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Current mainstay treatment for pulmonary embolism (PE) includes oral anticoagulation, thrombolytic therapy, catheter embolectomy
and acute surgical embolectomy. Surgical embolectomy is reserved for hemodynamically unstable patients (cardiogenic shock,
cardiac arrest) and contraindication to thrombolytic therapy. We report a case of saddle PE in a y...
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... extremity had 1+ pitting edema and Homans' sign was positive. Upper and lower extremities were warm to touch, and there was no cyanosis. Her electrocardiogram (Fig. 1) on presentation showed sinus tachycardia with a heart rate of 115 beats per minute, T wave in- versions in leads III and V3 and chest X-ray showed a widened superior mediastinum (Fig. 2). Labs were significant for elevated white blood cell count (15 000), initial troponin I was 0.83 ng/ml (normal 0-0.04), which increased to 1.99 and d-dimer on presen- tation was >5000 ng/ml DDU. Her initial arterial blood gas on 40% FiO 2 (5 l via nasal cannula) was pH: 7.31, PCO 2 : 31 mmHg, PO 2 : 231 mmHg, HCO 3 : 15.6 mEq/l, SPO 2 ...
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Percutaneous pulmonary angiography may be used for early diagnosis of pulmonary embolism in the hemodynamic unstable patient. Pulmonary embolectomy is an effective treatment option in patients with acute high‐risk pulmonary embolism.
Percutaneous pulmonary angiography may be used for early diagnosis of pulmonary embolism in the hemodynamic unstable...
Citations
... This view can be used to evaluate the both ventricles and right heart strain [13]. The right heart strain is the indicator of Pulmonary Embolism [14]. The subxiphoid view shows the left lobe of liver, and Inferior Vena Cava (IVC), Right Atrium. ...
Introduction:Echocardiography is the basic and important imaging technique used for the diagnosing the various numbers of Cardiac Conditions. This helps clinicians for diagnosing a various number of clinical variations. This functional data is needed to care for patients with many pathologies and used to diagnose a number of diseases. Trans-Thoracic Echocardiography is the most common Echocardiography done in every Cardiology Department of Centre. The use of 2D Echo provides the proper and fast diagnosis and allows the clinicians to make further diagnosis. In this study, we focus on Current Clinical Prole of the distributed Age Groups along with risk factors and advised recommendations with comparison of Diagnosis. Methods: In this case study, total of 1447 patients were divided in 6 Age Groups, proled for the outcomes of the 2D Echocardiography. We aimed to determine the Current Clinical Prole with the Diagnosis, Risk Factors and Advised Recommendations in each age group in a Cardiac Intensive Care Unit (CICU) in CHL Multispeciality Hospital and Research Center, Chandrapur using a prospective observational study. Patients: All consecutive patients followed up for 2D Echocardiography at the Cardiology Department between April 2021 and August 2021 were included if they were aged more than 18 years. Patients eligible for the study were evaluated for the current prole of the patient, risk factors and Advised Recommendations in each Age group. Results: In the study conducted, the clinical prole had a good result in suggesting that most of the patients in all age groups had the diagnosis of Good biventricular systolic function, No RWMA, Normal chamber dimension & Valve function. Uncontrolled Sugars and Accelarated Hypertension made worse for patient's cardiac management. Some Results of 2D Echo were also affected because of the emergency in the CICU, for which 2D Echo was postponed later or after stability of the patient. Past Medical History had the signicant role. The clinical prole helped us understand the proper diagnosis and recommendations done
... Pulmonary embolism is the third leading cause of cardiovascular death after myocardial infarction and stroke [1,2,4,5]. Anticoagulation is the primary choice of treatment for the majority of patients presenting with acute pulmonary embolism [2,4]. However, a greater risk of mortality in patients with right ventricular (RV) dysfunction may open the door to more aggressive treatment modalities [2]. ...
... Pulmonary embolism is the third leading cause of cardiovascular death after myocardial infarction and stroke [1,2,4,5]. Anticoagulation is the primary choice of treatment for the majority of patients presenting with acute pulmonary embolism [2,4]. However, a greater risk of mortality in patients with right ventricular (RV) dysfunction may open the door to more aggressive treatment modalities [2]. ...
... The annual incidence of pulmonary embolism has been reported to be between 39-115/100,000 population globally and is the third leading cause of cardiovascular mortality behind myocardial infarction and stroke [1,2,4,5]. Diagnosis can often be challenging due to the spectrum of presentations ranging from asymptomatic to cardiovascular collapse and death [1][2][3]. Health organisations world-wide have begun to adopt multidisciplinary pulmonary embolism response teams (PERTs) who are tasked with convening in real-time to aid clinical decision regarding management -taking into account risk factors and risk stratification scores, such as the pulmonary embolism severity index (PESI) to assess risk of early mortality [1,2,5]. ...
Pulmonary embolism is the third leading cause of cardiovascular death after myocardial infarction and stroke [1,2,4,5]. Anticoagulation is the primary choice of treatment for the majority of patients presenting with acute pulmonary embolism [2,4]. However, a greater risk of mortality in patients with right ventricular (RV) dysfunction may open the door to more aggressive treatment modalities [2]. We present the case of a patient who was diagnosed with a post-operative saddle pulmonary embolus that failed initial treatment with anticoagulation and required emergency thrombectomy to prevent mortality. A brief overview of treatment options is highlighted.
... The right ventricular dysfunction on echocardiogram has an important role for prognosis as seen in different studies that show a correlation between adverse outcomes and right ventricular dysfunction in pulmonary embolism [22]. Although in our study we did not study the correlation of RV dysfunction with adverse outcomes, it can however be used to risk-stratify patients with acute PE [23]. ...
Background
There is an increasing need to explore other non-invasive techniques for the diagnosis of pulmonary embolism in resource-limited countries.
Objective
To assess the validity of elevated D-dimer levels and right ventricular (RV) dysfunction on echocardiography in predicting definite massive pulmonary embolism among patients diagnosed with massive pulmonary embolism using computed tomography (CT) pulmonary angiography as the gold standard.
Methods
The patients with acute massive pulmonary embolism on CT pulmonary angiography were included. The participants underwent 12-lead electrocardiography, assessment of D-dimer levels, and bedside echocardiography to determine right ventricular dysfunction. The data were recorded on a proforma and analyzed using IBM SPSS software version 26.0 (IBM Corp., Armonk, NY).
Results
There were 160 patients in the study. The mean age was 49.19 ± 14.89 years. Elevated D-dimer levels were seen in 80.60% of the patients whereas ventricular dysfunction on echocardiography was seen in 90.00% of the patients. The sensitivity and specificity of elevated D dimer levels were 78.99% and 14.60%, respectively. The positive predictive values (PPV) and negative predictive values (NPV) for elevated D-dimer levels were 72.87% and 19.35%, respectively. In contrast, the sensitivity of ventricular dysfunction was 94.96% and specificity 24.39%. PPV was found to be 78.47% and NPV was 62.50%.
Conclusion
Positive D-dimer levels and ventricular dysfunction on echocardiography are sensitive enough to consider the diagnosis of massive pulmonary embolism but lack adequate specificity, thus, necessitating the presence of other noninvasive tests.
... Saddle pulmonary embolism is a medical emergency manifesting as a large clot with the potential for causing sudden hemodynamic collapse, and as many as 25% present as sudden death out of more than 100,000 cases reported annually (Nama et al. 2016). Though CTA exists as the gold standard for diagnosis of pulmonary emboli, patients may have contraindications to such a modality. ...
Pulmonary embolism is a potentially life-threatening condition that requires prompt diagnosis and efficient management such as in the form of thrombolysis or surgical thrombectomy. Saddle pulmonary emboli occurring at the bifurcation of the pulmonary artery are especially dangerous as they put afflicted individuals at risk for sudden hemodynamic collapse. While CT Angiography at present is the current imaging modality of choice, times exist when they are contraindicated and V/Q scintigraphy is used as the choice alternative. We present a rare catastrophic case of a saddle pulmonary embolism in an individual with a low-probabilityinterpretation on V/Q scintigraphy despite a clear depiction of the thrombus on echocardiography.
... Two such cases recently published in the Journal provide an insight into the successful treatment of clinically challenging presentations of intermediate to high and high-risk PE, one using thrombolysis [3] and the other surgical embolectomy [4]. ...
... The second case by Namana et al. [4] reports the case of a 47-year-old female with a saddle embolus extending into both main pulmonary arteries causing RV dysfunction without haemodynamic instability. A decision was made to proceed with surgical embolectomy, following which she recovered well, with improving RV function and discharged home 6 days later. ...
... This appeal of reduced bleeding complications has made embolectomy an emerging first-line option in treating acute massive PE, and more recently submassive PE, despite the lack of recommendations from the ESC and American Heart Association [1,2]. With such extensive thrombus as shown in figure 5 in the case by Namana et al. [4], thrombolysis is unlikely to attain complete clot lysis, and a significant proportion of these patients will have residual thrombus, placing them at risk of suboptimal initial benefit and chronic thromboembolic disease; potentially requiring further surgical intervention when clot extraction is more difficult, pulmonary hypertension is established and RV function is permanently impaired. ...
Patients presenting with acute pulmonary embolism (PE) and persisting haemodynamic instability need to be considered for primary reperfusion therapy with, commonly, thrombolysis or even surgical embolectomy [1]. Both treatment options can pose significant risks to the patient, but are potentially life-saving when used appropriately. Absolute contraindications to thrombolysis include cases where there is high risk of haemorrhage including previous haemorrhagic stroke, recent major surgery or trauma, recent gastrointestinal bleeding, central nervous system neoplasm or known bleeding diathesis [2]. In the presence of such contraindications, surgical embolectomy can be considered for intermediate to high and high-risk PE [1]. In clinical practice, the treatment decision is not always clear-cut and the ‘European Society of Cardiology (ESC)’ offers guidelines especially in situations where therapeutic options might be open to contention [1].
Background:
Massive or high-risk pulmonary embolism (PE) is a potentially life-threatening diagnosis with significant morbidity and mortality if treatment is delayed. Extracorporeal membrane oxygenation (ECMO) and large bore thrombectomy (LBT) in isolation have been used to stabilize and treat patients with massive PE, however, literature describing the combination of both modalities is lacking. We present a case series involving 9 patients who underwent combined ECMO and LBT and their outcomes.
Methods:
This was a retrospective chart review of patients with confirmed PE, who underwent LBT and ECMO. We retrospectively captured clinical, therapeutic, and outcome data at the time of pulmonary embolism response team (PERT) activation and during the follow-up period for up to 90 days.
Results:
Nine patients who had PERT activation with confirmed PE diagnosis have undergone combined LBT and ECMO initiation since the advent of our PERT program. The median age was 57 (range 28-68) years. Six patients out of 9 (55%) had cardiac arrest before therapy. All patients exhibited right heart strain on computed tomography and echocardiogram. The median ECMO duration was 5 days (range 2.3-11.6 days), with mean hospitalization of 16.1 days (range 1.5-30.9). Mortality was 22% at 90-day follow-up period.
Conclusion:
Patients with massive pulmonary embolism who suffer cardiac arrest have significant morbidity and mortality. ECMO in combination with LBT is a viable treatment option for patients with significant hemodynamic compromise.
Cosmetic split tongue procedure has become more common amongst the extreme body modification enthusiasts. Recent media statements addressing the adverse complications of such procedures have generated public interest. A 29‐year‐old patient presented with pre‐syncope symptoms with worsening chest pain three days after undergoing a surgical tongue split procedure. Further investigations showed sinus tachycardia with raised troponin levels and imaging confirmed an acute saddle pulmonary embolism (PE) with evidence of a right heart strain and dilatation of the pulmonary artery. She was treated with immediate treatment dose heparin which resulted in bleeding from the tongue surgical site which was managed by cauterisation and suturing. She was placed on long term warfarin treatment. Two months later, she developed further chest pain, which was diagnosed as pleuritis secondary to the pulmonary embolism. We highlight the potential seriousness of tongue split procedure and describe the dangerous consequences that extreme body modification can pose if the patient is not managed appropriately during the peri‐operative period.
