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PubMed2006

Thrombolytic therapy in pregnancy.

Pregnancy due to its physiological changes is a procoagulant state. The rate of cardiac valve prosthesis thrombosis, deep venous thrombosis and pulmonary embolism are all increased. Thrombolytic therapy with tissue plasminogen activator (rt-PA) is an approved therapy for ischemic stroke, myocardial infarction, pulmonary embolism and thrombosis of cardiac valve prosthesis. However, there are no data from controlled randomized trials in pregnant patients. Thrombolytic therapy has been rarely used in pregnancy with only 28 cases of rt-PA thrombolysis reported in the literature so far. Indications for rt-PA thrombolysis were stroke (n = 10), thrombosis of cardiac valve prosthesis (n = 7), pulmonary embolism (n = 7), deep venous thrombosis (n = 3), and myocardial infarction (n = 1). Remarkably, all thrombosis of cardiac valve prostheses occurred after switching from warfarin to heparin in order to prevent teratogenicity and fetal loss. Two patients died (7%) and three suffered from complications that were managed conservatively (11%). In another three patients thrombolysis was not successful. Thrombolysis complication rates were similar compared to non-pregnant patients for the above mentioned indications. Six out of the 26 fetus from surviving mothers died (23%), three of them after induced abortion for maternal reasons (12%). A likely causal relation to the prior thrombolysis could only be established in two fetal fatalities (8%). None of the live born children suffered a permanent deficit. Considering that rt-PA does not cross the placenta and taking into account that the complication rates do not exceed those of large randomised controlled trials thrombolytic therapy should not be withheld in pregnant patients in case of life-threatening or potentially debilitating thrombembolic disease.

Adult↗

PubMed1987

[Clinical picture and differential diagnosis of the pseudo-stroke syndrome in urgent somatic pathology].

A clinical and pathomorphological examination has covered 206 subjects who died due to various urgent somatic abnormalities (myocardial infarction, pulmonary thromboembolism, pneumonia, etc.) whose clinical picture was largely characterized by general cerebral and focal neurological symptoms. To denote the aforementioned conditions, the term "pseudo-stroke" has been utilized. Pathomorphological examination of the brain has revealed multiple cysts in the hemispheres and brain stem in 40.8%, single cysts in 17.0% and no focal damage to the cerebral matter in 42.2% of cases. On the basis of a retrospective analysis of neurological manifestations of the pseudo-stroke syndrome in urgent somatic abnormalities, the authors have identified the regularities of its course, criteria of differential diagnosis, and possible pathogenetic mechanisms of the development of the above conditions.

Aged↗

PubMed2001

Recombinant human macrophage colony-stimulating factor augments pulmonary host defences against Aspergillus fumigatus.

The in vivo and ex vivo effects of macrophage colony-stimulating factor (M-CSF) were studied in a profoundly neutropenic rabbit model in order to determine its potential to augment pulmonary host defence against Aspergillus. M-CSF (100-600 microg/kg/d) was administered prophylactically to neutropenic rabbits with pulmonary aspergillosis starting three days pre-inoculation and then throughout neutropenia. Rabbits receiving M-CSF had significantly increased survival (P=0.01) and decreased pulmonary injury, as measured by decreased pulmonary infarction (P=0.004), when compared with untreated controls. Microscopic studies demonstrated greater numbers of activated pulmonary alveolar macrophages (PAMs) in lung tissue of rabbits receiving M-CSF, in comparison to controls (P<0.001). PAMs harvested from rabbits treated with M-CSF had a significantly greater percent phagocytosis of Aspergillus fumigatus conidia than did PAMs from controls (P=0.04). These data indicate that prophylactic administration of M-CSF augments pulmonary host defence against A. fumigatus and suggest a potential role for this cytokine as adjunctive therapy in the treatment of pulmonary aspergillosis in the setting of profound neutropenia.

Animals↗

PubMed1984

A review of pulmonary artery catheterization in 6,245 patients.

From July 1977 to December 1982, 6,245 patients requiring cardiac and noncardiac operations had pulmonary artery (PA) catheterizations for perioperative monitoring. Their ages ranged from 4 to 94 years. PA catheters were inserted through the external or internal jugular vein in 6,146 patients, while arm veins were used in 99 patients. Complications included persistent PVCs requiring therapy in 193 (3.1%), right bundle branch blocks in three (0.048%), left bundle branch and complete heart block each in one patient (0.016%), intrapulmonary hemorrhage in four (0.064%), minor pulmonary infarcts in four (0.064%), perforation of right ventricle in one (0.016%), and death from uncontrollable pulmonary hemorrhage in one patient (0.016%). This investigation reveals a low incidence of morbidity associated with PA catheterization.

Adolescent↗

PubMed1984

CT diagnosis of segmental pulmonary artery embolus.

A patient with pathologically proven pulmonary embolism that was diagnosed on computed tomography (CT) is presented. The clot in an artery with a diameter less than 1 cm was clearly demonstrated as was an associated pulmonary infarct, which appeared hyperdense on contrast enhanced scan. The potential of CT to noninvasively demonstrate pulmonary embolism, particularly in smaller arteries, is discussed.

Acute Disease↗

PubMed2006

Case reports: polymethylmethacrylate lung embolus after limb-salvage surgery of the distal femur.

Limb-salvage surgery for malignant tumors frequently involves reconstruction with an endoprosthesis anchored to bone by using third-generation cementing techniques. A 10-year-old boy with osteosarcoma had a pulmonary embolus caused by polymethylmethacrylate after having limb-salvage surgery that used high-pressure cementing techniques. He experienced transient postoperative chest pain, and a new wedge-shaped radiodense pulmonary lesion appeared on a computed tomography scan of the chest. A thoracotomy for resection of suspected metastatic osteosarcoma revealed a pulmonary infarct caused by cement embolization. Awareness of this potential complication should prompt investigation of possible pulmonary embolism and may prevent unnecessary thoracotomy.

Biopsy↗

PubMed1985

Vascular occlusion and infarction in sickle cell crisis and the sickle chest syndrome.

A young adult with homozygous sickle cell anaemia (Hb SS) suffered a fatal sickle cell crisis complicated by the sickle chest syndrome. At necropsy multiple large infarcts of the lung, bone marrow, and pituitary gland were found. The large majority of pulmonary infarcts were not associated with either gross or microscopic vaso-occlusion. These findings are discussed and correlated with past and current opinions of sickle cell crisis and the sickle chest syndrome.

Adult↗

PubMed1997

[MRI of the pulmonary parenchyma. Clinical value and research prospects].

MR imaging of the lung is handicapped by three negative influences. First, the low proton spin density in lung tissue results in a low signal-to-noise ratio relative to the surrounding structures. Second, cardiac and respiratory motion induce artifacts that tend to obscure fine structural detail in the lung. Third, a considerable magnetic susceptibility gradient, arising from the large surface areas of air and tissue interfaces, produces a very low value for T2*. MR imaging can be used to stage the activity of interstitial lung disease and for the diagnosis of lipoid pneumonia and pulmonary infarction. In combination with MR angiography, perfusion MR imaging might eventually become a test for pulmonary embolisms.

Forecasting↗

PubMed1997

Thoraxsonography--Part II: Peripheral pulmonary consolidation.

In many cases of pulmonary diseases extending up to the pleura, ultrasound (US) helps to identify the etiology of the lesion. There are several sonomorphological criteria to differentiate peripheral pulmonary consolidations. Pneumonic infiltration shows a hypoechoic inhomogeneous echo texture, with multiple air inlets and bronchoaerograms. Fluid bronchogram indicates an obstructive pneumonitis. Pulmonary infarctions are visible in different stages as triangular pleural-based lesions in most cases of pulmonary embolism. The diagnostic accuracy of chest sonography in pulmonary embolism was 85%-90%. US-guided transthoracic biopsy shows a diagnostic yield of > 90% in malignancies and 50%-83% of benign lesions. The overall complication rate is very low: 1%-2% hemoptysis, 2%-4% pneumothoraces and 1%-2% requiring chest tube drainage. Color Doppler US can demonstrate the vascular patterns and may help in the understanding of underlying pathophysiology. Sonographic examinations of the upper and central mediastinum provide good results in 90-95% of cases. Some anatomical limitations of transcutaneous US can be circumvented by endoluminal US.

Biopsy, Needle↗

PubMed2003

Incidence of clinically unsuspected pulmonary embolism in mechanically ventilated lung transplant recipients.

BACKGROUND: The incidence of pulmonary embolism (PE) in lung transplant recipients has not been well established. The purpose of this study was to describe the incidence of clinically unsuspected PE in a cohort of lung transplant recipients requiring mechanical ventilatory support. These patients underwent surgical lung biopsy (SLBx) for progressive deterioration in the absence of a specific diagnosis. METHODS: We retrospectively reviewed all SLBx pathology reports for mechanically ventilated lung transplant recipients with clinical deterioration, progressive radiographic abnormalities, or both at any time after transplantation. Our objective was to determine the incidence of clinically unsuspected PE in this patient population during an 11-year period. RESULTS: Clinically unsuspected PE was identified in 8 (19.5%) of 41 mechanically ventilated lung transplant recipients after a median of 20 days (interquartile range: 16.3, 148.8 days) after transplantation. There was a tendency for clinically unsuspected PE to occur in the early postoperative period, with the majority of events (75%) occurring within 14 weeks of transplantation. Pulmonary infarction occurred in 37.5% of cases and occurred uniformly during the postoperative period. The finding of pulmonary emboli on SLBx lead to confirmatory investigations in five (62.5%) of eight patients and changed management in seven (87.5%) of eight patients. CONCLUSIONS: A high index of suspicion and reliance on ancillary diagnostic testing may be insufficient to establish the diagnosis of postoperative pulmonary emboli. PE is an underappreciated complication contributing to respiratory failure in the early postoperative period in lung transplant recipients, warranting identification of putative risk factors and consideration for prophylaxis.

Heart-Lung Transplantation↗

PubMed1991

[A case of tumor thrombus in the right atrium after multimodal treatment of testicular tumor].

A case was reported concerning a successful removal of tumor thrombus extending into the right atrium through the left brachiocephalic vein and the superior vena cava. The patient was a 34-year-old man who underwent a left inguinal orchiectomy for immature teratoma of testis in June 1987. The operation was followed by another three operations for excision of lymph node metastases and five courses of cisplatin based combination chemotherapy. In December 1988, the chest CT scan film revealed filling defect in the superior vena cava and the right atrium. Thrombus was detected using echocardiography and angiography. He had no symptom, but multiple pulmonary infarcts were also detected. In February 1989, the operation was performed by means of cardio-pulmonary bypass. A soft yellowish thrombus attached to the left venous angle was removed with resection of the left brachiocephalic vein. Microscopic findings revealed that the thrombus was metastatic testicular teratoma. With further treatment after the operation, he has been disease-free for 14 months now. We conclude that in this case aggressive surgical management following chemotherapy had great value to control the disseminated testicular tumor.

Adult↗

PubMed1988

[Assessment of interaction between the left and right ventricles using pressure-volume loops in various heart diseases].

To assess the interaction and interdependence of left and right ventricular function, ECG-gated radionuclide angiocardiography was performed immediately after cardiac catheterization during right atrial pacing for 11 patients with old myocardial infarction (MI), two with non-obstructive hypertrophic cardiomyopathy, one with aortic stenosis (AS), two with pulmonary infarction (PI), and one with neurocirculatory asthenia (NCA). Absolute left ventricular (LV) volume curves were obtained by the count-based method with attenuation factor corrections. Biventricular pressure and volume curves were digitized and synchronized to end-diastole, and pressure-volume (P-V) loops were constructed throughout a cardiac cycle. The stroke work index (SWI), the work index per min (WI/M) and the contractility index (CNTI) were calculated from the P-V loops. In a patient with NCA, LV end-diastolic volume decreased during rapid pacing, but no significant change in the LV end-systolic P-V relation was recognized. However, the entire right ventricular (RV) P-V loop was shifted toward the left during rapid pacing. In a patient with AS, the LV P-V loop was markedly enlarged and every parameter of LV function was much greater than that of the right ventricle due to increased LV afterload. The areas of RV P-V loops in two patients with PI were larger than those of other patients, because RV pressure was relatively high, and RV volume was increased. It is suggested that RV pressure and volume overloads prevail in patients with PI. In four MI patients with three vessel disease and having collateral circulation, the LV end-systolic P-V relationship was shifted toward the lower right, and every parameter (SWI, WI/M, CNTI) of LV function decreased by rapid pacing. Myocardial ischemia may be induced by rapid pacing stress, causing decreased LV contractility. It was concluded that the P-V loops obtained by RNA and catheterization are clinically useful for estimating the interaction and interdependence between right and left ventricular hemodynamics.

Adult↗

PubMed1977

Pulmonary artery flow-guided catheters in the perioperative period. Indications and complications.

The risk factor of pulmonary artery catheterization was assessed in 392 critically ill patients. Major indications for catheterization in the operating room were marginal cardiovascular reserve, anticipated large fluid and blood loss, and hypotensive anesthesia. Immediate complications included cardiac arrhythmia, carotid artery puncture, and pneumotherax. Long-term complications included positive bacterial cultures, pulmonary infarction and neuropathy. None of the complications were directly responsible for the deaths in this series. Pulmonary artery monitoring in critically ill persons is a relatively safe procedure.

Adult↗

PubMed1983

[Long-term outcome in nonmassive pulmonary embolism. Radiologic, scintigraphic and functional correlation].

54 cases of acute pulmonary embolism were followed for 3 to 4 years by serial chest radiography (plain film and tomography) to survey the radiographic outcome of complete and incomplete pulmonary infarcts in man. A perfusion lung scan (99Tcm-MAA), arterial blood gas analysis and spirometric data were recorded at similar time intervals to chest films in 30 patients. Our retrospective study showed that the most common long-term residual radiographic findings were linear pulmonary scars and localized pleural thickening. The analysis of the radiographic abnormalities with the lung scan showed a residual perfusion defect in 29% of cases, with complete clearing of the infarct on chest radiography. Long term impairment of pulmonary function, estimated with arterial blood gas analysis and spirometric tests, was never observed.

Adult↗

PubMed1986

Acute and chronic pulmonary thromboembolism: current perspectives. Part I: Glossary of terms, historic evolution and prevalence.

Despite considerable medical as well as surgical advances, the problem of pulmonary thromboembolism, both acute and chronic, continues to plague clinicians of all medical disciplines. Approximately 650,000 to 700,000 patients per year suffer from acute pulmonary thromboembolism in the United States. Of these, approximately 60,000-70,000 die as a direct result of it. Our knowledge of the etiology, pathology, pathogenesis of pulmonary infarction, pathophysiology, accurate diagnosis, proper management (including both primary and secondary prophylaxis) of deep vein thrombi and pulmonary thromboemboli has advanced considerably during the past 15 years. These advances, which have now been adopted in the clinical practice, have already begun to indicate that not only more cases of acute and chronic pulmonary thromboembolism are being recognized than before, but also the morbidity and mortality of this disease process is declining. This is likely to improve further as our quest for safe, accurate, noninvasive and inexpensive diagnostic methods continues. Medical thromboembolectomy using thrombolytic therapy is fast replacing the surgical thromboembolectomy for patients with acute massive pulmonary thromboembolism. Better thrombolytic agents, such as tissue plasminogen activator, which selectively lyses the thromboemboli without producing significant systemic lytic state and now undergoing clinical investigation, is likely to revolutionize the management of both acute and chronic pulmonary thromboembolism because of its propensity to dissolve plasminogen-bound thrombi of any age. The majority of the patients who suffer from acute pulmonary thromboembolism recover most of their lost lung function unless cardiopulmonary reserve was compromised prior to the onset of the acute episode.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗

PubMed2005

Predictors of operative mortality and cardiopulmonary morbidity in the National Emphysema Treatment Trial.

OBJECTIVE: We sought to identify predictors of operative mortality, pulmonary morbidity, and cardiovascular morbidity after lung volume reduction surgery. METHODS: Univariate and multivariate logistic regression analyses were performed. Candidate predictors included demographic characteristics, physical condition characteristics, pulmonary function measures, measures of the distribution of emphysema as determined by radiologists and by means of computerized analysis of chest computed tomographic scans, and measures of exercise capacity, dyspnea, and quality of life. End points analyzed were operative mortality (death within 90 days of the operation), major pulmonary morbidities (tracheostomy, failure to wean, reintubation, pneumonia, and ventilator for > or =3 days), and cardiovascular morbidities (infarction, pulmonary embolus, or arrhythmia requiring treatment). RESULTS: Five hundred eleven patients in the non-high-risk group of the National Emphysema Treatment Trial underwent lung volume reduction. The incidence of operative mortality was 5.5%, major pulmonary morbidity occurred in 29.8% of patients, and cardiovascular morbidity occurred in 20.0% of patients. Predictors for these end points are as follows: [table: see text]. CONCLUSIONS: Although lung volume reduction can be performed in selected patients with acceptable mortality, the incidence of major cardiopulmonary morbidity remains high. The lone predictor for operative mortality of lung volume reduction was the presence of non-upper-lobe-predominant emphysema, as assessed by the radiologist. Pulmonary morbidity can be expected in elderly patients who have a low diffusing capacity for carbon monoxide and forced expiratory volume in 1 second. When assessing morbidity, the computer-assisted chest computed tomographic analysis proved useful only in predicting cardiovascular complications.

Aged↗

PubMed1988

Systemic-to-pulmonary collateral vessels and shunts: treatment with embolization.

Abnormal collateral vessels develop frequently in patients with right ventricular outflow or pulmonary artery obstruction. Surgery is usually used to obliterate these vessels but may be difficult, involve prolonged operative time, or require a different thoracotomy than that used for correction or palliation of the cardiac anomaly. Sixteen trans-catheter embolization procedures were performed in 15 patients with systemic-to-pulmonary collateral vessels and shunts. In eight embolization procedures performed because of congestive heart failure or low oxygenation, clinical improvement was obtained in seven. In all six patients who underwent embolization preoperatively, the outcome of surgical correction or palliation was satisfactory. Hemorrhage ceased in the two patients with hemoptysis. There were two complications, one transient loss of femoral pulse and one segmental pulmonary infarction. Embolization is a useful adjunct to surgery and medical management of patients with systemic-to-pulmonary collateral vessels and shunts.

Adolescent↗

PubMedDate not supplied

Problems in assessment of pulmonary parenchymal consolidation in heart transplant candidates.

Radiologic assessment of the cause of pulmonary parenchymal consolidation in end-stage heart failure may be difficult. From August 1982 to May 1989, 22 patients being considered for orthotopic cardiac allografts had parenchymal consolidation on their chest radiographs, most commonly in the right lower lobe. Our purpose was to determine from standard radiologic studies whether this consolidation represented alveolar pulmonary edema in an atypical basal distribution, pneumonia, or pulmonary infarction. This differentiation is important because pneumonia is an absolute and infarction is a relative contraindication to surgery, whereas successful transplantation can be performed in a setting of pulmonary edema. The chest radiographs were reviewed retrospectively. When available, pulmonary angiograms, nuclear medicine ventilation/perfusion scans, and needle biopsy findings were also evaluated. The radiologic assessment was correlated with the results of surgical, autopsy, or clinical outcome. None of the conventional modalities was very accurate--the plain chest film was correct in only 63%, nuclear medicine studies in 50%. Angiography was the single most useful test, with an accuracy of 75%.

Diagnosis, Differential↗