging in Clinical Medicine series of the New England Journal of Medicine. Doctors at the University of California, San Francisco, Gavitt A. Woodard and Georg M. Wieselthaler, wrote that she came from her patient, a 36-year-old man who had long struggled with chronic heart failure. The patient would have a medical history including "heart failure with a 20% ejection fraction, aortic valve replacement bioprosthesis for bicuspid aortic stenosis, endovascular stent implantation of aortic aneurysm, and permanent pacemaker placement for complete heart block." the patient was admitted to the hospital's intensive care unit and was attached to a pump designed to help circulate blood throughout the body:

An Impella ventricular assist device was placed for the treatment of acute heart failure, and a continuous infusion of heparin was initiated for systemic anticoagulation. During the following week, the patient had episodes of small volume hemoptysis, increasing respiratory discomfort and increasing the use of supplemental oxygen (up to 20 liters administered through a high-flow nasal cannula). During an extreme coughing crisis, the patient spontaneously expectorated an intact cast of the right bronchial tree.

The patient was subsequently extubated and "had no further episodes of hemoptysis," the doctors wrote, but a week later he unfortunately "died of heart failure (volume overload and low cardiac output) despite the placement of the ventricular assist device" .

According to the Atlantic, Wieselthaler said that the use of the pump requires anticoagulants to "make blood thinner and prevent the formation of clots," although this carries the risk of uncontrolled internal bleeding. In this case, Wieselthaler told the journal that blood leaving the heart to store fresh oxygen in the circulatory system appears to have clumped into the right bronchial tree, coagulated, and then ejected by the patient in a confused way:

Once Wieselthaler and his team carefully unrolled the beam and designed it, they discovered that the architecture of the airways had been maintained so perfectly that they could identify it as the right bronchial tree based only on the number of branches and their alignment.

Wieselthaler added that one possible way for the clot to remain intact, instead of being broken, was a high concentration of fibrinogen, a blood plasma protein that helps form clots. The patient had an infection that both worsened heart failure and may have caused an accumulation of fibrinogen in the blood, resulting in a more rubbery clot, he told Atlantic.

Woodard told the magazine that it is also possible that the size of the clot may have contributed to its ejection, since it could have allowed the patient to "generate enough force from the entire right side of his chest to push it up and out. (Gizmodo got in touch with Woodard to clarify some persistent issues, and we'll update this article if we hear back.)

It may seem a bit like getting rubber looking at the proceeds of someone's medical misfortune, but even most doctors may never get a chance to see something like that. Although there are other conditions that can result in bronchial cylinders including infections and asthmatic conditions or lymphatic flow disorders that may cause mucus or lymphatic fluid accumulation respectively, Wieselthaler was emphatic in saying that the size of this is almost unprecedented.

"We were surprised," Wieselthaler told Atlantic. "It's a curiosity you can not imagine – I mean, this is very, very, very rare."

[New England Journal of Medicine via the Atlantic]

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