Massive pulmonary embolus complicating left atrial myxoma

Atrial myxomas may present with a classic triad of constitutional symptoms, embolic events, and intracardiac obstruction (1). We report a case of a massive pulmonary thromboembolus complicating a left atrial myxoma in the absence of an atrial or ventricular septal defect.     

Emergent pulmonary embolectomy: the treatment for massive pulmonary embolus

Massive pulmonary embolus usually leads to in-hospital mortality if not treated aggressively. Four patients were seen with severe cardiorespiratory compromise resulting from massive pulmonary emboli. Emergent pulmonary embolectomy was followed by marked clinical improvement, and 3 patients were subsequently discharged from the hospital. The clinical courses of these patients are described, and massive pulmonary embolus and its management are discussed.     

Retrograde pulmonary embolectomy in massive pulmonary embolism

The purpose of this study was introduction and evaluation of efficacy and safety of retrograde thromboembolectomy in acute massive pulmonary emboli. The method is described in a 56-year-old woman with acute massive pulmonary thromboemboli. Postoperative course was uneventful. The described surgical technique is not a panacea and definitely not the whole answer, but is a big part of the solution and may be accompanied with less adverse effects. Additionally, there is a need of being reviewed further in large experimental studies and measurements before it could be used safely as a new technique.     

Pulmonary embolectomy for acute massive pulmonary embolism.

During the period from 1961 to 1981, 40 pulmonary embolectomies were performed in 39 patients who were in extremis at the time of initiation of cardiopulmonary bypass. In a 460-bed hospital with more than 17,000 acute admissions and 4,000 operations per year, this small number represents the few patients who are potentially salvageable by urgent embolectomy. Preoperative angiography was performed in 57% of the cases, and in another ten patients suspected of having pulmonary emboli, angiography prevented unnecessary thoracotomy. Despite their moribund condition, 43% of the embolectomy patients lived. Excluding two patients with tumor occlusion of the pulmonary arteries and three patients with chronic cor pulmonale from old pulmonary emboli, the survival rate was 50%. Ten patients died because of hypoxemia and hypotension prior to initiation of cardiopulmonary bypass, and seven died of myocardial depression of multiple etiologies. Portable cardiopulmonary bypass affords the possibility of survival in moribund patients with acute massive pulmonary embolism. Preoperative angiography is recommended to guide appropriate surgical management.     

Acute massive pulmonary embolism following pulmonary resection

Eighteen cases of acute massive and fatal pulmonary embolism following pulmonary resection are summarized. Clinical presentation is distinct in this group of patients. In one-third of the cases there was radiological evidence of major embolism several hours before the acute dramatic episode. At necropsy there seemed to be no correlation between the vascular area obstructed and the acute clinical deterioration. Longest survival occurred in those patients with (a) the best pre-operative respiratory function, and (b) the least operative and post-operative complications.     

Bronchopleural fistula complicating massive pulmonary infarction

The clinical course of a patient who developed a lung abscess with a bronchopleural fistula following a massive infarction is described. Comparison of the events in this patient's illness with others reported in the literature reveals a recognizable syndrome which is characterized by three phases. The initial illness consists of massive infarction with its well-recognized sequelae. Following a short period of improvement, the second phase begins with the production of copious amounts of blood-tinged or purulent sputum, accompanied by fever, leucocytosis, and cardiac decompensation. This phase lasts several days to weeks and signifies excavation of the infarcted area. After another period of relative quiescence, the third phase, characterized by the abrupt onset of fever, pleuritic pain, cough, and acute dyspnoea, begins. These symptoms herald bronchopleural fistula. In view of the high mortality, prompt recognition of this syndrome and vigorous treatment appear to be mandatory.     

Necrotising pneumonia and empyema due to Clostridium perfringens complicating pulmonary embolus.

A fatal case of necrotising pneumonia due to Clostridium perfringens developing as a complication of pulmonary infarction is reported.     

Surgical management of massive pulmonary embolism

Between 1972 and 1976, 24 patients have been treated by open pulmonary embolectomy with the aid of cardiopulmonary bypass (CPB). In 17 (71 percent) acute pulmonary embolism occurred 3 to 60 days after a surgical procedure. The remaining seven (29 percent) patients had chronic medical diseases. The interval between clinical manifestation of acute pulmonary embolism and the performance of open embolectomy ranged from 8 to 36 hours. The definitive diagnosis in all patients was made by pulmonary arteriography. Candidates for pulmonary embolectomy were selected by assessment of hemodynamic stuides: shock, arterial Po2 less than 65 mm. Hg, acidosis, pulmonary artery pressure higher than 20 to 30 mm. Hg, and central venous pressure elevated (patients in Class III or IV according to the Greenfield classification). The definitive indication for embolectomy was occlusion of the main pulmonary artery of more than 50 percent as well as occlusion of the right or left pulmonary artery. Of the seven patients operated upon between 1973 and 1974, three (43 percent) died in the early postoperative period. Between 1975 and 1976 the operative mortality rate in 17 patients was 23 percent (four patients). Our results show that prompt diagnosis of acute massive pulmonary embolism and better selection of patients may improve significantly the survival rate after open pulmonary embolectomy with CPB.     

Paradoxical embolism

Paradoxical embolization of venous thrombus into the abdominal aortic bifurcation has been diagnosed by means of aortography. Lower limb phlebothrombosis accounting for the embolus formation has been demonstrated by phlebography. Arterial embolectomy and venous thrombectomy were successfully performed. Recovery was complete without sequelae.     

Tissue plasminogen activator and cardiopulmonary bypass for massive pulmonary embolus

Massive pulmonary embolus resulting in cardiac arrest and doubtful cerebral status may result in indecision as to whether to proceed to pulmonary embolectomy, especially if there is continuing cardiorespiratory instability. A case is reported on the use of fibrinolysis and cardiopulmonary bypass, allowing for the cerebral status of the patient to become more clearly defined while maintaining cardiopulmonary stability and attempting to treat the underlying pathological process.     

Successful thrombolysis for massive pulmonary embolism after pulmonary resection

We report the successful use of thrombolysis for acute massive pulmonary embolism 2 days after right lower lobectomy for bronchial adenocarcinoma. Pulmonary angiography revealed extensive clot unsuitable for surgical embolectomy. A bolus infusion of recombinant tissue plasminogen activator produced an immediate improvement in the patient’s hemodynamic state. There was substantial blood loss requiring the transfusion of 21 units of blood over the postoperative period. The patient made a successful recovery and remained well at 1 year.