Although it resembles a coral, root system, or other type of growth, the above photo actually shows six inches wide blood clots in the nearly perfect shape of the right bronchial tree of an Atlantic lung reported the Atlantic on Thursday. Even more disconcerting is the revelation that it has not been removed by medical personnel, but has been coughed up by a heart failure patient.
The photo was published in late November as part of the New England Journal of Medicines Images in the Clinical Medicine Series. The doctors at the University of California at San Francisco, Gavitt A. Woodard and Georg M. Wieselthaler, wrote that it was from their patient, a 36-year-old man who was struggling with chronic heart failure for a long time. The patient was reported to have a medical history including "heart failure with a 20% ejection fraction, bioprosthetic aortic valve replacement for bicuspid aortic stenosis, endovascular stenting of an aortic aneurysm and placement of a permanent cardiac pacemaker for a complete heart block." The patient was admitted to intensive care Hospital, it was connected to a pump designed to promote circulation throughout the body:
An Impella chamber assist device was used to treat acute heart failure and continuous heparin infusion was initiated for systemic anticoagulation. The next week, the patient had episodes of small-volume hemoptysis, increased respiratory distress, and increased use of supplemental oxygen (up to 20 liters delivered through a high-flow nasal cannula). In an extreme coughing attack, the patient spontaneously spat out an intact imprint of the right bronchial tree.
The patient was later extubated and "had no further hemoptysis episodes," the doctors wrote, but a week later he died unhappily of heart failure complications (volume overload and low cardiac output) despite placement of the ventricular assist device. "
According to the company, Wieselthaler says that using the pump requires anticoagulants to" make the blood thinner and prevent lump formation, "although this is associated with the risk of uncontrolled internal bleeding. In this case, Wieselthaler told the magazine, blood leaving the heart to replenish itself with fresh oxygen in the circulatory system seems to have accumulated in the right bronchial tree to be clotted and was then expelled by the patient in a confused form: [19659005AfterhavingcarefullyunrolledandlaidoutthebundleWieselthalerandhisteamfoundthattheairwayarchitecturewassoperfectlypreservedthatitcouldidentifyitastherightbronchialtreebasedsolelyonthenumberofbranchesandtheirorientation
Wieselthaler added that one way in which the clot remained intact and would not have been broken was a high concentration of fibrinogen, a protein in blood plasma that contributes to the formation of clots. The patient had an infection that both exacerbated heart failure and led to an accumulation of fibrinogen in the blood, resulting in a more rubbery clot, he told the Atlantic.
Woodard told the journal that it was also possible that the size of the clot might actually have contributed to its sputum, as it would have enabled the patient to "generate enough force from the entire right side of his rib cage to do so "Gizmodo has contacted Woodard to clarify matters, and we will update this article if we listen back.)
It may be a bit of a madness to think of the product staring at a medical misfortune, but even most doctors may never have the opportunity to see anything like this. Although there are other conditions that can lead to bronchial casts, including infections and asthmatic conditions or lymphatic flow disorders that can cause deposits of mucus or lymph fluid Wieselthaler emphasized that the size of this vessel is almost unprecedented.
We were amazed, "Wieselthaler told the Atlantic. "That's a curiosity you can not imagine – I mean, that's very, very, very rare."
[New England Journal of Medicine via the Atlantic]