Therapeutic Venesection in Patient of Pulmonary Thromboembolism on Heparin: A Case Report

Diagnosis of Pulmonary Arterial Hypertension and Pulmonary Embolism With Magnetic Resonance Angiography

Ventricular Function and Dyssynchrony Quantified by Speckle-Tracking Echocardiography in Patients with Acute and Chronic Right Ventricular Pressure Overload

We examined whether experimental lung embolization with autologous blood clots or with the infusion of microspheres increase cell-free hemoglobin levels and nitric oxide consumption by plasma samples from anesthetized lambs. These parameters were also measured in patients with acute pulmonary thromboembolism at baseline conditions and after thrombolysis, and in healthy controls. Controlled animal and clinical studies. University research laboratory and university hospital. Sheep and humans. Anesthetized lambs were embolized with intravenous injections of autologous blood clots or repeated injections of 300 μm microspheres. Control animals received saline. Blood samples were drawn from patients with acute pulmonary thromboembolism at baseline conditions and after thrombolytic therapy with streptokinase or alteplase. Hemodynamic measurements were performed and plasma cell-free hemoglobin concentrations were measured. A nitric oxide consumption assay was used to measure nitric oxide consumption by plasma samples. Embolization with blood clots or microspheres increased mean pulmonary artery pressure from ~15 to ~40 mm Hg in lambs. Both plasma hemoglobin concentrations and nitric oxide consumption increased in proportion to the hemodynamic alterations and correlated significantly. Patients with acute pulmonary thromboembolism had higher plasma hemoglobin concentrations and nitric oxide consumption than healthy controls. Thrombolysis with streptokinase or alteplase further increased both parameters, which peaked 1-3 days after thrombolysis. Our results show consistent evidence indicating a new mechanism involving increased hemoglobin decompartmentalization and augmented nitric oxide consumption, possibly contributing to the hemodynamic derangement of acute pulmonary thromboembolism.

A 35-Year-Old Patient With Midscapular Pain and Hypertension

Interventional therapies for severe pulmonary arterial hypertension (PAH) can provide right ventricular (RV) decompression and preserve cardiac output. Transcatheter stent placement in a residual ductus arteriosus (PDA) is one potentially effective option in critically ill infants and young children with PAH. We sought to assess recovery of RV function by echocardiographic strain in infants and young children following PDA stenting for acute PAH. Retrospective review of patients < 2years old who underwent PDA stenting for acute PAH. Clinical data were abstracted from the electronic medical record. RV strain (both total and free wall components) was assessed from echocardiographic images at baseline and 3, 6, and 12months post-intervention, as well as at last echocardiogram. Nine patients underwent attempted ductal stenting for PAH. The median age at intervention was 38days and median weight 3.7kg. One-third (3of 9) of patients had PAH associated with a congenital diaphragmatic hernia. PDA stents were successfully deployed in eight patients. Mean RV total strain was - 14.9 ± 5.6% at baseline and improved to - 23.8 ± 2.2% at 6 months post-procedure (p < 0.001). Mean free wall RV strain was - 19.5 ± 5.4% at baseline and improved to - 27.7 ± 4.1% at 6 months (p = 0.002). Five patients survived to discharge, and four patients survived 1 year post-discharge. PDA stenting for severe, acute PAH can improve RV function as assessed by strain echocardiography. The quantitative improvement is more prominent in the first 6 months post-procedure and stabilizes thereafter.

Patient: Female, 36-year-oldFinal Diagnosis: Severe ARDS secondary to COVID-19 leading to severe PAH and RV systolic function impairmentSymptoms: HypoxemiaMedication: —Clinical Procedure: —Specialty: Critical Care MedicineObjective:Rare diseaseBackground:Inhaled nitric oxide (iNO) is used as a treatment for pulmonary arterial hypertension (PAH). Severe hypoxia with hypoxic vasoconstriction caused by severe acute respiratory distress syndrome (ARDS) can induce pulmonary hypertension with hemodynamic implications, mainly secondary to right ventricle (RV) systolic function impairment.We report the case of the use of iNO in a critically ill patient with bilateral SARS-CoV-2 pneumonia and severe ARDS and hypoxemia leading to acute severe PAH, causing a ventilation/perfusion mismatch, RV pressure overload, and RV systolic dysfunction.Case Report:A 36-year-old woman was admitted to the Intensive Care Unit with a severe ARDS associated with SARS-CoV-2 pneumonia requiring invasive mechanical ventilation. Severe hypoxia and hypoxic vasoconstriction developed, leading to an acute increase in pulmonary vascular resistance, severe to moderate tricuspid regurgitation, RV pressure overload, RV systolic function impairment, and RV dilatation. Following 24 h of treatment with iNO at 15 ppm, significant oxygenation and hemodynamic improvement were noted, allowing vasopressors to be stopped. After 24 h of iNO treatment, echocardiography showed very mild tricuspid regurgitation, a non-dilated RV, no impairment of transverse free wall contractility, and no paradoxical septal motion. iNO was maintained for 7 days. The dose of iNO was progressively decreased with no adverse effects and maintaining an improvement of oxygenation and hemodynamic status, allowing respiratory weaning.Conclusions:Sustained acute hypoxia in ARDS secondary to SARS-CoV-2 pneumonia can lead to PAH, causing a ventilation/perfusion mismatch and RV systolic impairment. iNO can be considered in patients with significant PAH causing hypoxemia and RV dysfunction.

Background: The aim of this study was to study the clinical outcome of infants beyond neonatal period who presented with acute onset pulmonary artery hypertension of unknown etiology.Methods: This is a retrospective case record analysis of all the babies admitted to pediatric intensive care unit between January 2013 to March 2017 at Rajarajeswari Medical College with signs and symptoms of Pulmonary Arterial Hypertension on clinical examination and ECHO. Descriptive and inferential statistical analysis has been carried out in the present study. Results: Out of 49 infants beyond neonatal period who presented with Pulmonary Arterial Hypertension, 9 were females and 40 were males. 43 babies required ventilator support and 6 babies required only supplemental oxygen. Out of 33 babies who expired, cardiogenic shock and severe hypoxia was the main cause of death in 19, pulmonary hemorrhage in 4, acute kidney injury and fluid overload in 2, multi organ dysfunction in 1, septicemia in 4 and disseminated intravascular coagulation in 3. Babies who survived less than 72 hours cardiogenic shock and severe hypoxia was the main cause of death and babies who survived more than a week, pulmonary hemorrhage, acute kidney injury and fluid overload, multi organ dysfunction, septicemia and disseminated intravascular coagulation were the main cause of death. Conclusions: There is a need for research in infants beyond neonatal period with pulmonary arterial hypertension, to find out the etiology.

Resveratrol downregulates acute pulmonary thromboembolism-induced pulmonary artery hypertension via p38 mitogen-activated protein kinase and monocyte chemoattractant protein-1 signaling in rats

Acute lupus myocarditis and pulmonary arterial hypertension (PAH) are rare complications associated with systemic lupus erythematosus (SLE). No previous reports have shown the coexistence of these disorders. Here we present a 41-year-old patient with SLE who concurrently developed severe acute lupus myocarditis and PAH with digital gangrene as an initial manifestation. Acute lupus myocarditis and PAH were successfully treated with prednisolone and intravenous cyclophosphamide pulse therapy (600–700 mg × 6) along with anticoagulant therapy. Catheter-directed thrombolysis was required for digital gangrene caused by vasculitis. Concurrent development of these rare disorders may represent a common mechanism such vasculitis as an underlining cause of SLE.

ARTICLESHemodynamics in the conscious dog during progressive pulmonary arterial occlusionMM Laks, D Garner, F Morady, and HJ SwanMM Laks, D Garner, F Morady, and HJ SwanPublished Online:01 Mar 1972https://doi.org/10.1152/ajplegacy.1972.222.3.578MoreSectionsPDF (1 MB)Download PDF ToolsExport citationAdd to favoritesGet permissionsTrack citations ShareShare onFacebookTwitterLinkedInWeChat Previous Back to Top Next Download PDF FiguresReferencesRelatedInformationCited ByPulmonary and systemic haemodynamic disorders in the adult respiratory distress syndromeIntensive Care Medicine, Vol. 5, No. 3Hyperkinetic shock in viral and pneumococcal pneumoniasIntensive Care Medicine, Vol. 5, No. 2Mechanism of impaired water excretion in acute right ventricular failure in conscious dogs.Circulation Research, Vol. 42, No. 6Acute Pulmonary Artery Hypertension Produced by Distention of the Main Pulmonary Artery in the Conscious DogChest, Vol. 68, No. 6Cor pulmonale in childrenCurrent Problems in Pediatrics, Vol. 5, No. 4Dimensional changes of the left ventricle during acute pulmonary arterial hypertension in dogsThe American Journal of Cardiology, Vol. 33, No. 7The effect of acute pulmonary artery obstruction on the dog electrocardiogramAmerican Heart Journal, Vol. 87, No. 2Cardiovascular effects of nicotine in the conscious dogThe American Journal of Cardiology, Vol. 32, No. 7 More from this issue > Volume 222Issue 3March 1972Pages 578-582 Copyright & PermissionsCopyright © 1972 by American Physiological Societyhttps://doi.org/10.1152/ajplegacy.1972.222.3.578PubMed5022665History Published online 1 March 1972 Published in print 1 March 1972 Metrics

Polycythemia vera (PV) is a myeloproliferative neoplasm characterized by unregulated red blood cell production resulting in elevated hemoglobin and/or hematocrit levels. Patients often have symptoms such as fatigue, pruritus, and painful splenomegaly, but are also at risk of thrombosis, both venous and arterial. Ruxolitinib, a selective Janus kinase inhibitor, is approved by the US Food and Drug Administration as second-line cytoreductive treatment after intolerance or inadequate response to hydroxyurea. Although ruxolitinib has been widely used in this setting, limited data exist in the literature on ruxolitinib treatment patterns and outcomes among patients with PV in routine clinical practice. We report a retrospective, observational, cohort study of patients treated for PV with ruxolitinib across three US centers (academic and regional practice) from December 2014-December 2019. The study included 69 patients, with a median follow-up duration of 3.7 years (95% CI, 2.9–4.4). Our data demonstrate very high rates of hematocrit control (88% of patients by three months and 89% by six months); few patients required dose adjustments or suspension. No arterial thromboses were observed; however, the follow-up duration does not allow for the generation of meaningful conclusions from this. Three patients had thrombotic events; one was in the setting of a second malignancy, one post-operative, and a third related to prolonged immobility. We also found that 28% of patients initiated ruxolitinib as a result of poorly controlled platelet counts, second only to hydroxyurea intolerance (46%) as a reason to start therapy. In clinical practice, ruxolitinib continues to be effective in controlling hematocrit levels after three and six months of treatment in patients and is associated with low thrombotic risk.

Background : Vital stability and right side heart failure are major prognostic factors of acute pulmonary thromboembolism. While it is important to recognize right side heart failure, it is often difficult in real practice. Recently, several studies have described early diagnostic tools for detecting right side heart failure including echocardiography and biochemical markers. This study, we evaluated the prognostic role of the B-type natriuretic peptide (BNP) in an acute pulmonary thromboembolism. Methods : Thirty-four patients with a diagnosis of acute pulmonary thromboembolism were enrolled in the study. The BNP levels were measured and echocardiography was performed at the Emergency Department. Data on the prognostic factors including ventilatory support, vital stability, pulmonary artery pressure, degree of tricuspid valve regurgitation, complications and death was collected from the patients' medical records. The patients with an acute pulmonary thromboembolism were divided into two groups based on the vital stability and the BNP level and the cutoff values and prognostic factors of the two groups were compared. Results : The predictors of the vital stability that influence the prognosis of patients with acute pulmonary thromboembolism were the BNP level, ventilatory support and death. The plasma BNP levels showed a strong correlation with the vital stability, ventilatory support, thrombolytic therapy and death. When the BNP cutoff level was set to 377.5 pg/dl in a ROC curve, the sensitivity and the specificity for differentiating between the groups with stable or unstable vital signs was 100% and 90%, respectively. Conclusion : This study indicates that a measurement of the plasma BNP levels may be a useful prognostic marker in patients with an acute pulmonary thrombo-embolism.

Sildenafil for Pulmonary Arterial Hypertension: Exciting, But Protection Required

Angiotensin converting enzyme inhibitors (ACEI) and theophylline have been reported to decrease the elevated hemoglobin (Hgb) and hematocrit (Hct) levels in the renal transplant recipients with erythrocytosis. We conducted a prospective randomized, open labeled, crossover trial with theophylline, and an ACEI, fosinopril in nine stable renal transplant recipients with erythrocytosis. Aim of the study was to determine and compare the efficacy of these medications in stable renal transplant patients. At three months, compared to baseline, fosinopril significantly reduced the elevated hemoglobin (Hgb 17.2 ± 0.6 vs. 14.9 ± 1.4 gm/dL, p = 0.0023), and hematocrit levels (Hct 51.3 ± 2.4 vs. 43.7 ± 4.6%, p = 0.003). In contrast theophylline therapy was associated with a non-significant rise in hemoglobin (17.4 ± 0.7 vs. 18.1 ± 0.9 gm/dL, p>0.05) and hematocrit (52.4 ± 2.7 vs. 54.7 ± 3.9%, p>0.05). With fosinopril compared to theophylline, there was a significant difference in the change in hemoglobin (baseline to three months 2.8 ± 1.7 vs. −0.7 ± 0.69 gm/dL respectively, p = 0.017), and the change in hematocrit (baseline to three months 9 ± 6 vs. −2.3 ± 2.7% respectively, p = 0.027). Four patients (44.4%) did not tolerate theophylline and did not complete the theophylline arm. To conclude, in our study, fosinopril effectively decreased the elevated hemoglobin and hematocrit in patients with post transplant erythrocytosis, and was superior to theophylline, while theophylline was ineffective and poorly tolerated in this condition.

Background: Idiopathic scoliosis can cause pulmonary dysfunction due to thoracic pressure that triggers hypoxia, theoretically increasing hemoglobin and hematocrit levels as a compensatory mechanism. Objective: This study aims to describe the levels of hemoglobin and hematocrit in patients with idiopathic scoliosis at the Orthopedic Clinic of RSUP Dr. M. Djamil Padang. Methods: This research employed a descriptive retrospective method, collecting medical record data of idiopathic scoliosis patients from 2018 to 2022. The data analyzed included age, gender, hemoglobin levels, and hematocrit levels prior to surgery. Out of 17 patients recorded, nine met the inclusion criteria. Results: The results showed that all patients were in the adolescent age category (10–18 years), with the highest age range being 14–16 years. All patients were female. A total of 44% of patients had hemoglobin levels of 13–14 g/dl, while 55% had hematocrit levels of 40–42%. Conclusion: The conclusion of this study is that there was no significant increase in hemoglobin and hematocrit levels before surgery, indicating no clear evidence of hypoxia compensation through elevated hemoglobin and hematocrit levels in patients with idiopathic scoliosis at RSUP Dr. M. Djamil Padang.