Man coughs up cast of his right bronchial tree

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A 36-year-old man was admitted to the intensive care unit with an acute exacerbation of chronic heart failure. His medical history included heart failure with an ejection fraction of 20%, bioprosthetic aortic-valve replacement for bicuspid aortic stenosis, endovascular stenting of an aortic aneurysm, and placement of a permanent pacemaker for complete heart block. An Impella ventricular assist device was placed for management of acute heart failure, and a continuous heparin infusion was initiated for systemic anticoagulation. During the next week, the patient had episodes of small-volume hemoptysis, increasing respiratory distress, and increasing use of supplemental oxygen (up to 20 liters delivered through a high-flow nasal cannula). During an extreme bout of coughing, the patient spontaneously expectorated an intact cast of the right bronchial tree. The right bronchial tree consists of three segmental branches in the upper lobe (blue arrows), two segmental branches in the middle lobe (white arrows), and five segmental branches in the lower lobe (black arrows). The patient’s trachea was subsequently intubated, and flexible bronchoscopy revealed a small amount of blood in the basilar branches of the right lower lobe. The patient was extubated 2 days later and had no further episodes of hemoptysis. One week after extubation, he died from complications of heart failure (volume overload and poor cardiac output) despite placement of the ventricular assist device.