[HSF] Pulmonary embolism-RV dysfunction

Fri Aug 3 01:59:02 EDT 2007

Just another historic note. In the 60's when leg exercises , 
compressive stockings and prophlactic anticoagulation were not widely 
accepted, we saw a lot of pulmonary emboli.
Streptokinase and urokinase were the only possible lytic agents and it 
was already clear that they were pretty useless with anything more than 
a fresh clot, Louis Del Guercio floated a polyethylene catheter into 
the rght ventricle and showed that when the mean pressure exceeded a 
certain level the mortality was extremely high. With phasic pressures 
it was apparent that not only was the systolic pressure high indicating 
 >50% of the vascular bed was blocked, but so also was the ventricular 
diastolic pressure, indicating right ventricular failure. Our thesis 
was that when the right ventricle was in failure from pulmonary 
embolism the only way to save the patient's life was immediate removal 
of the obstructing clot. We did this at normothermia with bicaval 
cannulation, pulmonary arteriotomy, gentle removal of the clot with 
gallstone forceps, gentle suction and minimal handling of the lung. If 
we got the patients relatively early the results were genuinely 
excellent. Obviously there is much more to say about this subject but 
the point of our observations was that right heart failure presaged 
death and our simple pressure measurement gave us a bedside clue. 
Cardioactive drugs were simply useless. This seemed such a certain 
observation to us that we set up an emergency bedside pump set up in a 
hospital where we did not normally do open heart surgery and "saved" a 
few patients (one in the radiology dept). I believe I can genuinely say 
that with streptokinase, heparin and inotropic and vasoconstrictor 
drugs patients with evidence of right heart failure died. Taking the 
clots out with bypass support produced live patients. We saw ouselves 
as fulfilling Gibbons' goal. This was applied science and I daresay 
nothing to be ashamed of.
John Flege's posting said this in one sentence,
Bob

-----Original Message-----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thu, 2 Aug 2007 7:01 am
Subject: Re: [HSF] Pulmonary embolism-RV dysfunction

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 ?> >> >> >
> ---------------------------------> > Moody friends. Drama queens. 
Your life?
> Nope! - their life, your story.> > Play Sims Stories at Yahoo! 
Games.> >
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