[HSF] Pulmonary embolism-RV dysfunction

[prasannasimha]

Better compared to what ? I was referring to mechanical thrombolysis 
versus enzymatic thrombolysis in the immediate postoperative patient.

There is another part of the story- ability to get the patient into an 
OR in time to do a pulmonary embolectomy.That can be at times a real 
challenge - you have to be sick at the right time and place !!
In a hemodynamically unstable patient getting a patient in to an OR may 
itself be a challenge than into a cathlab for mechanical fragmentation. 
This can allow stabilization rapidly. We have done this quite a few 
times in our hospital.
An extreme example (I am quoting this as an anecdotal example ;-)  .Now 
we have to debate whether this "constitutes "evidence") was the father 
of one of our duty doctors. He was admitted and was in extremis when he 
saw me. I enquired what was happening. His father had pulmonary Kochs, 
destroyed right lung and had pulmonary embolism and was in cardiogenic 
shock and also with obvious terrible gas exchange with emboli in the 
aerated lung. We managed to shift him into the cathlab and managed to 
fragment the clot which caused a dramatic improvement in lung perfusion, 
hemodynamics, RV function and gas exchange. We did give him Urokinase 
infusion thereafter. He was a patient on sky high (Gamma suprarenin as 
per Roberto) which could be stopped within minutes of mechanical 
thrombolysis. I bet with his lung function he would have been a terrible 
candidate for CPB !!
One thing with mechanical lysis - it can be attempted and you can always 
bail out with surgery if required.
http://www.ajronline.org/cgi/content/full/183/3/589
In this study there were no deaths in patients who were having 
hemodynamic impairment. Adding chemical thrombolysis could always be 
deferred if required.
Prasanna

Ani Anyanwu wrote:
> Prasanna
>  
> Can you provide data or experience to back this viewpoint that catheter based lysis is better?
>  
> My reading of the literature is that RV dysfunction is a risk factor for death and mandates immediate surgical removal. Consensus statements and writings also seem to promote surgery as the method of choice in this regard.
>  
> Ani
>
>
>
>   
>> Date: Fri, 3 Aug 2007 13:53:40 +0530> From: prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Pulmonary embolism-RV dysfunction> CC: > > Yesif there is recent major surgery then catheter directed mechanical lysis> would be better- allows the PA pressure to fall. Nature will do tis natural> thrombolysis. This is the way nonfatal PE's resolve. We are just allowing> nature to take its course by keeping the patient alive till then. We can> accelerate this with thrombolysis if the other factors are not detrimental.,> > On 8/3/07, yadav del <yadavluck at yahoo.com> wrote:> >> > An year back the particular plastic surgery unit lost a patient from> > bleeding at surgical site[Abdominoplasty and liposuction] after thrombolysis> > for PE.May be it would have made them not to take lightly the risk of> > bleeding from thrombolysis in the immediate post op period> >> > I think hard data is lacking even for thrombolysys for ry dysfunction> > criteria alone for advantage in terms of mortality. one of the studies> > showed no difference in 2 month mortality with or with out thrombolysis for> > this category of patients.> > One of the studies showed benefit in terms of end point of combined> > mortality and need for escalation of therapy[like adding inotropes].> >> > Regional throbolysis over few hours often leads to systemic lytic> > state with same risks of bleeding.> > We advised filter for this patient and plastic surgeons followed the> > advise of internists who felt they would advise it only in the circumstance> > of further progress in thrombosis inspite of anticoagulation.> > She had relative resistance to heparin [ptt 45 at 2200 units per hr> > heparin infusion and it responded to FFP.> >> > prasannasimha <prasannasimha at gmail.com> wrote:> > Catheter based mechanical lysis with a pigtail followed by thrombolysis> > can be done. If not then consideration for surgical embolectomy could be> > thought of. We have done quite a few catheter based lysis which gives a> > dramatic reduction in PA pressure and recovery of RV function.> > Prasanna> >> > yadav del 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.> > > _______________________________________________> > > OpenHeart-L mailing list> > >> > > Send postings to:> > > OpenHeart-L at lists.hsforum.com> > >> > > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > > disclaimers posted at:> > > http://www.hsforum.com/listdisclaim> > > -----------------------------------------> > >> > >> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> >> >> > ---------------------------------> > Pinpoint customers who are looking for what you sell.> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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