Massive thromboembolism due to transcatheter ASD closure with ASDOS device

Transcatheter occlusion of atrial septal defects (ASD) is currently being investigated as an attractive alternative to surgical correction. Thromboembolic events are rare in both techniques. However, we report a case of massive systemic embolization and residual left atrial thrombus after secundum ASD transcatheter closure by the ASDOS device (Atrial Septal Defect Occlusion System, Dr. Ing Osypka Corporation, Germany). The patient was successfully treated by femoral embolectomies, surgical removal of the device and closure of the ASD without a patch. No thrombophilia was found on subsequent exploration. Transcatheter ASD closure with the ASDOS device may therefore expose the patient to severe embolic complications. Further evaluation is needed before this technique can be safely recommended.     

Massive pulmonary thromboembolism: medical or surgical treatment?

Anticoagulant-thrombolytic therapy and surgery, remain the topics of recent advances in the treatment of pulmonary embolism. The Authors have treated 3 patients with anticoagulant-thrombolytic therapy, and 14 patients with pulmonary embolectomy with cardiopulmonary bypass. By this experience, they suggest an indication for medical or surgical treatment for pulmonary embolism.     

Massive pulmonary thromboembolism with left axis deviation and low voltage

The classic electrocardiographic abnormalities observed in massive or submassive thromboembolism in the absence of preexistent cardiac or pulmonary disease are: S1Q3T3 pattern, right axis deviation, "pulmonary" P wave, ST segment depression or elevation, subepicardic ischemia and transient right bundle branch block. Left axis deviation due to pulmonary embolism was first described in 1949; this same finding and the presence of low voltage of the frontal plane owed to pulmonary embolism has been reported occasionally in the last decades, but it has had little diffusion. We report on a patient with no prior cardiac or pulmonary disease who suffered massive pulmonary thromboembolism. Electrocardiographically left axis deviation and low voltage of the horizontal plane attributed to pulmonary thromboembolism was observed. The mechanisms that originate this electrocardiographic changes in pulmonary embolism are unknown. Since the electrocardiogram is aspecific method for the diagnosis of this disorder, and the presence of the mentioned changes originate a greater difficulty in the diagnosis; we consider is important to publish it.     

Simple mechanical thrombectomy with intrapulmonary arterial thrombolysis in pulmonary thromboembolism: a small case series

Pulmonary thromboembolism （PTE） is a life-threatening condition with a high early mortality rate caused by acute right ventricular failure and cardiogenic shock. We report a series of three patients who presented with acute and subacute submassive PTE. They were suc-cessfully treated by simple catheter-based mechanical thrombectomy and intrapulmonary arterial thrombolysis. Mechanical fragmentation and aspiration of thrombus was performed by commonly used J-wire, multi-purpose and Judkin Right guiding catheters and this obviated the need of specific thrombectomy devices.     

肺动脉置管溶栓术治疗肺栓塞（附65例报告）

目的探讨肺动脉置管溶栓术治疗肺动脉血栓栓塞（肺栓塞）的临床疗效及安全性。方法对65例肺栓塞患者行肺动脉置管溶栓术;57例合并静脉血栓者经股静脉或右颈内静脉置人腔静脉滤器,溶栓治疗结束前复查肺动脉造影及下肢静脉造影。出院后长期口服华法林。术后6个月复查血管超声及肺动脉3DCT血管造影。结果置入腔静脉滤器57枚,均一次性释放成功,释放过程平均耗时2．2min,滤器弹跳幅度〈2mm且无倾斜。65例患者平均溶栓时间6．72d。溶栓治疗后呼吸困难消失55例,呼吸困难减轻7例,死于呼吸、循环衰竭1例。血栓明显消融52例,部分消融11例,少量消融1例。术后合并脑出血1例。6个月后复查肺动脉及肢体静脉血栓无明显增多。结论肺动脉置管溶栓术治疗肺栓塞效果确切,可明显改善患者症状,血栓消融程度高,损伤小,并发症少,但应严格掌握溶栓时机。     

Massive air embolus treated with rheolytic thrombectomy

The incidence of air embolism during diagnostic cardiac catheterization and percutaneous coronary intervention is reported at a rate of 0.84% and 0.24%. Although there is no optimal technique to restore blood flow after blockage by air emboli, treatment options include manual aspiration or forcefully injecting saline, with auxiliary supportive measures like 100% oxygen or an intra-aortic balloon pump. The AngioJet (Possis Medical, Inc., Minneapolis, Minnesota) device is a catheter-based device for thrombus removal in which high-velocity saline jets are used to create a localized low-pressure zone at the distal catheter tip (Bernoulli effect), resulting in the maceration and removal of thrombus through an exhaust lumen. The use of rheolytic thrombectomy has been studied in thrombus-containing native coronary arteries as well as saphenous vein graft lesions. We report a case of a massive air embolus that occurred after activation of an AngioJet catheter in a thrombus-laden right coronary artery (RCA). The AngioJet catheter was then utilized to effectively aspirate the air embolus with restoration of coronary blood flow. Use of a guiding catheter that is nonocclusive or with side holes to ensure continuous blood flow from the central aorta may help avoid entrainment of air into the coronary artery during activation of the AngioJet thrombectomy catheter. To our knowledge, this is the first reported case of such a potential complication. In the event of such a complication, the AngioJet catheter can be implemented to aspirate a coronary air embolus.     

Arterial thromboembolism in pregnancy

Arterial occlusion resulting from primary thrombus formation in an artery or due to embolization from a site elsewhere in the circulation is uncommon in women of childbearing age. Myocardial infarction, stroke and peripheral arterial occlusion are rare in pregnant or puerperal women. Although atherosclerosis is the most common cause of arterial thromboembolism in the general population, other mechanisms--for example, prosthetic heart valves and drugs which cause vasospasm--are also important in young and pregnant patients. The clinical sequelae of arterial thromboembolism include sudden death and significant long-term morbidity. The best management must be the recognition of women at risk and, where possible, risk reduction and the introduction of measures to prevent acute events.     

Venous thromboembolism in pregnancy

In Western nations, venous thromboembolism (VTE) is an important cause of morbidity and the most common cause of maternal death during pregnancy and the puerperium. Pregnancy is a hypercoagulable state in which coagulation is activated and thrombolysis inhibited. This prothrombotic risk is compounded when hereditary and acquired thrombophilias and other prothrombotic risk factors are present. The risk of venous thrombotic events is increased fivefold during pregnancy and 60-fold in the first 3 months after delivery (postpartum period) compared with nonpregnant women. Many of the signs and symptoms of VTE overlap those of a normal pregnancy, which complicates the diagnosis. Patients with history of previous VTE should use graduated compression stockings throughout pregnancy and the puerperium, and should receive postpartum anticoagulant prophylaxis. The indications for antepartum anticoagulant prophylaxis are somewhat controversial. This article reviews the management of VTE during pregnancy and in the postpartum period.     

Venous thromboembolism in pregnancy

Opinion statement  Low molecular weight heparins (LMWHs) appear to be as safe and effective as unfractionated heparin (UFH) for venous thromboembolic disease (VTED) treatment or prophylaxis during pregnancy. Experience with other parenteral anticoagulant drugs is very limited, and no alternative oral anticoagulants are available to date. In addition to cost, challenges of long-term LMWH use during pregnancy that have not been addressed by controlled clinical trials include a) ideal dosing as pregnancy advances, b) the need for LMWH monitoring by anti-Xa activity levels, and c) ideal therapeutic management as the delivery date nears. Because therapeutic-intensity anticoagulation during pregnancy is challenging, many practitioners favor a more “aggressive” approach toward VTED prophylaxis in women perceived to be at very high risk of thrombosis during pregnancy. Best evidence to date suggests that most women with thrombophilias or with a previous “situational” VTED event probably do not require VTED prophylaxis antepartum, but postpartum anticoagulation prophylaxis is recommended for a few weeks. For those with a history of previous idiopathic VTED or VTED associated with “hormonal challenge” (such as with contraceptive use or previous pregnancy), prophylaxis beginning antepartum may be considered and discussed with the patient. Selected cases of “severe” thrombophilia are probably best managed by initiation of pharmacologic VTED prophylaxis antepartum. However, it must be emphasized that data from prospective controlled clinical trials are lacking.     

Massive pulmonary embolism in pregnancy treated with streptokinase and percutaneous catheter fragmentation

Despite heightened awareness, pulmonary embolism remains a majorcause of maternal mortality in the antenatal period and onewhich has not decreased in incidence over the four trienniasince 1976. We report a patient who suffered massive pulmonaryembolism with circulatory collapse in the second trimester andwho was treated with intravenous streptokinase followed by percutaneousmechanical dispersion of thrombus using a catheter and guidewire. She made an excellent recovery despite complicating antepartumhaemorrhage. In life-threatening circumstances pharmacologicalthrombolysis is mandatory particularly for hospitals withouta cardiac catheterization laboratory on site.     

Acute pain episodes,acute chest syndrome,and pulmonary thromboembolism in pregnancy

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Percutaneous thrombectomy for pulmonary embolism

The current treatment of massive pulmonary embolism (PE) has been either thrombolysis or surgical embolectomy. Percutaneous rheolytic thrombectomy, however, has emerged as an alternative treatment in patients with contraindications to thrombolysis. This case illustrates the usefulness of the AngioJet(R) thrombectomy catheter in patients with contraindications to thrombolytics. Three-dimensional computed tomography imaging demonstrated the effectiveness of treatment in this patient with massive PE.     

Massive pulmonary thromboembolism demonstrated at necropsy in Japanese psychiatric patients treated with neuroleptics including atypical antipsychotics.

BACKGROUND: There may be an increased risk of pulmonary thromboembolism (PTE) with antipsychotic drugs, so this association was investigated in autopsy cases of sudden unexpected death determined by the Department of Legal Medicine of a Japanese university hospital. METHODS AND RESULTS: Records of 1,125 forensic autopsies (808 males, 317 females) performed during the study period for investigation of the cause of sudden unexpected death were reviewed and a logistic regression analysis was performed to explore whether age, gender, body mass index (BMI), and antipsychotic drug use were associated with fatal PTE. Among all records, 34 (3.0%; 14 males, 20 females) indicated the use of antipsychotic drugs and 28 (2.5%; 9 males, 19 females) indicated PTE as the cause of death. Of the 28 subjects who died from PTE, 8 had taken antipsychotic drugs (29%) and all were female. Female gender and antipsychotic drug use accounted for a significantly higher risk of PTE death with an odds ratio of 4.22 (95% confidence interval (CI), 1.82-9.78; p<0.01) and 10.49 (95% CI, 3.95-27.85; p<0.01), respectively. CONCLUSIONS: Japanese women taking antipsychotic drugs may be at particular risk for PTE.     

大块肺栓塞

背景:急性大块肺栓塞(PE)有特别高的死亡率。我们采用辅助的治疗措施,尤其是溶栓和下腔静脉滤器植入治疗的频率以及这些治疗措施怎样影响大块肺栓塞病人的临床结果。方法和结果:从国际合作肺栓塞登记(ICOPER),在2392个急性肺栓塞的病人并且已知动脉收缩压,其中108(4．5％)有大块肺栓塞,定义收缩压<90 mm Hg,2284(95．5％)没有大块肺栓塞,其收缩压>90 mm Hg。通过活检初诊为肺栓塞的在大块肺栓塞有16个(15％),在非大块肺栓塞有29个(1％),(P<0．001),90天死亡率在大块肺栓塞和非大块肺栓塞分别各占52．4％(95％的可信区间43．3％-62．1％)和14．7％(95％的可信区间13．3％-16．2％)。其住院出血并发症发生分别是17．6％和9．7％以及复发肺栓塞分别是12．6％和7．6％,(P<0．001)。在大块肺栓塞的病人,溶栓,手术取栓,导管取栓有73个病人(68％)。33个病人溶栓,3个病人手术取栓,1个病人导管取栓。溶栓治疗没有降低90天死亡率(溶栓,46．3％,95％的可信区间为31．0％-64．8％;非溶栓 55．1％,95％的可信区间为44．3％-66．7%;危险比,0．79,95％的可信区间为0．44-1．43)90天再发肺栓塞率在溶栓和非溶栓相似(均为12％;P=0．99)11个接受植入下腔静脉滤器的病人在90天内没有复发肺栓塞,其中10个(90．9％)存活至少90天。下腔静脉滤器与降低90天死亡率相关(危险比,0．12;95％的可信区间为0．02-0．85)。结论:2/3的大块肺栓塞的病人没有接受溶栓和血栓取出术。与直觉相反的是,溶栓并没有降低90天死亡率和再发肺栓塞的发生率。观察到下腔静脉滤器降低死亡率需要进一步调查。     

Massive pulmonary pseudotumor

The term pulmonary pseudotumor may be used to describe a well-demarcated interlobar pleural effusion. Pseudotumors are located within pulmonary fissures and are commonly associated with congestive heart failure and other processes that cause transudative pleural effusions. Pseudotumors are typically diagnosed presumptively on chest radiographs based on their lenticular configuration. We report a case of a massive pseudotumor opacifying one third of the right hemithorax on a frontal radiograph. CT scan of the chest showed a loculated effusion within the oblique fissure measuring 10 x 5 cm. The Hounsfield unit characteristic of the effusion was similar to that of freely layering liquid in the contralateral hemithorax that was shown to be a transudate. The pseudotumor resolved with medical management over 8 weeks. This case proves that even a massive pulmonary pseudotumor will resolve with conservative management.