Per­fect cast likely side ef­fect from heart pump de­vice

National Post (National Edition) - - CANADA - ADriAn HumpHreys Na­tional Post [email protected]­tion­al­ Twit­ter: AD_Humphreys

A man un­der­go­ing treat­ment for heart fail­ure coughed up an enor­mous, in­tact blood clot that formed a per­fect cast of the air pas­sage­ways of his lung.

The com­plete­ness of the clot, once un­folded onto blue med­i­cal cloth, as­tounded doc­tors; they could trace the three branches of the up­per lobe of the lung, the two branches in the mid­dle lobe and five seg­men­tal branches in the lower.

Span­ning about 15 cm by 17 cm, it was such a per­fect cast of air­ways that they knew pre­cisely where the clot had come from, the right bronchial tree of the pa­tient’s lung.

Al­though called a tree, it more re­sem­bles roots. Imag­ine tug­ging on a ro­bust dan­de­lion when sud­denly the en­tire in­tri­cate root sys­tem slips out of the ground with­out bits snap­ping off as it came.

Rather than doc­tors pulling the red, bloody mass out of the pa­tient’s lung, how­ever, the man un­ex­pect­edly hacked it out him­self, as the doc­tors later noted: “Dur­ing an ex­treme bout of cough­ing.”

The strange sam­ple of a med­i­cal anom­aly prompted two of his doc­tors at the Univer­sity of Cal­i­for­nia, San Fran­cisco — Gavitt Woodard, a tho­racic sur­geon, and Ge­org Wieselthaler, the car­dio­tho­racic sur­gi­cal chief — to write a note on the case, pub­lished this week in the New Eng­land Jour­nal of Medicine.

The pub­lic’s re­sponse has been a mix­ture of won­der and hor­ror.

Var­i­ous me­dia re­ports have twisted the sci­ence of the thing, pre­sent­ing it as a pa­tient lit­er­ally cough­ing up a lung, a com­mon ex­pres­sion for what it feels like to cough pro­fusely.

“Man coughs up part of lung while be­ing treated for heart fail­ure,” says a Fox News head­line, fail­ing to note or no­tice that it is a cast of the in­side of the lung — like pour­ing con­crete into a mould and then re­mov­ing the mould, only with blood rather than con­crete — that came out of his mouth, rather than the lung it­self.

The Daily Mail On­line even cap­i­tal­ized their mis­di­rec­tion in its head­line, “Man, 36, coughs up part of his LUNG,” it says.

The in­tri­cate ex­pec­to­rate is where blood leaked into the air pas­sages of the pa­tient’s lung and hard­ened, what is med­i­cally called co­ag­u­la­tion. The so­lid­i­fy­ing blood pro­voked in­tense cough­ing to clear it. And clear it, it did.

Any re­lief from the pro­duc­tive cough­ing did not last, how­ever. The pa­tient was al­ready dy­ing from heart fail­ure. De­spite in­ter­ven­tion, he died nine days af­ter hack­ing out the clot.

The doc­tors do not iden­tify their pa­tient by name, but say he was a 36-year-old man be­ing treated in the in­ten­sive care unit, suf­fer­ing from chronic heart fail­ure.

He had con­sid­er­able in­ter­ven­tion, in­clud­ing an aor­tic-valve re­place­ment, stent­ing of an aor­tic aneurysm and a per­ma­nent pace­maker that had been im­planted for com­plete heart block.

The un­usual clot is likely ex­plained by the next in­ter­ven­tion.

Doc­tors placed an Im­pella ven­tric­u­lar as­sist de­vice into his heart through an artery, which is a heart pump that tem­po­rar­ily sup­ports a pa­tient by mov­ing blood through the heart to the rest of the or­gans in the body. Ac­cord­ing to the man­u­fac­turer’s web­site, it is a treat­ment de­signed for “no-op­tion pa­tients.”

Blood clots are a known pos­si­ble side ef­fect of the pump.

“Blood clots may de­velop, which can travel through your blood ves­sels and block the blood flow to other or­gans, in­clud­ing your lungs mak­ing breath­ing dif­fi­cult,” ac­cord­ing to the Im­pella web­site.

To re­duce clot­ting, doc­tors use a blood thin­ner called hep­arin.

Over the next week, the pa­tient had pe­ri­odic cough­ing fits, hack­ing up small amounts of blood or blood-stained mu­cus, the doc­tors wrote in their pub­lished case note.

He had in­creas­ing trou­ble breath­ing and needed sup­ple­men­tal oxy­gen to ease it.

“Dur­ing an ex­treme bout of cough­ing, the pa­tient spon­ta­neously ex­pec­to­rated an in­tact cast of the right bronchial tree,” the doc­tors’ wrote.

Tubes were in­serted down his throat and a scope used to ex­am­ine the pa­tient’s air­ways. Two days later, the tubes were re­moved and he had no fur­ther bloody cough­ing, the doc­tors wrote.

A week later, how­ever, the pa­tient died from com­pli­ca­tions of heart fail­ure.

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