[HSF] Pulmonary embolism-RV dysfunction

[Michael Firstenberg]

Without knowing too much more of her details - this is someone who we would
operate on right away.  She is obviously having cardiopulm problems and
being young (and hopefully few comorbidities) she should tolerate fishing
the PEs out without too much trouble.  We have been doing more and more
recently and getting good outcomes even in very sick people.  Although you
can ride her out, it will place a strain on her and I would be very
concerned about the long term consequences of chronic PEs with pulmonary
hypertension - I think that is a horrible problem to management medically
and operatively - and I am not sure anyone knows the naturally history.
Unlike chronic PEs, if they are acute you do not have to circ arrest (and if
you are good you do not even have to arrest the arrest - although I would,
but that is me).  It could be a quick pump run - go on, arrest with
antegrade, open up the PA's fish everything out, close, get out of Dodge.
But, be prepared for an acute reperfusion injury with hypoxemia and RV
dysfunction - milrinone and nitric oxide can be very helpful.  If the
patients are stable then this operative is not as gruesome as it was once
thought to be and it can be a very satisfying operation.

good luck

-michael


On 8/2/07, Ani Anyanwu <anianyanwu at hotmail.com> wrote:
>
> Read paper in circulation by Aklog et al from Brigham (I think also a
> recent update in Annals by Byrne et al). If this patient has emboli in the
> main PAs with RV dysfunction then that would be regarded as an indication
> for surgery. She is very young and summation of literature suggests presence
> of RV dysfunction is a risk factor for mortality. Filter will be placed via
> RA at time of surgery so will not dislodge groin thrombi. Leaving her PA
> full of clot - if she survives - sets her up for chronic thromboembolic
> disease.
>
> Ani
>
>
>
> > Date: Thu, 2 Aug 2007 19:42:42 +1000> From: chanju at gmail.com> To:
> OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Pulmonary embolism-RV
> dysfunction> CC: > > Hi Dr Del,> > Need more information - what is the
> degree of RV dysfunction? CVP, PA> pressures, echo?> > In my opinion (which
> is very junior), she should be offered an IVC> filter and anticoagulation,
> but in the absence of major haemodynamic> compromise would not offer
> embolectomy.> > She should also be screened for procoagulable states-protein
> C, S,> factor V leiden, antithrombin III etc> > I would be interested to
> hear how you proceed.> > Regards,> Justin> > > On 8/2/07, yadav del <
> yadavluck at yahoo.com> wrote:> >> >> > 25 yrs old female developed pulmonary
> embolism on 2 nd post op day after repair of incisional hernia. CT scan
> showed emboli at both hila .Only left lower lobe artery is spared from
> emboli. Duplex scan showed bilateral ilio- femoral dvt. She iss
> haemodynamically stable. Saturation 94% with out oxygen and 98% on 2litres
> oxygen. Echo showed RV dysfunction.> >> > Should she be offered pulmonary
> embolectomy in view of RV dysfunction ?> >> >> >
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