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Study design:Qualitative systematic review.Objectives:To examine the validity of the prevailing notion that pulmonary embolism (PE) is rare in the chronic spinal cord injury (SCI) population.Setting:USA.Methods:Review surveys of adult SCI subjects >2 months after injury in which PE has been looked for and its prevalence estimated.Results:A total of 16 surveys of chronic SCI subjects published between 1956 and 2009 offered data on PE prevalence. Two autopsy surveys, 178 subjects paralyzed >2 months, revealed no PE. Eleven surveys of the cause of death, 3193 subjects paralyzed 1-25 years, revealed PE in 2.1%. Two surveys of survivors of SCI, 5761 subjects paralyzed 1-25 years, revealed PE in 0.4%. Our survey of 112 subjects paralyzed 1-50 years before death, revealed PE in 21 (18.7%), based on autopsy, imaging, clinical and electrocardiographic evidence. In 7 (33%) of the 21 subjects with PE, pulmonary hypertension by transthoracic echocardiography was detected, indicating recurrent and/or unresolved PE.Conclusion:PE is not infrequent in the chronic SCI subject; but its presentation may be subclinical; and its apparent recurrence may lead to pulmonary hypertension. [ABSTRACT FROM AUTHOR]

Study design:Case report.Objectives:The aim of this report was to describe an example of pulmonary embolism (PE), recently suggested to be highly prevalent in persons with chronic spinal cord lesions.Setting:Veterans Affairs Hospital, Boston, MA, USA.Methods:Chart review.Results:A 60-year-old man with paraplegia, T10 motor complete, underwent laminectomy for correction of an arteriovenous malformation. After 41 days, he sustained a massive PE-suggested by right bundle branch block (RBBB) on an electrocardiogram (ECG) and diagnosed by perfusion lung scanning. He was treated with anticoagulants, the lung scan and RBBB resolving within 1 month of initiating treatment. After 5 years, he developed vertebral osteomyelitis at L5-S1 and was treated with antibiotics and bed rest. After 7 days, he was mobilized to a wheelchair, and during a transfer back to bed, he developed anxiety, dyspnea, fluctuating consciousness, low blood pressure and RBBB, absent by ECG 4 days earlier. He expired 20 min after onset of symptoms. The autopsy revealed a fresh thromboembolus occluding both main stem branches of the pulmonary artery.Conclusion:Massive PE after surgery in a patient with chronic paraplegia recurred 5 years later in association with severe infection and mobilization after bed rest, which resulted in death. [ABSTRACT FROM AUTHOR]

Background: In patients admitted for heart failure (HF), unrecognized elevation of left ventricular end-diastolic pressure (LVEDP) at the time of discharge may have a role in the high rehospitalization rate for HF on follow-up., Methods and Results: In a small, prospective study (n = 50), patients admitted for HF were randomized to management guided by daily noninvasive estimated LVEDP monitoring (Group I, open) to a target LVEDP of <20 mm Hg or management based on clinical assessment alone without knowledge of the estimated LVEDP (Group II, blinded). Noninvasive estimated LVEDP was measured by the VeriCor monitor, which uses the Valsalva maneuver to derive the LVEDP. The primary endpoints were the reduction of estimated LVEDP at discharge and the HF rehospitalization rate on follow-up. Estimated LVEDP was significantly reduced at discharge in the open group compared with the blinded group (mean estimated LVEDP 19.7 ± 1.3 mm Hg vs 25.6 ± 1.5 mm Hg, respectively, P = 0.01). The rehospitalization rates for HF on follow-up were significantly improved in the open group compared with the blinded group (at 1 month: 0% vs 25%, respectively [P = .05]; at 3 months: 0% vs 32% [P = .01]; at 6 months: 4% vs 36% [P = .01]; at 1 year: 16% vs 48% [P = .03])., Conclusions: When HF is managed by clinical assessment only, estimated LVEDPs remain high at discharge, resulting in early and frequent rehospitalization for HF. Therapy guided by estimated LVEDP monitoring optimizes filling pressures and reduces HF rehospitalization rates., (Copyright © 2011. Published by Elsevier Inc.)

Objectives: To evaluate right bundle branch block (RBBB) on electrocardiograms (ECGs) as a screening tool for the diagnosis of pulmonary embolism (PE) in a chronic spinal cord injury (SCI) population and to determine the prevalence of PE., Design: Retrospective analysis., Setting: Boston Veterans Affairs Healthcare System., Participants: Consecutive SCI participants (N=112) who were followed at this institution until death between 1999 and 2005 at an average age of 71 years, a duration of paralysis of 31 years, with a tetraplegic level in 62%, and no useful motor function in 84%., Intervention: Not applicable., Main Outcome Measures: PE, as a cause of RBBB, was diagnosed by autopsy, a source of thromboembolism, imaging, or other ECG signs of PE. Chronic obstructive lung disease was diagnosed by pulmonary function tests and myocardial infarction by ECG or echocardiogram., Results: Twenty-nine participants (26%) had RBBB (6 with incomplete RBBB). Evidence that PE caused RBBB was found in 21 (72%), with 4 (3 massive) found by autopsy, 4 by the presence of an embolic source, 3 by imaging, 2 by the intermittent course of RBBB, 1 by abrupt onset of RBBB before death, and 7 by other ECG signs. RBBB represented chronic obstructive lung disease or myocardial infarction in the remaining 8. The onset of RBBB occurred either within months of SCI in 5 (1 before SCI) or years after SCI in 24 (6-50y, median 32y). RBBB was constant in 27 and intermittent in 2. The duration of RBBB ranged from 20 minutes to 31 years, median 4 years., Conclusions: RBBB may be a useful initial screening test for PE complicating chronic SCI. PE, often recurrent and sometimes fatal, is prevalent in chronic SCI.

Fascicular conduction abnormalities are frequently reported following adult cardiac surgery, but their pathogenesis and long-term outcomes remain unclear. In this article, we review the epidemiological features, pathogenesis, diagnosis, and management, and the short-term and long-term significance of fascicular conduction abnormalities following coronary artery bypass graft (CABG) surgery, based on data from 30 studies. Conduction disturbances have an incidence of 3.4% to 55.8% after CABG surgery, the most common being right bundle branch block (RBBB). RBBB is usually transient and benign. Although a slew of factors have been implicated in the pathogenesis of fascicular conduction disturbances, the two most important factors are myocardial ischemia and type of cardioplegia. While a 12-lead electrocardiogram is the gold standard for diagnosis, additional tests such as myocardial enzymes or echocardiography may have additional diagnostic and prognostic value. Short-term prognosis after RBBB is good, but its impact on long-term survival is unclear. We conducted a meta-analysis, the first of its kind in this area, using long-term survival data from five studies. There was no difference in long-term survival between patients who developed conduction disturbances after CABG surgery, and those who did not, indicating a benign influence of conduction disturbances on long-term survival, and the lack of the necessity for monitoring or pacing. While the older literature reported an adverse impact of fascicular conduction disturbances on long-term survival, the more recent studies report a substantially reduced mortality after CABG surgery, despite a higher incidence of conduction disturbances, pointing to the effect of improved surgical techniques.