What are the airway complications of total artificial heart?
Case Report :
The patient was a 52-year-old African American male with a past medical history of nonischemic cardiomyopathy (ejection fraction of 15%) from a viral infection, coronary artery disease with implantable cardioverter, diabetes mellitus, and chronic kidney disease stage III who was admitted with decompensated heart failure. The patient had weight gain, renal failure, and congested liver due to heart failure. The patient continued to deteriorate clinically, requiring dialysis for renal failure and mechanical ventilation and venoarterial extracorporeal membrane oxygenation (ECMO) for hypoxic respiratory failure and biventricular failure. On day 8, he underwent TAH implantation and ECMO decannulation. The patient required almost daily platelet transfusions for thrombocytopenia due to worsening liver dysfunction. Despite being coagulopathic, low dose bivalirudin was initiated with a partial thromboplastin time goal of 40–60 s given the high increased risk of clot in the setting of a TAH. His respiratory status was stable until hospital day 14 when he developed acute onset hypoxia. Chest X-ray revealed complete opacity of the left lung. He underwent bronchoscopy, which demonstrated severe mucous plugging of the left bronchus. During bronchoscopy, a left main stem airway cast was removed with subsequent expansion of his left lung. On hospital day 19, the patient developed increased peak airway pressures. He became difficult to ventilate and experienced sudden onset loss of TAH flows and resultant hypotension. A large blood clot was pulled through the endotracheal tube (ETT) using a 14-french suction catheter with the return of ventilation and improvement in TAH flows. A bronchoscopy the following morning revealed diffuse hemorrhage. The bivalirudin was held. Subsequently, the patient again developed increased peak airway pressures and decreased TAH flows. An emergent bronchoscopy revealed a large clot at the carina spilling from left to right main bronchus. The clot was noted to cause air trapping through a ball-valve phenomenon allowing air to enter but not escape [Figure 1]a and [Figure 1]b....