That’s A Very Interesting Chest X-ray…

Labs and Lytes 004

Author: Nick Bingham 
Reviewer: Chris Nickson

An 80 year old man was transferred from a rural hospital after a fall from a chair he was standing on while reaching for a packet of biscuits. He sustained left-sided chest injuries. This is on the background of a recent admission at a tertiary hospital.

His CXRs are shown below.

TAVI radiopedia 1

Image from Radiopaedia.org: http://images.radiopaedia.org/images/5494605/634de58ed21a8b0b0fd619fb3ef9e1_big_gallery.jpg

TAVI radiopedia 2

Image from Radiopaedia.org: http://images.radiopaedia.org/images/5494613/739ae2dd988e3ef14765c43c5df884_big_gallery.jpg

Q1. What do the CXRs show?

Summary of findings on PA and lateral CXRs:

  • Dual-lead left-sided pacing device in situ.
  • The lungs show changes consistent with COAD.
  • Ill-defined opacity isdemonstrated in both lower zones represents overlying soft tissues superimposed on ribs and pulmonary parenchyma.
  • TAVI (transcatheter aortic valve implant) in situ, best seen on the lateral CXR
  • there is no pneumothroax or subcutanesous emphysema.

Rib fractures may not be visible on a CXR. A CT chest is often warranted to further define the injuries. Elderly patients with rib fractures, even in the absence of other significant findings on CXR often warrant admission to HDU to monitor complications and optimise analgesia.

Always consciously look for and actively exclude a pneumothorax on any CXR you look at.

Q2. What is the significance of the TAVI?

The TAVI was the reason for the recent tertiary hospital admission. Such patients are typically on dual anti-platelet agents aspirin and clopidogrel, and thus have a bleeding diathesis.

Here are some things worth knowing about TAVIs:

  • They are used in patients at high surgical risk for an open aortic valve replacement (AVR)
  • They are associated with better outcomes than medical therapy alone
  • There is no survival benefit compared to open AVR
  • Stroke and vascular complications are more common in TAVI than in AVR
  • There is a lack of long-term data regarding longterm valve function in TAVI patients

References and Links

All case-based scenarios on INTENSIVE are fictional. They may include realistic non-identifiable clinical data and are derived from learning points taken from clinical practice. Clinical details are not those of any particular person; they are created to add educational value to the scenarios.

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