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Query: UMLS:C0034065 (pulmonary embolism)
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A young man with a history of deep vein thrombosis and pulmonary embolism 11 years ago presented again with acute pulmonary embolism and was treated initially with intravenous heparin at our institution. Five days later he had another massive bout of pulmonary embolism causing hypotension. Pulmonary angiography confirmed the presence of thrombi in both pulmonary arteries, with complete obstruction of the left pulmonary artery. He was treated successfully by emergency pulmonary embolectomy. Blood investigations later confirmed the diagnosis of protein S deficiency and he was started on warfarin therapy for life. Massive pulmonary embolism should be treated aggressively. Thrombolytic therapy accelerates clot lysis, reduces pulmonary pressures, restores pulmonary capillary volume and reverses right heart failure faster than heparin alone. There is also a trend towards decreased mortality with thrombolysis. In the presence of shock, the patient should be resuscitated and if facilities for emergency embolectomy are available, surgery is a viable alternative to thrombolysis, especially if the clot burden is massive. In young patients with recurrent venous thromboembolism in the absence of obvious predisposing factors, it is important to exclude inherited plasma protein deficiencies of protein S, protein C, antithrombin III, plasminogen and fibrinogen.
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PMID:Massive acute pulmonary embolism in protein S deficiency--a case report. 794 58

The occurrence of cardiac manifestations and their relationship with the lupus anticoagulant (LA) in SLE was studied in 74 patients who were followed up for 22 years (median), of which 16 years were after the initial LA testing. Pericarditis was the most common cardiac event occurring in 16 (22%) patients but it did not correlate with LA. Valvular heart disease, coronary artery disease, left ventricular failure and/or cor pulmonale were observed in 16 (22%) patients. Taken together, their occurrence was associated with a history of leg ulcers (odds 3.8, P = 0.028) but not with LA or other common clinical manifestations of the antiphospholipid syndrome. Valvular heart disease in five patients was significantly associated with LA (P = 0.05). Cor pulmonale due to chronic pulmonary embolism was present in two patients with LA. Myocardial infarctions in five patients occurred late in the course of disease but in relatively young patients (mean 43 years). Fatal myocardial infarction in the absence of atherosclerosis in two LA-positive patients supports a pathogenetic role for LA in these cases. In conclusion, of the various cardiac complications in SLE, valvular heart disease and cor pulmonale appear to be connected with the antiphospholipid syndrome. Both conditions should be actively sought in patients with LA to decrease possible adverse events (arterial emboli and right ventricular failure) affecting the patients' prognosis.
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PMID:Lupus anticoagulant and cardiac manifestations in systemic lupus erythematosus. 795 2

Pulmonary embolism remains an important cause of mortality despite recent advances in medical therapy. The inferior vena cava filter has been devised for treatment of pulmonary embolism. The Gunter inferior vena cava filter was inserted percutaneously in 6 patients with recurrent pulmonary embolism despite anticoagulation therapy. No complications were observed during this procedure. Two patients died after filter placement (one after six weeks one after 1.5 year) because of right heart failure observed before procedure. The other four patients showed no signs of pulmonary embolism during four years follow-up. We conclude that percutaneous insertion of the Gunter filter is a safe and effective technique for prevention of recurrent pulmonary embolism.
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PMID:[Long term observations of patients after percutaneous inferior vena cava filter placement for recurrent pulmonary embolism]. 819 Jun 56

Fulminant pulmonary embolism associated with cardiac arrest has an extremely high mortality. The feasibility of pulmonary embolectomy initiated during resuscitation is still under discussion. Between January 1975 and October 1992, embolectomy was performed in 34 patients, 21 to 79 years of age. Diagnosis was established primarily by indirect parameters (medical history, ECG, blood gas analyses, Swan-Ganz catheter in 22 cases). Only in 12 instances, imaging techniques as angiography, ventilation perfusion mismatch, and transesophageal echocardiography were performed. Fifteen patients did not require resuscitation (group A); 6 had to be resuscitated and underwent surgery after reestablishing circulation with catecholamines (group B); 13 patients were connected to extracorporeal circulation during continuous cardiopulmonary resuscitation (30 to 210 minutes) (group C). Embolectomy was performed using extracorporeal circulation with the heart beating (n = 8), or fibrillating (n = 15), or using cardioplegia (n = 11). Twenty-two patients received a caval clip or ligature at the end of the procedure. Fifteen patients (44%) died early postoperatively. The mortality rates for groups A, B, and C were 33%, 66% and 46%, respectively. Nine patients died of right heart failure, 4 of brain death, and 2 of septical complications. Of the surviving patients, only one had ischemic brain damage. In two cases a recurrent pulmonary embolism occurred after a follow-up of 16 years (mean follow-up 4.9 years). We conclude, that even with subtotal obstruction of the pulmonary artery, effective cardiopulmonary resuscitation with maintenance of uncompromised brain function is possible. In emergency situations, the decision to operate may be based only on clinical features without imaging diagnostic procedures.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Surgical aspects of fulminant pulmonary embolism]. 832 5

We evaluated retrospectively the clinical indicators for the treatment of 15 patients with severe pulmonary embolism. All patients had moderate or severe pulmonary hypertension with deteriorated oxygenation. Thrombolytic agents and catecholamines were administered and mechanical ventilation was performed so as to treat right heart failure and improve oxygenation. In 14 patients, the pulmonary artery pressure decreased gradually and PaO2 increased in response to these therapies. The 14 patients were discharged from ICU without any symptoms. One patient died of cerebral hemorrhage due to the side effects of tissue plasminogen activator. We conclude that the pulmonary artery pressure and PaO2 are useful indicators for the treatment of the early phase of severe pulmonary embolism. Moreover, timely use of cetecholamine is very important for the maintenance of pulmonary circulation and acceleration of thrombolysis.
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PMID:[Retrospective analysis of 15 cases with severe pulmonary embolism]. 843 61

A 72-year-old female, who had received medication for hypertension and angina pectoris was hospitalized with complaining of an abrupt dyspnea. Roentgenogram of the chest revealed no abnormal findings except cardiac enlargement. An electrocardiogram showed overloading of the right ventricle. Arterial blood gas analysis of room air showed 55.4 mmHg of PaO2, 25.5 mmHg of PaCO2 and 7.30 of PH, respectively. Acute and massive pulmonary embolism was diagnosed by an emergent pulmonary arteriography. Despite intensive treatment such as infusion of urokinase and heparin for four days, thrombus was still detected in the left main pulmonary artery by a transesophageal echocardiography. By the result of ineffective conservative therapy, embolectomy was performed under cardiopulmonary bypass. However mechanical respiratory support was required for a long time due to the right heart failure, she is doing well for a year after the operation.
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PMID:[Acute massive pulmonary embolism--report of a case]. 845 37

Surgical intervention in fulminant pulmonary embolism (PE) is still associated with an overall 30% fatal outcome which increases to about 60% when cardiopulmonary resuscitation (CPR) is necessary. Despite unfavorable conditions like hemodynamic instability, failed lysis or CPR, the surgical strategy might have a certain impact on the patient's outcome since 30-40% of the surgical mortality is related to persistent right heart failure and early thromboembolic recurrence. From 1/88 to 8/94 a total of 25 patients (15 females, 10 men, mean age 57 [25-78]) years underwent emergency pulmonary embolectomy with the use of the heart-lung machine. Seventeen patients were operated upon between 1988 and 1992. A standard approach by central pulmonary artery incision with extraction of adjacent pulmonary emboli using forceps, suction of Fogarty catheters was used. Six of these patients (35%) died, with four out of six operated upon under CPR. Since 1993 we have used a modified surgical strategy in eight patients. Five patients (63%) were operated on after or under CPR. In these cases, left and right pulmonary arteries were incised peripherally and all segmental arteries were desobliterated selectively using small suction devices. Thereafter the right atrium was opened and inspected. After removal of the inferior caval vein cannula all inferior body blood was taken with cardiotomy suction while both legs and the abdomen were massaged centripetally to mobilize additional fresh thrombotic material. In three cases up to 50 cm long thrombi could be delivered. All patients have survived to date with two patients receiving a LGM caval filter placed percutaneously after bilateral postoperative phlebography had revealed ongoing thrombotic disease. We conclude that selective desobliteration of every segmental pulmonary artery in combination with simultaneous clearance of major body veins from additional thrombotic material will probably lower surgical mortality in these critically ill patients.
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PMID:Modified surgical concept for fulminant pulmonary embolism. 856

The results of direct pulmonary embolectomy in 20 cases of pulmonary embolism treated in our facility from 1982 to May, 1995 was analyzed. The ages of the patients ranged from 25 to 72 years (mean: 46 years). The male-to-female ratio was 12:8. The 20 cases were divided into three groups based on the type of pulmonary embolism: Group I (4 cases of acute massive pulmonary thrombo-embolism). Group II (12 cases of chronic pulmonary thrombo-embolism) and Group III (4 cases of tumor embolism). In Group I, 2 patients developed shock and 2 developed severe right heart failure. Emergency thrombectomy using cardiopulmonary bypass succeeded in saving the lives of 3 patients in this group. In Group II, the preoperative NYHA grade was II in 1 case, III in 9 cases, and IV in 2 cases. The preoperative systolic pressure of the pulmonary artery ranged from 24 to 90 mmHg (mean: 74 mmHg). Surgery through a thoracotomy was carried out on 7 cases (on the right side in 4 cases on the left in 3 cases). Of these 7 patients, 2 died of heart failure and respiratory failure because thromboendarterectomy was inadequate. In another 2 patients, symptoms improved enough to allow them to resume their previous lives. The other three patients showed no change in their symptoms after surgery, but they could be discharged. The remaining 5 patients in Group II underwent surgery through the median approach. Deep hypothermia with circulatory arrest was used in the latter 4 of these 5 patients during surgery. 3 patients died during the perioperative period because adequate thromboendarterectomy was not possible and because their preoperative condition was very poor. 2 patients who were able to be performed adequate thromboendarterectomy showed good postoperative courses. Of the 4 patients in Group III, one patient survived 11 months after surgery, but the other 3 died during the preoperative period because very little embolus could be removed. These results allow us to conclude that the lives of patients with acute pulmonary thromboembolism can be saved by early detection and prompt surgery, but that management of chronic pulmonary thromboembolism involves difficulties in selecting surgical cases and in performing thromboendarterectomy.
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PMID:[Review of results after surgery for pulmonary embolism]. 866 69

Between 1975 and 1993, lung resections were performed in 1735 patients because of malignancies, with an early postoperative mortality of 7.2% (125 patients). Early postoperatively acute cardiorespiratory failure was experienced by 32 patients (1.85%), of whom 26 died despite immediate resuscitation measures. In 20/26 patients autopsy was performed revealing central pulmonary embolism as the cause of death in 19 of them. In one patient a rupture of the free posterior left ventricular wall following transmural myocardial infarction was found. Two patients who could be resuscitated successfully were operated on with extracorporeal circulation after pulmonary angiography had been performed to confirm the diagnosis; however they died 2 days later of right heart failure. Of the survivors three cases had myocardial infarctions, one patient had arrhythmias of unknown etiology. Immediate embolectomy with the use of extracorporeal circulation was performed in two patients, only on the ground of suspected pulmonary embolism and without further diagnostic measures. Both patients survived. Of the 23 cases, with proven pulmonary embolism 17 were still under postoperative prophylaxis with heparin. Six patients were already fully mobilized. We conclude that massive pulmonary embolism is a frequent early postoperative fatal complication after lung resections, which cannot be safely prevented by postoperative heparinization. The only successful life-saving measure in the case of central pulmonary embolism is immediate pulmonary embolectomy, if necessary without further diagnostic measures.
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PMID:Pulmonary embolism: a frequent cause of acute fatality after lung resection. 874 59

The authors report two cases of pulmonary valve endocarditis which required emergency surgical treatment. A 74 year old patient with trivalvular endocarditis (pulmonary, aortic, mitral), due to Sptreptococcus D bovis, developed cardiogenic shock with acute pulmonary oedema and underwent double aortic and pulmonary valve replacement with Carpentier-Edwards prostheses and simple resection of a mitral valve vegetation. Another 36 year old drug addict developed isolated pulmonary valve endocarditis due to Staphylococcus aureus infection complicated by pulmonary regurgitation with right ventricular failure and by septic pulmonary embolism with persistent sepsis: he underwent pulmonary valve replacement with a Bravo 300 bioprosthesis. The postoperative course was uncomplicated in both cases, with interruption of the infection and normalisation of the haemodynamic status. The insidious and severe nature of pulmonary valve endocarditis is demonstrated by these two cases, confirming previous reports which have underlined the poor prognosis of this condition. Surgery has been shown to be effective and well tolerated and should be integrated early in the therapeutic strategy, the results being all the better when an aggressive attitude is taken.
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PMID:[Pulmonary valve replacement for endocarditis. Apropos of 2 cases]. 876 8


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