Abstract Introduction Acute respiratory distress syndrome (ARDS) is a life-threatening condition where inflammation results in diffuse lung damage. This damage results in hypoxemia and poor lung compliance with non-cardiac pulmonary edema on imaging. When confronted with suspected acute respiratory distress syndrome, it is important to keep in mind the possibility of other conditions that present with similar findings. Case A 34-year-old man with a history of recurrent urinary tract infections was transferred to our intensive care unit from an outside hospital for venovenous extracorporeal membrane oxygenation evaluation given acute respiratory distress syndrome. He presented there for three days of fevers, chest pain, and dyspnea. He deteriorated rapidly in the emergency department and required endotracheal intubation. He was admitted to the intensive care unit and underwent bronchoscopy which revealed a large amount of red-tinged “bronchorrhoea” throughout his lungs prior to transfer. Upon arrival to our intensive care unit, his fraction of inspired oxygen was 0.6 and his positive end-expiratory pressure was 10. He was on norepinephrine and vasopressin for hemodynamic support with a pulse pressure of 19 mmHg. Given his narrow pulse pressure, transthoracic echocardiogram was obtained demonstrating a flail mitral valve leaflet, vegetation, and mitral regurgitation. This demonstrated that his pulmonary infiltrates were from mitral regurgitation and not ARDS. Cardiothoracic surgery was consulted and determined that he needed emergent mitral valve replacement. However, he remained hypoxemic given persistent pulmonary edema. He was cannulated for left atrial veno-arterial extracorporeal membrane oxygenation for offloading of his heart and had subsequent improvement in his pulmonary edema and oxygenation. This enabled him to be taken to the operating room. At the conclusion of surgery, he was decannulated from extracorporeal membrane oxygenation. He was extubated one day after surgery. He was discharged and is doing well on follow-up. Discussion Mitral regurgitation can drive pulmonary edema and hypoxemia. In a patient without known heart failure presenting with mitral insufficiency, valvular disease may be lower on the differential. Echocardiography should be considered for all patients with new hypoxemia and bilateral pulmonary infiltrates to help determine if cardiac dysfunction is the cause. In patients with mitral regurgitation who need urgent operative intervention, offloading of the left ventricle with mechanical circulatory support should be considered to reduce pulmonary edema and improve oxygenation. Left atrial venoarterial extracorporeal membrane oxygenation is a good temporizing option in these cases as it allows for offloading of the heart, reduction of pulmonary edema, and hemodynamic support. This abstract is funded by: None
VanDreumel et al. (Fri,) studied this question.