Chronic pulmonary thromboembolism in a patient with a fontan circulation: percutaneous management.

Chronic pulmonary embolism is a common complication in patients with Fontan circulations. When anticoagulation is ineffective and surgery is contraindicated, percutaneous techniques may be considered. The authors report the first case of successful catheter intervention in a 30-year-old woman with a Fontan circulation who presented with NYHA class IV symptoms and chronic and complete obstruction of her left pulmonary artery.     

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肺血栓栓塞症(PTE)溶栓治疗最主要的并发症是出血,部分患者会出现发热、皮疹等情况。高龄、既往有基础疾病、溶栓前后进行动静脉穿刺以及溶栓剂量过大是造成出血的主要原因。对于PTE患者,需要掌握溶栓治疗的适应证和禁忌证,溶栓前仔细询问相关病史,评价溶栓的风险效益比,并在治疗前采取相应的预防措施,可以降低出血的发生率。一旦发生出血情况,应根据出血的部位和出血量的大小,进行相应的处理。     

Anticoagulation in the management of venous thromboembolism in the cancer patient

Cancer is associated with a four to sevenfold increased risk of venous thromboembolism (VTE). This risk is influenced by the site and extent of cancer and its treatment. Despite its availability, effective VTE prophylaxis is used in less than 50% of oncology patients. Pharmacologic VTE prophylaxis should be administered to all hospitalized medical and surgical oncology patients for the duration of their hospitalization or up to 10–14 days, whichever is longer. Extended duration (up to 4 weeks post-operation) VTE prophylaxis is recommended for high-risk surgical oncology patients. Routine use of prophylaxis in ambulatory medical oncology patients awaits prospective testing of VTE risk assessment models. Routine prophylactic dose anticoagulation to prevent central venous catheter (CVC) thrombosis is ineffective and not indicated. Low molecular weight heparin is the first line choice for acute and chronic therapy of VTE in cancer patients. Therapy should continue for at least 3 months or the duration of the malignancy, whichever is longer. Anticoagulation is indicated for at least 3 months or the duration of the catheter for CVC thrombosis. Preliminary data indicate that some cancer patients with pulmonary embolism may be managed as outpatients. Prospective validation of these studies and testing of current risk assessment strategies in oncology patients is warranted. Management of recurrent VTE and unsuspected VTE in the cancer patient are also reviewed.     

辛伐他汀对大鼠急性肺栓塞的保护作用

目的探讨辛伐他汀对大鼠急性肺栓塞的保护作用及其机制。方法将72只Sprague-Dawley大鼠随机分为假手术组,肺栓塞模型组和辛伐他汀干预组,每组24只。在造模后2h,6h,24h分别测定各组大鼠的右心室收缩压（RVSP）和平均肺动脉压（mPAP）,分离肺脏进行HE染色及肺脏病理学检查。在造模后6h测定各组大鼠的动脉血气和肺血管内皮型一氧化氮合酶（eNOS）蛋白表达。应用ELISA法测定各组大鼠血浆白介素-6（IL-6）和肿瘤坏死因子Ⅱ（TNF-α）水平。结果肺栓塞模型组大鼠不同时间点的mPAP,RVSP均较假手术组明显升高（P〈0．01）。辛伐他汀干预组大鼠不同时间点的mPAP、RVSP与肺栓塞模型组比较均显著降低（P〈0．05）。肺栓塞模型组大鼠6h氧分压（PaO2）与假手术组大鼠比较明显降低（P〈0．01）;辛伐他汀干预组大鼠6hPaO2与肺栓塞模型组大鼠比较明显升高（P〈0．05）。肺栓塞模型组大鼠6h肺小动脉eNOS蛋白表达较假手术组降低（P〈0．01）,辛伐他汀干预组组大鼠6h肺小动脉eNOS蛋白表达较肺栓塞模型组明显升高（P〈0．05）。肺栓塞模型组大鼠各时间点血浆IL-6,TNF-α水平较假手术组有升高趋势（P〉0．05）。辛伐他汀干预组大鼠各时间点血浆IL．6、TNF—α水平较肺栓塞模型组大鼠略有降低（P〉0．05）。结论辛伐他汀干预可降低急性肺栓塞大鼠的mPAP和RvsP,减轻低氧血症,改善内皮细胞功能,但对血浆IL-6．TNF-α水平无影响。     

The effect of exercise modality on exercise-induced hypoxemia.

To investigate the effect of exercise mode on arterial oxyhemoglobin saturation (SaO2), 13 healthy, actively training men who displayed exercise-induced hypoxemia (EIH) performed two incremental maximal exercise tests: uphill treadmill running and cycle ergometry. At maximum, treadmill running resulted in a lower SaO2 (88.6+/-2% versus 92.6+/-2.0%) a lower ventilatory equivalent for carbon dioxide (VE/VCO2; 28.8+/-0.6 versus 31.2+/-0.9), and a higher maximal oxygen consumption (VO2, MAX; 4.83+/-0.11 l x min(-1) versus 4.61+/-0.14 l x min(-1) when compared to cycle ergometry. When data were combined from maximal running and cycling. SaO2 was correlated to VE/VCO2 (r = 0.54). However, there was no relationship between the differences in SaO2 and ventilation between exercise modes. This suggests that ventilation is important in the maintenance of SaO2, but that the difference observed in SaO2 between treadmill running and cycle ergometry cannot be explained by differences in ventilation and must be due to differences in diffusion limitation or ventilation-perfusion inequality.     

Treatment of pulmonary thromboembolism.

The epidemiology, diagnosis, treatment, and prophylaxis of PE are rapidly advancing. Our array of diagnostic imaging tools has expanded to include echocardiography and spiral chest CT with contrast. We have also gained a keen appreciation for the importance of risk stratification of our patients. The decision to administer thrombolysis or undertake embolectomy may now depend upon the presence of right ventricular dysfunction even if systemic arterial pressure is normal. Finally, the availability of low molecular weight heparins broadens our options for pharmacologic management.     

Insidious pulmonary fibrosis occurring at the hypoperfusion area in a patient with chronic pulmonary thromboembolism

A 69-year-old woman who had been diagnosed with chronic pulmonary thromboembolism (CPTE) developed ground glass opacities in the right lung where perfusion scintigraphy showed defects of the bloodstream. Bronchoalveolar lavage fluid (BALF) showed that some macrophages had phagocytosed hemosiderin. Video-assisted thoracoscopic surgical biopsy revealed lung fibrosis, narrowing of the pulmonary artery and organization of many cholesterol granulomas. We hypothesized that hyperperfusion of the bronchial artery, which occurred to compensate for hypoperfusion of the pulmonary artery, induced alveolar hemorrhage following thrombolytic and anticoagulation treatments, and that the degraded products from blood cells induced the formation of lung fibrosis and cholesterol granulomas.     

Incidence of pulmonary thromboembolism in Japan.

Pulmonary thromboembolism (PTE) is considered an uncommon disease in Japan and there are not any reported prospective studies on the incidence of PTE in Japan. The objective of the present study was to determine the number of patients with PTE per year in a prospective study using a questionnaire. Letters were sent to clinical departments in university schools of medicine or medical colleges, and to hospitals with more than 100 beds. The diagnosis of PTE was to be confirmed by (1) pulmonary artery stenosis or occlusion on pulmonary angiography, (2) mismatch of pulmonary perfusion scintigraphy and pulmonary ventilation scintigraphy, (3) changes on pulmonary perfusion scintigraphy performed twice, or (4) autopsy. The questionnaire elicited 2,341 replies (the withdrawal rate was 40.7%). In 231 hospitals, 237 patients were diagnosed definitely during the study period of 2 months from 1 August to 30 September 1996. From this it was estimated that there are 3,492 (95% confidence interval: 3,280-3,703) patients with PTE per year, which implies that the incidence is 28 persons per 1,000,000 people per year, confirming that PTE is rare in Japan.     

重视并进一步规范肺血栓栓塞症的影像学诊断

近年来，我国对肺血栓栓塞症一深静脉血栓栓塞（PTE—DVT）的认识明显提高，但对PTE和DVT的相关性，对静脉血栓栓塞症（VTE）这一完整概念的重要性仍缺乏足够的认识。影像学检查是PTE-DVT确诊的主要依据，国内影像科和临床医生在应用过程中仍存在很多误区，如对检查手段的合理选择、检查方法的优势互补缺乏正确的认识；对操作技术缺少规范化的培训，对检查结果的综合分析缺乏足够的经验。因此，亟须加强对PTE-DVT影像学诊断的重视和普及。     

The role of transesophageal echocardiography in the management of patients with acute and chronic pulmonary thromboembolism

Acute and chronic pulmonary thromboembolism carry high mortality. The role of transesophageal echocardiography (TEE), however, has not been well delineated in patients with suspected pulmonary thromboembolism. The aim of the present study was to demonstrate the value of Tee in patients with various clinical manifestations of pulmonary thromboembolic disease. Twelve patients--ten males and two females, age 47-85 years--are presented in whom central pulmonary thromboembolism was found by TEE. Six patients were referred for breathlessness and had moderate to severe pulmonary hypertension (PH) with (3) or without (1) right atrial thrombus or had right heart dilatation (1) or right ventricular myxoma (1) on transthoracic echocardiography (TTE). Thrombolysis (2), surgery (2), and heparin (2) treatment was performed without angiography. All but one patient recovered. Six patients had severe PH by TTE, one of them had a right atrial thrombus. Angiography was done in five patients in whom surgery was considered. Pulmonary thromboendarterectomy was successfully performed in two patients, it was contraindicated in two patients for advanced age or severe left ventricular dysfunction, both patients died during follow-up, and two patients were waiting for surgery. In conclusion: TEE has a definite role in the management of patients with acute pulmonary thromboembolism or in pulmonary embolism associated with right-sided intracardiac masses and in the selection of patients with PH for pulmonary thromboendarterectomy.