Search

A 51-year-old woman with antiphospholipid syndrome was readmitted to the hospital two years after successful surgical pulmonary thrombendarteriectomy for severe chronic thromboembolic pulmonary hypertension (CTEPH). Exertional dyspnea, chest pain and ECG pattern could suggest relapse of pulmonary thromboembolism. However, no signs of pulmonary hypertension were found at echocardiography. Coronary angiography revealed proximal critical occlusion in the left anterior descending artery which was successfully treated with PTCA and stenting. Coronary artery disease may mimic relapse of CTEPH and this should be remembered especially in patients with antiphospholipid syndrome, who have increased risk of coronary artery disease especially in the presence of other classical risk factors.

A case of a 59-year-old man with recurrent angina associated with ST-segment elevation in leads II, III, aVF and V4R-V6R, cardiogenic shock and complete atrio-ventricular block, is presented. Coronary angiography was normal. Therapy with calcium channel blockers was effective. Difficulties in the treatment of patients with variant angina are discussed.

Aim: To assess correlation between exercise tolerance and Doppler-derived indices of right ventricular (RV)--pulmonary arterial coupling in patients with different location of vascular lesions causing pulmonary hypertension (PH)., Material: 45 patients: 21 with thromboembolic (TE-PH) and 24 with arterial PH defined as systolic pulmonary arterial pressure (SPAP) > 40 mm Hg. The two groups were similar as far as SPAP (74,8 +/- 15,2 vs 76.5 +/- 14,1 mm Hg, p = ns) and distance covered during 6 minute walk test (339 +/- 116 vs 320 +/- 127, p = ns) are concerned., Results: Flow velocity curve in the RV outflow tract were different in the two groups. Time from onset to peak velocity of ejection (acceleration time, AcT) as well as to midsystolic deceleration were shorter in TE-PH then in arterial PH (59.0 +/- 6.3 vs 68.1 +/- 15.4 msec, p = 0.015 and 123.8 +/- 17.9 vs 137.9 +/- 29.7 msec, p = 0.071, respectively). In the whole studied group as well as in arterial PH significant correlation between exercise tolerance and Doppler-derived indices of RV--pulmonary arterial coupling were found (r = 0.51, p < 0.001 and r = 0.72, p = < 0.001, respectively). Interestingly, no such relationship was found in TE-PH, (r = 0.16, p = ns)., Conclusion: In contrast to arterial PH, pressure wave prematurely reflected from the intraluminal thrombi seem to disturb the RV ejection pattern and its correlation with exercise tolerance in TE-PH. Whether progression or effects of treatment on arterial PH can be assessed by monitoring changes in Doppler-derived indices of RV--pulmonary arterial coupling requires further studies.

Background: Clinical value of electrocardiographic features of torsade de pointes (TdP) has not yet been well established., Aim: To compare the mode of onset and ECG characteristics of slow (s-TdP) and fast (f-TdP) episodes of TdP., Methods: 54 episodes of TdP recorded in 6 patients (5 females, one male, mean age 64.4 years) with acquired long QT syndrome were analysed. Baseline rate of TdP (V-V), ventricular rate variability (VRV), coupling interval (CI) at the onset of TdP, prematurity index (PI) and the first cycle length (FCL) were compared between 31 s-TdP (<200 beats/min) and 23 f-TdP (> or =220) episodes of TdP., Results: Episodes of f-TdP were preceded by a significantly faster basal rhythm than s-TdP (R-R interval: 922 ms vs 1062 ms, p=0.03). QT interval was almost identical in both groups (517 ms vs 515 ms, NS, respectively). No significant differences were noted in the CI of the initiating beat (488 ms vs 472 ms, NS) nor in the PI (0.53 vs 0.47, NS). TdP was most frequently spontaneously terminated by a gradual slowing of the tachycardia rate; 58% of s-TdP and 39% of f-TdP episodes stopped in this way. An acceleration of ventricular rate before termination of TdP was noted in 32% of s-TdP and in 26% of f-TdP episodes. Episodes of f-TdP were longer than s-TdP episodes (mean of 19.7 vs 6.7 ventricular complexes per one episode, p=0.0003). There were significant differences in the VRV parameter (p=0.0005) and FCL (p=0.004) between both types of TdP. Faster TdP were characterised by lower ventricular rate variability (VRV - 19.5 msec) than s-TdP (VRV - 39.4 msec). Of 54 episodes of TdP, 9 (16.6%) degenerated into VF and required DC shock. Of 31 s-TdP episodes, one (3.2%) degenerated into VF compared with 8 (34.7%) episodes of f-TdP (p<0.04)., Conclusions: Episodes of fast TdP were characterised by a longer duration, shorter first cycle of the arrhythmia and lower ventricular rate variability than episodes of slow TdP. Fast episodes of TdP were preceded by faster baseline rhythm before TdP. Faster TdP more frequently degenerated into VF than slower episodes.

A case of 63-years old man suffering from CTEPH and chronic renal failure due to diabetic nephropathy is presented. First diagnosis of pulmonary hypertension was made at the beginning of 2000. Then the secondary anticoagulant prophylaxis were introduced. Despite such treatment there was no improvement and level of pulmonary hypertension increased. Finally, the pulmonary thrombectomy was considered because of proximal location of thromboembolic obstruction in pulmonary artery. Before surgery, the hemodialysis was started. Pulmonary thrombendarterectomy along with right coronary artery bypass grafting were performed in November 2001. The procedure was conducted successfully. The patient's condition improved and pulmonary pressure dropped substantially. During follow-up anticoagulant prophylaxis and hemodialysis are continued. It might be conducted that pulmonary thrombendarterectomy can be successfully performed also in patients with complex coexisting conditions.

Unlabelled: Pulmonary hypertension (PH) represents an important diagnostic problem, because of its non-specific clinical presentation., Aims of the Study: Estimation of sensitivity and specificity of spiral computed tomography (SCT) in diagnosis of PH. Estimation of the influence of the cause and character of PH on morphology of pulmonary arteries and right ventricle-pulmonary artery coupling., Material and Methods: 102 patients with clinical suspicion of acute pulmonary embolism (APE) or chronic PH (54F, av. age 51.3 +/- 17.3). Diameters of pulmonary arteries obtained in SCT, systolic pulmonary pressure calculated from the tricuspid gradient pressure, and indices of the right ventricle-pulmonary artery dynamical coupling (AcT) obtained from the echo-Doppler method were compared., Results: Increased diameter (> 18 mm) of interlobar arteries was the most specific sign of PH (specificity 92%, sensitivity 45%). Diameter of proximal pulmonary arteries and pulmonary pressure was correlated in patients with APE (r = 0.487, p < 0.003), but not in those with chronic PH (r = 0.223). In a group of patients with pulmonary arterial hypertension (PAH), enlargement of proximal pulmonary arteries seemed to result in less disturbed right ventricle-pulmonary artery dynamic coupling., Conclusions: 1. SCT measurements of diameters of pulmonary arteries have relatively low sensitivity for PH, precluding its reliable exclusion. 2. The relationship between the pulmonary pressure and the diameters of pulmonary arteries was found in acute but not in chronic PH, in which right ventricle-pulmonary artery dynamical coupling seemed less disturbed when pulmonary arteries were markedly dilated.

A case of 78 year-old woman with primary hypothyroidism and atrial fibrillation treated with sotalol, complicated with cardiac arrest due to ventricular fibrillation (VF) and torsade de pointes (TdP) is presented. The QT interval was prolonged to 660 msec. Episodes of polymorphic ventricular tachycardia and VF recurred. Lidocaine, tosylate bretylate and betabloker successfully eliminated VF but short-lasting episodes of TdP were still present. Increased doses of hormonal substitution with thyroid hormones successfully eliminated malignant ventricular arrhythmias and normalised QT interval to 430 msec.

The incidence of deep vein thrombosis in Western World is estimated at about 1 case/1000/year and of pulmonary embolism at 0.5 case/1000/year. Mortality in untreated pulmonary embolism is 30%. With adequate treatment (anticoagulation) it can be decreased to 2-8%. Deep vein thrombosis and pulmonary embolism are frequent complications of various surgical procedures, especially of orthopedic interventions on hip joint. When surgery has to be performed in patient with high risk of pulmonary embolism, anticoagulant prophylaxis should be performed. Venous thromboembolic disease is the most important cause of mortality in trauma patients. We present a case of 46 years old man with bilateral fracture of femoral bone after car accident injury in whom signs of deep venous thrombosis and pulmonary embolism were observed despite the use of anticoagulant prophylaxis.

20 consecutive patients with thromboembolic pulmonary hypertension underwent pulmonary thromboendarterectomy. Mean pulmonary artery pressure decreased from mean 49.9 +/- 9.8 to 25.1 +/- 8.8 mm Hg (p < 0.0001), pulmonary vascular resistance decreased from mean 5.58 +/- 2.58 to 1.62 +/- 0.79 mm Hg/l*min-1 (p < 0.0001) and cardiac output increased from 3.71 +/- 1.18 to 6.92 +/- 1.64 l/min. Sixteen patients had marked clinical improvement. Two patients died in early and 2 patients in late postoperative period due to unrelieved pulmonary hypertension and postoperative complications.

The aim of the study was to assess effectiveness and safety of the LGM inferior vena cava (IVC) filters in patients with venous thromboembolic disease. In the Department of Internal Medicine of Institute of Tuberculosis and Lung Diseases in Warsaw 79 LGM IVC filters have been inserted since 1993. Indications for filters placement were as follows: recurrent pulmonary embolism (pe) despite anticoagulation--17 patients (pts), severe bleeding complications of thrombolytic or anticoagulant therapy--11 pts, contraindications for thrombolytic and/or anticoagulant treatment--5 pts, massive pe--14 pts, chronic thromboembolic-major vessel pulmonary hypertension (CTEPH)--30 pts, extensive deep vein thrombosis of lower limbs or vena cava inferior in patients with urgent indications for surgery--24 pts. Each filter placement was preceded by cavography. The diagnostic procedures (mainly ultrasonography) were performed after 3-6 and 12 months in the first year then once yearly during follow-up period. Oral anticoagulants (OA) or low-molecular-weight heparins (LMWH) were instituted in the majority of patients. 58 patients are still alive, 21 patients died. Only two non-fatal episodes of recurrent pe were documented. Other complications were rare and insignificant. We have not observed excess rate of recurrent deep venous thrombosis nor thrombosis at the filter site. The LGM IVC filters are effective and safe in such selectively chosen group of patients.

A broad spectrum of indications for low molecular weight heparin (LMWH) requires an assessment of side effects especially during prolonged administration. There are common risk factors for venous thromboembolism (VTE) and osteoporosis; heparin is "the drug of choice" for VTE treatment. The aim of our study was to assess the effect of treatment and prophylaxis with LMWH (enoxaparine sodium) and oral anticoagulant (acenocoumarol) for bone structure. Material consists of in- and outpatients. 49 densitometries were performed in 31 patients (in 15 cases double examination). We observed a decrease of bone mineral density in comparison to the initial examination in most cases: mean change of bone mass for examined areas was 3.05%.

The aim of the study was to assess effectiveness and safety of inferior vena cava filters in patients with cancer and concurrent thromboembolic disease. The LGM filters were inserted in 10 cancer patients. Diagnosis of malignancy was established prior filter placement in 8 patients and after the procedure in 2 patients. Follow-up physical examination and ultrasound procedures (Echo, Duplex-Doppler) were performed after 1, 3, 6, 12, 24 months. Mean period of observation lasted 12 month. All patients received prolonged anticoagulation either oral anticoagulants or low molecular weight heparins after filter placement. Our results confirm that the LGM filters are effective and well tolerated in patients with malignancies. There were no important complications both early and late related to filter placement and no evidence of recurrent pulmonary emboli.

We have attempted to determine the outcome of 87 out-patients who were lost from follow-up. Several factors have been assessed: causes of lost from follow-up duration of oral anticoagulation, recurrent venous thromboembolic events, cause of death (if applicable).

The analysis of 49 fatal cases of venous thromboembolism--VTE (15% of total ambulatory patients number during long observation was performed. The advanced age of patients, multiple risk factors, underlying circulatory and respiratory tract diseases, malignancies, previous episodes of VTE especially with secondary pulmonary hypertension were the most important factors determining fatal prognoses in those patients.

In 18 patients with proximal deep venous thrombosis (PDVT) confirmed by phlebography, no symptoms and signs of pulmonary embolism (PE) were observed. All patients were treated with nadroparin. During first 6 days of treatment in all patients perfusion lung scans were performed. 8 patients (44.4%) of all group developed lung scans positive for PE (silent PE). Period of successful treatment of PDVT was 10 days. No evidence of recurrent PE were observed during the period of treatment. We conclude that: 1. Frequency of silent PE in patients with PDVT is very high-lack of symptoms and signs of PE does not exclude the presence of PE in this group of patients. 2. In all patients with PDVT perfusion lung scan should be performed even in cases with no symptoms and signs of PE. 3. Low molecular weight heparins administered subcutaneously are effective in treatment either silent PE or PDVT.

43-year old woman, with considerable overweight had been admitted to Intensive Medical Care Unit with suspicion of pulmonary embolism (PE). The patient had the limb immobilized in gypsum for last several weeks. This episode was tangled with recurrent thrombosis of deep veins in the left limb, treated with heparin and oral anticoagulants irregularly without sufficient control. Taking into consideration the data of anamnesis, clinical picture and the results of ECG, chest X-ray, gasometric and echocardiographic examination we got much closer to the recognition of PE. Our suspicion of PE was confirmed by the result of pulmonary angiography. Indications for thrombolytic treatment (r-tPA) had been established. During the following hours considerable improvement of general state was observed. The therapy was continued with constant drip infusion of heparin. No prolongation of therapeutic PTT was observed. The deficit of AT III was diagnosed. In this situation the patient was given AT III to obtain normalization of its level and therapeutic extension of PTT. Therefore there were settled indications for the operation of uterus with myoma changes. As the rich thrombolytic material in the leg's vein was found the patient was implanted LGM Filter, with excellent prophylactic effect (no PE in perioperative period). The clinical course of our case enabled to present most of diagnostic, therapeutic and preventive methods applied in venous thromboembolism.

In the Department of Medicine at the Institute of Tuberculosis and Lung Diseases 50 LGM inferior vena cava filters have been inserted since 1993. Indications for filters placement were as follows: recurrent pulmonary embolism (PE) despite anticoagulation-16 patients (pts), severe bleeding complications of thrombolytic or anticoagulant therapy-9 pts, contraindications for thrombolytic and/or anticoagulant treatment-3 pts, massive PE-6 pts, chronic thromboembolic-major vessel pulmonary hypertension (CTEPH)-18 pts, extensive deep vein thrombosis of lower limbs or vena cava inferior in patients with urgent indications for surgery-10 pts. In every patient diagnostic procedures were performed after 1, 3, 6, 12, 24 and 36 months of follow-up period. Only one non-fatal episode of recurrent PE was documented. Other complications were rare and insignificant. The LGM inferior vena cava filters are effective and safe in such selectively chosen group of patients.

12 patients (7 male and 5 female) with confirmed pulmonary embolism (PE) with: angiography-5 cases, conventional contrast-enhanced CT-2 cases, echocardiography-2 cases, autopsy-3 cases were diagnosed as clinically acute PE. Criteria of clinically acute PE were: cardiac arrest-1 case-2 cases, shock-1 case, acute cor pulmonale-9 cases and acute cor pulmonale with shock. All patients were treated with heparin, administered with therapeutic prolongation of aPTT. Clinically acute PE (if possible confirmed with angiography, TC and/or echocardiography) was treated with rtPA administered in 10 minutes lasting bolus in doses 0.6-0.8 mg per kg of body weight (50 mg of rtPA during 10 minutes administered into peripheral veins). In 9 patients with pulmonary hypertension, significant decrease of tricuspidal gradient (measured echocardiographically during several hours after administration of rtPA) was documented. Improvement in PaO2, SaO2 and decrease of heart rate and respiratory rate were also achieved. No serious bleeding complications were observed after mentioned treatment. Control investigations (conventional contrast-enhanced CT and spiral CT) performed several days after rtPA administration revealed thrombus in pulmonary artery. We conclude: I rtPA administered in bolus simultaneously with heparin significantly decreased pulmonaryhypertension; rtPA administered simultaneously with heparin is safe method of treatment of PE; hemodynamic improvement after administration of rtPA is not univocal with full fibrynolitic effect.

CTEPH have not been widely recognised until recently. Introduction of the new, sophisticated, non-invasive diagnostic tools accounts for rapid progress in that field. Patients with high pulmonary hypertension have a very poor prognosis. Medical treatment (vasodilators, anticoagulants) does not change outcome. Pulmonary thromboendarterectomy is the only therapeutic option for the patients. It is essential to prevent further episodes of pulmonary embolism both over the long term and during the high risk perioperative period by means of inferior vena cava filters. In the Department of Medicine, Institute of Tuberculosis and Lung Diseases 18 LGM ivc filters have been inserted in patients with CTEPH since 1994. In 7 patients PTE was performed-in 5 cases good result was achieved, 2 patients died after surgery. In the latter group 5 patients died mainly because of severe heart failure. Only one non-fatal episode of pulmonary embolism was observed. It should be concluded that the LGM ivc filters are safe and effective in preventing episodes of pulmonary embolism in patients with CTEPH.

In 10 patients with thromboembolic disease 1 Gunther filter and 9 LGM filters were inserted. Indications for filter placement were: pulmonary hypertension caused by recurrent pulmonary embolism in 3 cases; planned surgery in 2 patients with pulmonary embolism and deep venous thrombosis; recurrent pulmonary embolism despite of anticoagulant treatment in 2 cases, previously performed thrombo-endarterectomy in 1 case; contraindications for anticoagulant treatment in 1 case and complications of anticoagulant therapy also in 1 case. No serious complications after filter placement were observed.

Case of recurrent, clinically acute massive pulmonary embolism treated with rtPA (administered 0.6 mg/kg, during 10 minutes simultaneously with heparin) is presented. Minimal clinical improvement was observed after mentioned procedure. Good clinical response was achieved after LGM filter insertion into vena cava inferior. Clinical course was complicated by Dressler-like syndrome successfully treated with steroids. Problems of massive pulmonary embolism, vena cava filter prophylaxis and pericardial complication of pulmonary embolism are discussed.

MOFS Multi-Organ-Failure-Syndrome has not been recognized until past 10 to 20 years. There are many different causes that may lead to MOFS. Recently it has become clear that MOFS is the clinical endstage of the systemic hypermetabolic response to injury that is heralded by acute lung injury and followed by hepatic and renal failure and often by death. The lung injury may range from relatively slight increase of pulmonary small vessels leakage to the adult respiratory distress syndrome (ARDS). In the first part of the following paper there are presented two clinical cases resulted in MOFS. Pathophysiology, current therapy and prophylaxis of MOFS are reviewed in the second part.

Acute massive pulmonary embolism (AMPE) is an event that places the recipient at an unusually high risk of sudden death. Among 183 patients with thromboembolic disease, AMPE has been diagnosed clinically in 58 cases (32%). Diagnostic criteria: cardiac arrest (24 cases--41%), shock (12--21%) acute cor pulmonale (ACP 15--26%) and ACP with shock (7 cases--12%). There were 33 women and 25 men aged 22-88 years in this group. In 25 patients heparin (H), in 7 streptokinase (S), in 1 tPA, in 7 S after H have been used, 26 patients (45%) survived, 32 (55%) died: there were 20 sudden deaths. Advanced underlying cardiopulmonary diseases or/and recurrent pulmonary embolism seem to be the most important predictors of fatal outcome of AMPE.

Oral anticoagulants are generally accepted as secondary prophylaxis in patients with thromboembolic disease. Long term oral anticoagulant treatment of 24 survivors of clinically acute massive pulmonary embolism (AMPE) was assessed. There were following indications for such a treatment: recurrent PE/DVT in history and/or continuous risk factors. In the group of survivors of AMPE with continuing risk factors or the recurrence of that disaster the long-term oral anticoagulant therapy is effective, relatively safe and therefore justified.

Thromboembolic pulmonary hypertension is an uncommon condition with poor prognosis. Vasodilators may be effective in some patients with that disease. The effect of nifedipine on hemodynamics was investigated in two patients with thromboembolic pulmonary hypertension treated with acenocoumarol. Nifedipine was administered in 20 mg doses hourly during right cardiac catheterization and was repeated after 1 hour until a decrease in systemic pressure occurred. Patients received 80 mg and 120 mg of nifedipine. Pulmonary artery pressures decreased in both cases. An increase of cardiac output and decrease of pulmonary vascular resistance were observed after 60-80 mg of nifedipine and continued to the end of the investigation. No effect on heart rate was observed. We suggest that high doses of nifedipine may be--in some patients--effective in reducing thromboembolic pulmonary hypertension.

Two cases of MOFS (multi-organ-failure-syndrome) are presented. Pulmonary embolism was an initial presentation in one case, acute pneumonia in the other. In both cases intensive supportive treatment including mechanical ventilation was instituted because of acute respiratory failure. Sequential dysfunction and/or failure of other organs were observed. Both patients died despite 3 and 7 weeks of intensive treatment, respectively. In both cases MOFS was confirmed by autopsy.

Controlled oxygen-therapy was used in 30 out of 49 patients (61%) with the acute respiratory failure or exacerbations of the chronic respiratory failure treated at ICU (Group Y), while artificial ventilation in the remaining 19 patients (39%; Group B). An improvement was achieved in 70% of patients of Group A and 42% in Group B. Overall improvement was achieved in 59% of the treated patients. There were 69% of treated patients with infections. Totally 41% of the treated patients died (30% of Group A and 58% of Group B). An analysis of the results has been carried out in various subgroups of the treated patients, i.e. the acute and exacerbated respiratory failure as well as partial and complete respiratory insufficiency. The result of high risk patients have also been analysed. This subgroup included sudden cardiac arrest, shock and non-compensated acidosis. Favourable effects of the intensive care of patients with infections have been discussed with particular reference to the life hazard in case of septic complications. Emphasis is on the unfavorable effects of therapy in patients with respiratory failure complicated with pulmonary embolism. Indications to the use of respirator and complications of the artificial ventilation have been discussed.

The therapeutical efficacy of CEFOBID (Pfizer) a third generation cephalosporine (natrium cephaperasone salt) was studied in 10 patients with acute respiratory infections including 6 with pneumonias. The therapeutical effect was arbitrarily judged according to the applied three point scale--"good", "satisfactory", "lack of effect". A "good" effects was seen in 6 patients, in 2 "satisfactory", in further two "lack" of effect was observed. Thus CEFOBID proved to be of beneficial effect in eight out of ten patients. One should stress that in the group that responded to treatment were all cases of pneumonia. CEFOBID was well tolerated. In this preliminary study the beneficial therapeutical effect in Gram negative opportunistic infections is stressed.