A 36-year-old man was admitted to the intensive care unit with an acute exacerbation of chronic heart failure. His medical history included severe 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 initiated to manage acute heart failure, along with a continuous heparin infusion for systemic anticoagulation.
Over the following week, the patient developed small-volume hemoptysis, worsening respiratory distress, and increasing oxygen requirements, up to 20 liters via high-flow nasal cannula. During an intense coughing episode, he spontaneously expectorated an intact cast of the right bronchial tree. This cast included three segmental branches of the upper lobe (blue arrows), two segmental branches of the middle lobe (white arrows), and five segmental branches of the lower lobe (black arrows).
The patient was subsequently intubated, and flexible bronchoscopy revealed a small amount of blood in the basilar branches of the right lower lobe. He was extubated two days later without further hemoptysis. Despite ongoing management with the ventricular assist device, the patient died one week after extubation due to complications of heart failure, including volume overload and poor cardiac output.