Pulmonary cineangiography in acute pulmonary embolism

The usefulness of selective pulmonary cineangiography as a supplement to conventional pulmonary angiography was evaluated in 36 patients. In 13 of the 14 patients whose conventional angiographic results were equivocal, pulmonary cineangiography of questionable areas permitted a definitive diagnosis to be made. In 21 of the 22 patients whose conventional angiographic studies were considered definitely positive or negative, the cineangiographic results were in complete agreement. Thus, the principal value of supplemental pulmonary cineangiography is in patients whose conventional angiograms yield equivocal results. Its usefulness in this situation derives from its ability to delineate the details of flow and motion within the pulmonary vasculature.     

M-mode echocardiography in acute pulmonary embolism

Twenty-two patients with acute pulmonary embolism were examined by M-mode echocardiography. It was possible to examine both ventricles (with precordial approach) and the right branch of the pulmonary artery (with suprasternal approach) in all patients. With significant pulmonary embolism there occurs dilatation of the right ventricle and of the right branch of the pulmonary artery. The size of the right branch of the pulmonary artery in patients was significantly different from that of healthy volunteers. However, no significant correlation between the degree of anatomic changes (documented by echocardiography) and haemodynamics in the lesser circulation was found. Literature concerning other possibilities of echocardiography in the diagnosis of acute pulmonary embolism is reviewed. Echocardiography represents a suitable complement to diagnostic methods used for the assessment of acute states.     

Leukocytosis in acute pulmonary embolism.

PURPOSE: The purpose of this investigation is to assess the level of leukocytosis in acute pulmonary embolism (PE). BACKGROUND: Limited data exist regarding leukocytosis in acute PE. One reason that the prevalence of leukocytosis in acute PE is unknown, despite an extensive number of investigations of PE, may relate to the fact that acute PE is usually associated with other conditions that themselves may cause leukocytosis. METHODS: Hospital records of 386 patients with a diagnosis of acute PE were reviewed retrospectively. Patients with no other possible or definite cause of leukocytosis were analyzed separately. A diagnosis of PE was made by a high-probability interpretation of the ventilation/perfusion lung scan or pulmonary angiogram. RESULTS: Among patients with PE in whom other possible or defined causes for leukocytosis were eliminated, 52 of 266 (20%) had a WBC count > 10,000/mm3. None had a WBC count that was > or = 20,000/mm3. Patients with the pulmonary hemorrhage/infarction syndrome had an increased WBC count in 32 of 183 (17%) vs 20 of 83 (24%) in patients who did not have pulmonary hemorrhage/infarction syndrome (not significant). CONCLUSION: A modest leukocytosis may accompany (and possibly be caused by) PE. Its presence should not dissuade the clinician from objectively pursuing the diagnosis of PE.     

The electrocardiogram in acute pulmonary embolism

Electrocardiograms of 90 patients with arteriographically documented acute submassive or massive pulmonary embolism and no associated cardiac or pulmonary disease were studied. Patients were derived from the Urokinase-Pulmonary Embolism Trial National Cooperative Study. In massive embolism, the electrocardiogram was normal in 6% (3 of 50) of patients. With submassive embolism, 23% of patients (9 of 40) had a normal electrocardiogram. Since one or more of the traditional manifestations of acute cor pulmonale (S₁Q₃T₃, right bundle branch block, P pulmonale, or right axis deviation) occurred in only 26% of patients, one could not rely exclusively upon these electrocardiographic abnormalities for the diagnosis of pulmonary embolism. The most common electrocardiographic abnormalities were nonspecific T wave changes which occurred in 42% of patients and nonspecific abnormalities (elevation or depression) of the RST segment which occurred in 41% of patients. Left axis deviation occurring in 7% of the patients was as frequent as right axis deviation. Low voltage QRS complexes, previously undescribed in pulmonary embolism, occurred in 6% of patients. None of the patients had atrial flutter or atrial fibrillation, which appears to occur more typically in patients with pulmonary embolism who have preexistent cardiac disease. All of the varieties of electrocardiographic abnormalities disappeared in some of the patients by 2 wk. Inversion of the T wave was the most persistent abnormality. Larger defects on the lung scan or pulmonary arteriogram occurred in patients with various abnormalities on the electrocardiogram than in patients with normal electrocardiograms. The pulmonary arterial mean pressure and/or right ventricular end-diastolic pressure was significantly higher in patients with several varieties of abnormal electrocardiograms, although the partial pressure of oxygen in arterial blood, in general, did not differ from that in patients with normal electrocardiograms. These hemodynamic correlations, made for the first time in patients, suggest that acute ventricular dilatation, possibly in combination with hypoxemia, is a causative factor of the electrocardiographic changes in acute massive or submassive pulmonary embolism.     

Residual pulmonary thromboemboli after acute pulmonary embolism

BackgroundAfter an acute pulmonary embolism (PE), the complete resolution of thromboemboli may not be routinely achieved. The rate of persistence may depend on the time and the diagnostic technique used for evaluation.Patients and methodsPatients were diagnosed with acute PE by means of computed tomography angiography (CTA). While they were receiving anticoagulant therapy, a second CTA was used to explore the rate of persistence of residual thromboemboli. During the initial episode, the plasma levels of Troponin I and natriuretic peptide, patient demographics, and hemodynamic and gas exchange data were evaluated as risk factors for persistence of pulmonary thromboemboli.ResultsIn this study 166 patients were diagnosed. A second CTA was not made in 46 (28%) patients for different reasons. In 120 (72%) patients a second CTA was made 4.5 [SD2.34] months after the initial episode (range 2–12 months). Complete clearance of thrombi occurred in 89 (74%, 95% CI 65–81) patients. Residual thrombi remained in 31 (26%, 95% CI 18–34) patients. In 6%, 13% and 81% of the patients the size of the residual thrombi was greater, similar to and smaller than initially diagnosed, respectively.The risk factors for residual thrombi included the thrombotic burden (OR 1.95), the alveolar to arterial difference of oxygen (OR 1.64), and the clinical antecedents of venous thromboembolic disease (OR 0.65).ConclusionsAfter 4.5 months of anticoagulant therapy, residual pulmonary thromboemboli persisted in 26% of the patients. The risk factors for residual thromboemboli include a greater initial thrombotic burden, a deeper gas exchange disturbation and a history of previous venous thromboembolism.     

Fibrinolysis for acute pulmonary embolism

Acute pulmonary embolism (PE) presents as a constellation of clinical syndromes with a variety of prognostic implications. Patients with acute PE who have normal systemic arterial blood pressure and no evidence of right ventricular (RV) dysfunction have an excellent prognosis with therapeutic anticoagulation alone. Normotensive acute PE patients with evidence of RV dysfunction are categorized as having submassive PE and comprise a population at intermediate risk for adverse events and early mortality. Patients with massive PE present with syncope, systemic arterial hypotension, cardiogenic shock, or cardiac arrest and have the highest risk for short-term mortality and adverse events. The majority of deaths from acute PE are due to RV pressure overload and subsequent RV failure. The goal of fibrinolysis in acute PE is to rapidly reduce RV afterload and avert impending hemodynamic collapse and death. Although generally considered to be a life-saving intervention in massive PE, fibrinolysis remains controversial for submassive PE. Successful administration of fibrinolytic therapy requires weighing benefit versus risk. Major bleeding, in particular intracranial hemorrhage, is the most feared complication of fibrinolysis. Alternatives to fibrinolysis for acute PE, including surgical embolectomy, catheter-assisted embolectomy, and inferior vena cava (IVC) filter insertion, should be considered when contraindications exist or when patients have failed to respond to an initial trial of fibrinolytic therapy. Patients with massive and submassive PE may be best served by rapid triage to specialized centers with experience in the administration of fibrinolytic therapy and the capacity to offer alternative advanced therapies such as surgical and catheter-assisted embolectomy.     

Role of echocardiography in acute pulmonary embolism

The difficulty in making an accurate diagnosis of acute pulmonary embolism is well known. To clarify the role of echocardiography, including Doppler echocardiography, in acute pulmonary embolism, we examined hemodynamic and echocardiographic parameters in 9 patients with acute pulmonary embolism just before and after treatment with urokinase. As hemodynamic parameters normalized after treatment, echocardiographic parameters such as deformity index of the left ventricle (LV-DI), end-diastolic dimension of the right ventricle (RVDd), the left ventricle (LVDd), the inferior vena cava, and RVDd/LVDd all significantly changed toward normal. Highly significant correlations were found between the echocardiographic and hemodynamic parameters, the best of which was between the LV-DI and systolic pulmonary artery pressure (r = -0.885, p less than 0.001). Doppler echocardiography quantitatively evaluated the grade of tricuspid regurgitation, and accurately estimated systolic pulmonary artery pressure. We conclude that echocardiography, including Doppler echocardiography, sensitively reflects the right ventricular pressure and volume overload of acute pulmonary embolism, is quite useful for its diagnosis which is often difficult, and is suitable for noninvasive follow up of these patients.     

急性肺栓塞心电图分析

目的对急性肺栓塞的心电图特征进行总结及分析,旨在提高急性肺栓塞的诊断及治疗水平。方法随机选取我院2008年3月至2013年3月期间所收治的86例急性肺栓塞患者,回顾性分析心电图改变。结果86份心电图中,有79例心电图异常,占据总体的91．8％,有7例心电图正常,占据总体的8．2％。结论在急性肺栓塞的临床诊断过程中,心电图检查及心电图变化特征是非常重要的,具备着不可或缺的作用及价值,医务人员应当提起高度重视,并且在临床诊断中加以应用及推广。     

CT肺动脉栓塞指数与危险分层的相关性分析

目的:探讨急性肺栓塞患者CT肺动脉栓塞指数与危险分层的相关性。方法:纳入72例连续收治的急性肺栓塞患者,均经CT肺动脉造影确诊。按指南对患者进行危险分层并计算CT肺动脉栓塞指数,用Spearman法计算CT肺动脉栓塞指数与急性肺栓塞危险分层的相关系数,用受试者工作特征曲线评估CT肺动脉栓塞指数对每个危险分层的预测效能。结果:在72例急性肺栓塞患者中,低危组32例、中危组31例、高危组9例,三组CT肺动脉栓塞指数分别为(26.2±16.4)%、(52.9±10.6)%和(85.6±5.4)%,CT肺动脉栓塞指数与急性肺栓塞危险分层的相关系数为0.881(P<0.01)。肺栓塞指数对危险分层中的高危组预测效能最高,敏感性为66.7%,特异性为90.5%,曲线下面积达0.929(P<0.01)。结论:急性肺栓塞患者CT肺动脉栓塞指数与危险分层呈显著正相关。