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Biomedical subjects

H I Palevsky

Publications and source records attributed to H I Palevsky.

At least 37 records · Page 2Linked to original sources
PubMed1997

Therapeutic options for severe pulmonary hypertension.

Pulmonary hypertension occurs as a consequence of numerous and varied conditions, all of which result in an elevation of pulmonary vascular resistance. Over the past decade, significant progress has been made in understanding the factors which contribute to the progressive nature of pulmonary vascular disease, and in identifying new treatments for pulmonary hypertension. The majority of these therapeutic options are pharmacologic, but for specific circumstances, surgical therapy may be a consideration. This article discusses nonspecific therapies for all patients with pulmonary hypertension, vasodilator therapy (including screening for vasodilator responsiveness, standard oral agents, and newer intravenous or inhalational therapies) and surgical options applicable to specific situations.

Anticoagulants↗
PubMed1997

Pulmonary hypertension in systemic autoimmune disease.

Rare in occurrence, insidious in onset, and relentless in its course, pulmonary hypertension in systemic autoimmune disease remains one of the most challenging entities to diagnose and treat today. The subtlety and nonspecificity of its symptoms and signs, the lack of availability of sensitive, noninvasive, accurate diagnostic tests, the rudimentary understanding we have of its pathogenesis, the multiplicity of findings on histopathologic survey, and the paucity of data from large-scale therapeutic trials in this population all pose many frustrations for patient and physician. Although supportive, symptomatic therapy remains the mainstay of treatment, we continue to await the results of carefully conducted clinical trials investigating antiinflammatory drugs and vasodilators. Careful scrutiny of the histologic lesions seen in pulmonary hypertension has shown striking similarity with the changes of PPH in some patients, and close follow-up of patients diagnosed with PPH has shown that some of them later develop evidence of a specific autoimmune disease like scleroderma. A natural tendency to extrapolate the use of therapeutic modalities of PPH to patients with autoimmune disease-associated pulmonary hypertension then results. We are thus encouraged by the lessons learned from the past about PPH; studies of patients with PPH have identified a subset of them who enjoy a distinct survival advantage with use of vasodilators or transplantation. We remain hopeful that future investigations in the treatment of autoimmune disease-associated pulmonary hypertension will yield similar information, and that we will be able to provide afflicted individuals some long-awaited improvements in quality and duration of life.

Autoimmune Diseases↗
PubMed1997

Bilateral sequential lung transplantation for pulmonary alveolar microlithiasis.

Pulmonary alveolar microlithiasis (PAM) is characterized by deposition of calcium phosphate within the alveolar airspaces. There is currently no effective medical therapy and affected individuals may progress to end-stage lung disease requiring transplantation. Two patients with PAM underwent bilateral sequential lung transplantation. This study reviews the clinical manifestations of PAM and discusses the particular difficulties that may be encountered in the use of lung transplantation as treatment for this uncommon disease. Also addressed is the question of recurrence in the allograft.

Adult↗
PubMed1996

Comparison of diagnostic performance with ventilation-perfusion lung imaging in different patient populations.

PURPOSE: To determine if patient age, chest radiographic abnormalities, or history of cardiopulmonary disease or venous thromboembolism affected diagnostic performance with ventilation-perfusion (V-P) imaging. MATERIALS AND METHODS: Receiver operating characteristic (ROC) analyses were performed on the final V-P imaging interpretation data obtained during the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study. Diagnostic performance with V-P imaging was not substantially different in patients with varying ages, an abnormal chest radiograph, or a history of venous thromboembolism or cardiopulmonary disease. CONCLUSION: Because diagnostic performance with V-P imaging in detection of pulmonary embolism was similar among the patient populations examined, an abnormal chest radiograph or history of venous thromboembolism or cardiopulmonary disease does not appear to adversely affect overall diagnostic performance in evaluation of acute pulmonary embolism.

Adult↗
PubMed1996

Bilateral lung volume reduction surgery for advanced emphysema. A comparison of median sternotomy and thoracoscopic approaches.

STUDY OBJECTIVES: To compare short-term outcomes following bilateral lung volume reduction surgery performed by median sternotomy (MS) and video-assisted thoracoscopic surgery (VATS). METHODS: Bilateral lung volume reduction surgery was performed by MS in 80 patients and by VATS in 40. All patients underwent preoperative assessment with pulmonary function testing, arterial blood gas determination, and 6-min walk test (6MWT). Pulmonary function testing and 6MWT were repeated at 3 to 6 months postoperatively. RESULTS: The mean age of the VATS group was lower than that of the MS group (59.3 +/- 9.4 vs 62.4 +/- 6.9 years; p = 0.001), but there were no differences in baseline functional parameters of disease severity (FEV1, FVC, residual volume [RV], arterial PCO2, or 6MWT). All patients in both groups were extubated at the completion of surgery, but 17.5% of patients in the MS group and 2.5% in the VATS group (p = 0.02) subsequently required reintubation at some point during the postoperative course. Thirty-day operative mortality was 4.2% for the MS group and 2.5% for the VATS group (p = not significant). However, total in-hospital mortality was 13.8% for the MS group, while it remained 2.5% for the VATS group (p = 0.05). Mortality was largely confined to patients 65 years of age or older. There was no significant difference in duration of air leaks or length of hospital stay between the two groups. Functional outcomes achieved with the two techniques were similar. Specifically, there was no difference between the two groups in mean postoperative FEV1, FVC, RV, or 6MWT, or in the magnitude of change in these parameters over preoperative values. CONCLUSIONS: Bilateral lung volume reduction surgery performed by either MS and VATS approaches leads to similar improvements in pulmonary function and exercise tolerance. VATS is associated with a significantly lower incidence of respiratory failure and a trend toward decreased in-hospital mortality and may be the preferred technique, particularly for high-risk patients.

Carbon Dioxide↗
PubMed1996

GI complications after orthotopic lung transplantation.

OBJECTIVES: Recently, lung transplantation has been performed with increasing frequency and improved outcomes. GI complications have been observed and reported in patients undergoing cardiac and renal transplantations but only recently have been reported in patients after lung transplantation. No large cohort has been systematically analyzed for all GI complications after lung transplantation. The present study describes, categorizes, and assesses risk factors for the development of such GI complications. METHODS: Records of 45 patients who underwent 47 single or bilateral orthotopic lung transplants between November 1991 and January 1994 were reviewed. RESULTS: Twenty-three patients (51%) had 64 GI complications requiring 13 operations on eight patients. The incidence of major abdominal procedures in the entire transplant cohort was 18% (8/45). Their operative mortality rate was 63% (5/8). Eighteen different types of nonoperative complications occurred and were subclassified into major and minor complications. Complications were defined as major if they required medical or surgical intervention and altered patient management. Most GI complications (73%) occurred within 1 month after transplantation. No risk factors were identified to ascertain who will develop GI complications. CONCLUSIONS: GI complications occur in more than one-half of lung transplant recipients early after transplantation and in the absence of identifiable risk factors. Because there are no precedent risk factors to suggest who will develop GI complications, clinicians must be alert to any warning signs and symptoms. The majority of complications are nonoperative, responding to conservative therapy, but there is a higher overall mortality rate for patients requiring operative intervention, necessitating an aggressive search for major, life-threatening complications in these immunosuppressed patients.

Female↗
PubMed1995

Pulmonary thromboembolism: recent developments in diagnosis with CT and MR imaging.

Recent technical advances in computed tomography (CT; helical and electron beam) and magnetic resonance (MR) imaging have spurred a renewed interest in these modalities for the diagnosis of acute and chronic pulmonary embolism (PE). These techniques can enable accurate clot detection down to segmental pulmonary arteries, with CT currently allowing more accuracy than that with MR imaging. Ongoing technical advances, particularly in MR angiography, will likely increase diagnostic accuracy. Inability to reliably detect subsegmental acute emboli may not prove to be a clinically significant limitation if lung imaging is coupled with evaluation for deep venous thrombosis. MR imaging can potentially accomplish this within a single examination. Incorporation of CT and MR imaging into diagnostic algorithms for suspected PE can be cost-effective. Evaluation of these new modalities should be based on patient outcome, not solely on clot detectability. Well-designed clinical trials are warranted before CT and MR imaging can be used routinely in the diagnosis of acute PE.

Acute Disease↗
PubMed1994

Scintigraphic appearance of albuterol-induced inhibition of hypoxic pulmonary vasoconstriction.

Alveolar hypoxia is known to result in localized pulmonary arterial vasoconstriction. As a consequence, blood is diverted from poorly ventilated alveoli, maintaining ventilation-perfusion (V/Q) matching and thereby reducing the deleterious effects on gas exchange. An incomplete alveolar hypoxic vasoconstrictive response can be easily demonstrated by radionuclide V/Q lung scanning. A case of albuterol-induced inhibition of hypoxic pulmonary vasoconstriction is described in a patient with steroid-dependent asthma. The utility of V/Q lung scanning as a simple, noninvasive test to detect this phenomenon in patients with primary airway disorders who deteriorate despite appropriate therapy is also briefly discussed.

Administration, Inhalation↗
PubMed1994

MR imaging with spatial modulation of magnetization in the evaluation of chronic central pulmonary thromboemboli.

PURPOSE: To assess the diagnostic value of magnetic resonance (MR) imaging with SPAMM (spatial modulation of magnetization) in the identification of chronic central pulmonary thromboemboli. MATERIALS AND METHODS: Twelve patients with pulmonary hypertension and five healthy volunteers were prospectively studied with a 1.5-T MR imaging system. The SPAMM technique was integrated into a conventional cardiac-synchronized spin-echo (SE) sequence. Six of the 12 patients had central thromboemboli. RESULTS: In the healthy subjects, intravascular stripes in the central pulmonary arteries disappeared as a result of flow within 100 msec after the R wave. Areas of persistent stripes were identified in seven of eight central pulmonary arteries with thromboemboli. Conversely, in the 16 central pulmonary arteries without clot, intraluminal stripes disappeared despite the presence of flow-related signal (sensitivity = 88%, specificity = 100%, accuracy = 96%). CONCLUSION: SPAMM appears to be a simple and effective technique for differentiating central pulmonary arterial thromboemboli from flow-related signal frequently observed with pulmonary hypertension.

Adult↗
PubMed1994

Life-threatening pulmonary emboli and cor pulmonale: treatment with percutaneous pulmonary artery stent placement.

Large, central bilateral pulmonary emboli led to cor pulmonale and severe hypoxemia in a patient who had recently undergone cardiac surgery. After percutaneous catheter fragmentation and thrombolysis of the emboli failed, the left and right interlobal pulmonary arteries were recanalized by placement of self-expanding Wallstent endoprostheses through the clots. Pulmonary perfusion was restored to the lower lobes, and the patient demonstrated rapid clinical improvement.

Coronary Artery Bypass↗
PubMed1994

Ventilation-perfusion lung scanning in the evaluation of pulmonary hypertension.

UNLABELLED: The objective of this study was to define the sensitivity, specificity and accuracy of ventilation-perfusion (V/Q) lung scanning in distinguishing chronic thromboembolic pulmonary hypertension (PHT) from other nonembolic causes of PHT. METHODS: The V/Q lung scans from 75 patients in whom a confirmed cause of PHT was established were retrospectively reviewed. Twenty-five patients (33%) had chronic thromboembolic PHT, whereas 35 patients (47%) and 15 patients (20%) suffered from primary PHT and secondary nonthromboembolic PHT, respectively. RESULTS: A high-probability V/Q scan interpretation had a sensitivity of 96% and a specificity of 94% for detecting patients with thromboembolic PHT. The combination of high- and intermediate-probability V/Q scan interpretations had a sensitivity of 100% for detecting patients with thromboembolic PH; however, the specificity decreased to 86%. Of the 35 patients with primary PHT, all but one patient had low-probability V/Q scan interpretations. CONCLUSION: In this series, a low-probability V/Q scan interpretation effectively excluded the diagnosis of chronic thromboembolic PHT. In patients with an intermediate- or high-probability V/Q scan interpretation, pulmonary angiography was required to confirm the diagnosis of chronic thromboembolic PHT and determine whether surgical intervention was indicated. The V/Q lung scan appears to be a highly sensitive test for chronic thromboembolism in the diagnostic evaluation of patients with PHT. However, its role needs to be defined further by application to a prospectively recruited cohort of patients with PHT.

Adolescent↗
PubMed1993

Pulmonary artery hemodynamics in primary pulmonary hypertension.

OBJECTIVES: The present investigation compared and contrasted steady and pulsatile pulmonary hemodynamics at rest and during exercise in patients with primary pulmonary hypertension and normal control subjects. BACKGROUND: A complete description of the relation between pressure and flow in the pulmonary circulation includes both steady and pulsatile hemodynamic behavior. Patients with primary pulmonary hypertension provide a unique opportunity to study the effects of primary alterations in pulmonary vasculature on pulmonary artery vascular hydraulic load. METHODS: Catheter tip pressure and velocity recordings from the main pulmonary artery in 8 patients with primary pulmonary hypertension and 10 control subjects were used to derive the pulmonary artery input impedance spectrum and the extent of pulse wave reflection at rest and during exercise. RESULTS: As expected, in patients with primary pulmonary hypertension, mean pulmonary artery pressure (50 +/- 10 mm Hg) and pulmonary vascular resistance (880 +/- 446 dynes.s.cm-5) were markedly elevated at rest and remained so during exercise (mean pressure 71 +/- 15 mm Hg, mean resistance 750 +/- 530 dynes.s.cm-5). Pulmonary artery characteristic impedance was elevated at rest and did not change with exercise (rest 55 +/- 25 dynes.s.cm-5; exercise 66 +/- 33 dynes.s.cm-5). Measures of arterial wave reflection indicated that the extent of wave reflection in the pulmonary bed in those with primary pulmonary hypertension is large at rest (reflection coefficient 0.89 +/- 0.09) and that the composite reflected wave arrived during the midportion of right ventricular ejection. Although the extent of wave reflection decreased with exercise (reflection coefficient 0.81 +/- 0.10, p < 0.05), the magnitude and timing of these reflections remained adverse. Furthermore, in patients with primary pulmonary hypertension, the stroke volume response to exercise was strongly related to rest levels of pulmonary artery diastolic pressure, pulmonary vascular resistance and the reflection factor, whereas no such relation was found in the control subjects. CONCLUSIONS: In addition to the expected abnormalities in steady measures of pulmonary artery hemodynamics at rest in patients with primary pulmonary hypertension, rest and exercise measures of oscillatory behavior (characteristic impedance and pulse wave reflection) are perturbed. Measures of steady and pulsatile behavior, particularly wave reflection, appear to have an important role in the exercise response of these patients.

Blood Flow Velocity↗
PubMed1993

Detailed analysis of patients with matched ventilation-perfusion defects and chest radiographic opacities.

We performed a retrospective evaluation of the data obtained from the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study to determine the prevalence and distribution of pulmonary embolism (PE) in patients with matching ventilation-perfusion (V/Q) defects and chest radiographic opacities (triple matches). From the 1,487 patients in whom diagnostic V/Q scans were obtained, 247 (17%) patients were recorded as having matching V/Q defects and chest radiograph opacities in at least one lung zone. Diagnostic angiograms were available for 275 lung zones (233 patients) which demonstrated matching V/Q defects and chest radiograph opacities. The overall prevalence of PE in all lung zones with triple matches was 26%. The prevalences of PE in the upper, middle and lower lung zones were 11%, 12% and 33%, respectively. Pulmonary embolism was significantly more common in lower lung zone triple matches compared with the upper and middle lung zone triple matches (p < 0.005). There was no correlation between the size of the V/Q and chest radiographic abnormalities and the prevalence of PE. We conclude that in patients with matching V/Q defects and chest radiographic opacities isolated to the upper and middle zones the V/Q scan can be interpreted as representing a low probability of PE. Similar findings in the lower lung zones represent an intermediate probability of PE. The application of this modification to V/Q scan interpretation criteria will aid in reducing the number of intermediate V/Q lung scan interpretations.

Humans↗
PubMed1993

Role of radionuclide imaging in patients with suspected pulmonary embolism.

The accurate diagnosis of acute pulmonary embolism often represents a challenge to clinicians. The ventilation/perfusion (V/Q) lung scan provides a safe, noninvasive technique, which has been widely used in the diagnosis of pulmonary embolism. Although some controversy still exists in the management of patients with suspected pulmonary embolism, diagnostic strategies for investigating patients have incorporated V/Q scanning, noninvasive venous studies of the lower extremities and clinical assessment of the likelihood of pulmonary embolism. The combination of these strategies will provide acceptable diagnostic accuracy for evaluating patients with suspected pulmonary embolism in the majority of cases.

Humans↗