Major Pulmonary Thromboembolism Research Articles

Open Pulmonary Thromboembolectomy in Patients with Major Pulmonary Thromboembolism

PurposeWe retrospectively analyzed open pulmonary thromboembolectomy in patients with acute and chronic pulmonary thromboembolism.Materials and MethodsBetween August 1990 and May 2005, 12 consecutive patients with acute and chronic pulmonary thromboembolism underwent open pulmonary thromboembolectomy at Yonsei Cardiovascular Center. Their mean age was 47.5 years, and 7 of the patients were female. Among 12 patients, 5 had acute onset, and 7 had chronic disease, and 9 patients were associated with deep venous thrombosis. Extent of pulmonary embolism was massive in 3 patients with hemodynamic instability, and submassive in 8 patients. Preoperative echocardiogram revealed elevated right ventricular pressure in all patients, and 7 patients were in NYHA functional class III or IV. Pulmonary thromboembolectomy was performed in all patients under total circulatory arrest.ResultsThere were 2 hospital deaths (16.7%). Among the patients who survived, mean right ventricular pressure was decreased significantly from 64.3 mmHg to 34.0 mmHg with improvement of NYHA functional class.ConclusionOpen pulmonary thromboembolectomy is thought to be an immediate and definitive treatment for massive pulmonary embolism with optimal results. Even though operative mortality is still high, early diagnosis and immediate surgical intervention in highly selective patients may improve the clinical outcome.

Factor V Leiden Homozygosity, Dyspnea, and Reduced Pulmonary Function

Factor V Leiden homozygosity predisposes patients to deep venous thrombosis and major pulmonary thromboembolism. Consequently, factor V Leiden homozygosity could, via unrecognized repeated minor pulmonary thromboemboli, cause chronic pulmonary disease. We tested the hypothesis that factor V Leiden homozygosity is associated with pulmonary symptoms and signs. We studied a general population sample of 9253 individuals from the Copenhagen City Heart Study who were examined in 1991-1994. Of these, 6475 participants were also examined in 1976-1978 and/or 1981-1983. End points were dyspnea and lung function. Among 20 factor V Leiden homozygotes, a mean +/- SD of 32% +/- 11% had severe dyspnea compared with 6% +/- 0.3% of 8534 noncarriers (chi(2) test; P<.001). The corresponding adjusted odds ratio for severe dyspnea was 5.4 (95% confidence interval, 1.9-15.7). During follow-up, forced expiratory volume in 1 second and forced vital capacity were 5% to 10% lower in homozygotes vs noncarriers (analysis of variance; P = .003 and P = .03). The annual mean +/- SD loss of forced expiratory volume in 1 second and forced vital capacity was 39 +/- 8 mL/y and 35 +/- 8 mL/y in homozygotes vs 21 +/- 10 mL/y and 15 +/- 10 mL/y in noncarriers (t test; P = .03 and P = .04), respectively. Factor V Leiden heterozygosity (n = 699) did not influence pulmonary symptoms and signs. We demonstrate a previously unrecognized clinical presentation of factor V Leiden homozygosity with severe dyspnea and decreased pulmonary function.

Comparison of Effect Between Thrombolysis and Anticoagulation in Major Pulmonary Thromboembolism

Background 'Major pulmonary thromboembolism' is defined as right ventricular (RV) dysfunction, with or without shock, accompanied by significant morbidity and mortality. In this study, those with major pulmonary thromboembolism were divided into the shock and RV dysfunction only groups, and then investigated the mortality and complications in thrombolysis or anticoagulation, respectively. Methods In a retrospective study, between January 1995 and December 2004, 60 eligible patients with a major pulmonary thromboembolism, admitted in Asan Medical Center, were included. Results A total of 57 patients were treated with medical therapy. Thrombolysis was performed in 13 patients (23%) and anticoagulation in 44 (77%). There were no differences in the APACHE II and SOFA scores between the two groups. 6 (46%) and 11 (25%) patients died in the thrombolysis and anticoagulation groups, respectively (p=0.176). In the 19 patients (33%) showing shock, thrombolysis was performed in 9 (47%) and anticoagulation in 10 (53%). 4 (44%) of the 9 patients treated with thrombolytic agents and 3 (30%) of the 10 treated with anticoagulants died (p=0.650). In the 38 patients (67%) showing RV dysfunction only, thrombolysis was performed in 4 (11%) and anticoagulation in 34 (89%). 2 (50%) of the 4 patients treated with thrombolytics and 8 (24%) of the 34 treated with anticoagulants died (p=0.279). Three patients (23%) who underwent thrombolysis had a major bleeding episode, compared with 2 (5%) who were treated with anticoagulants (p=0.072). Conclusion The results of our study showed that thrombolysis did not lower mortality and tended to increase major bleeding compared with anticoagulation in both the shock and RV dysfunction only groups. Further evaluation of the efficacy and safety of thrombolytic therapy for major thromboembolism appears warranted in Korea.

A Case of Huge Right Atrial Thrombi Treated with Thrombolytic Agent

Thrombi in the right atrium (RA) are infrequent, and are rarely diagnosed before death. In addition, right heart thrombi are frequently associated with major pulmonary thromboembolism, and carry a very high risk of mortality, and therefore, require accurate diagnosis and prompt treatment. RA thrombi are generally associated with dilatation of the atrium, a low cardiac output state, intracardiac catheters, such as endocardial pacemakers and central venous hyperalimentation catheters, recent cardiac surgery, involving the atrium, and peripheral deep vein thrombosis. In addition, some systemic diseases, such as malignant tumors, amyloidosis and nephrotic syndrome, have been shown to contribute to the formation of an intracardiac thrombus. Echocardiography is valuable in the diagnosis of RA thrombi. There are some options in the treatment of RA thrombi, such as anticoagulant therapy using heparin, thrombolytic therapy and surgical removal. However, there is still adverse criticism as to the selection of the correct treatment method. A patient with RA thrombi, who presented with sudden cardiogenic shock, was diagnosed by two-dimensional echocardiography. He had been in a prolonged bed-ridden state because of quadriparesis caused by an injury to the cervical spine. The RA thrombi were successfully treated with anticoagulant and thrombolytic agents. (Korean Circulation J 2004;34(3):328-332)

P12 Fibrinolytic therapy in major pulmonary thromboembolism

P12 Fibrinolytic therapy in major pulmonary thromboembolism

Pulmonary Thromboembolism Complicating Recurrent Placental Abruption at 29 Weeks' Gestation

A patient with major pulmonary thromboembolism associated with recurrent placental abruption is described. Delivery by Caesarean section was necessary, followed by full heparinization. The use of peripartum heparinization and Caesarean section is reviewed.

Right heart thrombus: Recognition, diagnosis and management

The clinical, echocardiographic, hemodynamic, angiographic and pathologic features of five patients who had right heart thrombus are presented and their management is discussed. Two modes of presentation were recognized. In four patients, right heart thrombus complicated peripheral venous thrombosis and was associated with major pulmonary thromboembolism and right heart obstruction. In the fifth, it complicated myocarditis with heart failure and appeared to cause right heart obstruction. Two-dimensional echocardiography was diagnostic of right heart thrombus in four patients and showed evidence of right heart dysfunction in those with major pulmonary thromboembolism. The diagnosis was confirmed at surgery in three patients and at autopsy in one. Three patients successfully underwent surgical removal of the thrombus followed by anticoagulation. One patient was treated successfully with anticoagulation alone. The only death occurred in the patient with myocarditis.

Quantitative Radiocardiography in Major Pulmonary Thromboembolism

Cardiac index (CI) and pulmonary blood volume index (PVBI) were measured by quantitative radiocardiographic studies using radioactive 113mindium and a scintillation probe in 37 patients with confirmed major pulmonary thromboembolism. The mean PBVI was 185 +/- 11 ml/sq m (SE) and was significantly less than normal (310 +/- 5 ml/sq m [SE]; P less than 0.001). Six patients with major pulmonary thromboembilism had a PBVI within the normal range (262 to 358 ml/sq m; mean +/- 2 SD), and the mean pulmonary vascular occlusion was 21 percent in these patients. Eighteen patients (49 percent) died, and the most significant correlate of mortality was CI, which was depressed (less than 2.7 L/min/sq m) in all but two. Twenty-three serial determinations of pulmonary blood volume (PBV) ranging from 1 to 18 days after the initial study showed a mean increase in PBV of 27 ml/day in ten survivors. Quantitative radiocardiographic studies provide a means of diagnosing major pulmonary thromboembolism by measuring decreases in PBVI; it can assess the magnitude of major pulmonary thromboembolism and can assess CI and, thereby, predict risk of mortality; and it provides a means of following the resolution rate of major pulmonary thromboembolism.