ABSTRACT
The case of a 56 year-old male with acute lymphoid leukemia and no signs of activity for the last four months is reported. He presented with superior vena cava thrombosis caused by a Hickman catheter, and had positive blood cultures for Candida albicans and Staphylococcus epidermidis. Despite adequate antimicrobial therapy, the fever persisted, and the patient was submitted to surgical thrombectomy. One week following the procedure, the fever returned, and thrombosis of the superior vena cava extending to the right atrium was identified by transesophageal echocardiography (TEE). The patient underwent thrombolytic therapy with streptokinase, and no thrombus could be identified in the control TEE. No hemorrhagic or thromboembolic complication occurred. The patient was discharged with oral anticoagulation.
Subject(s)
Humans , Male , Middle Aged , Streptokinase , Fibrinolytic Agents/therapeutic use , Superior Vena Cava Syndrome/drug therapy , Catheters, Indwelling , Thrombectomy , Echocardiography, Transesophageal , Remission Induction , Superior Vena Cava Syndrome/etiology , Superior Vena Cava Syndrome/surgery , Superior Vena Cava SyndromeABSTRACT
PURPOSE--To evaluate pre and post-hemodynamic changes after thrombolytic therapy in patients with acute pulmonary embolism with multiple pulmonary segments compromised. METHODS--Nine patients, 5 females, aged between 27 and 83 (mean 62 +/- 16) years, with the onset of symptoms preceding 7 days, were submitted to thrombolytic therapy, administered after baseline perfusion-ventilation lung scan, echodopplercardiography (ECO) and hemodynamic measurements with a Swan-Ganz thermodilution catheter. The same procedures were done after the thrombolytic infusion. Streptokinase (SK) was used in 7 (78) cases and recombinant human tissue-type plasminogen activator (rt-PA, alteplase) in 2 with the following doses: SK-250,000 i.u. infusion over 30 min, then 100,000 i.v/h over 24 to 72 h and rt-PA-20 mg in bolus infusion, then 80 mg over 6 h. Thrombolytic was infused in pulmonary artery trunk in 8 (88) cases and a peripheral vein in 1 (12) case, until mean pulmonary artery pressure (PAP) reached 20 mmHg. All patients received i.v. heparin and oral anticoagulation after thrombolytic therapy. RESULTS--A significant (p < 0.05) decrease in right atrial pressure (12 +/- 3 vs 8 +/- 2 mmHg), PAP (32 +/- 5 vs 19 +/- 2 mmHg), pulmonary vascular resistance (397 +/- 125 vs 87 +/- 24 dyne.s/cm5) and increase in cardiac output (3.4 +/- 0.5 vs 5.5 +/- 1.0 l/min) and stroke volume (30 +/- 5 vs 57 +/- 10 ml/beat) were observed after thrombolytic infusion. Two patients died as a result of pulmonary infection unrelated to the embolic event or thrombolysis. Minor bleeding complications occurred in two cases and major in one patient with orthopedic prosthesis. CONCLUSION--Thrombolytic therapy exert desirable effects on hemodynamic abnormalities, achieving lungs scan and ECO improvement in patients with acute pulmonary embolism.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Pulmonary Embolism , Fibrinolytic Agents/therapeutic use , Hemodynamics/drug effects , Thrombolytic Therapy , Pulmonary Embolism , Aged, 80 and over , Catheterization, Swan-Ganz , Echocardiography, Doppler , Electrocardiography , Femoral Vein , Acute DiseaseABSTRACT
Three patients, two females, ages ranging from 62 to 78 years were studied, evolving with hypotension, acute pulmonary edema and cardiogenic shock. One had anterior myocardial infarction, and in two, infero-posterior. Due to severe hemodynamic instability and necessity of vasoactive drug therapy to maintain adequate arterial pressure, coronary angiography was performed in two, showing total occlusion of the circumflex artery and severe mitral regurgitation. In one case, angioplasty on the circumflex artery was successfully achieved. No hemodynamic improvement was observed, however. Doppler echocardiography depicted mild to moderate mitral regurgitation in the three cases. Transesophageal echo confirmed the clinical suspicion of papillary muscle rupture: total rupture of antero-lateral papillary muscle in one patient, as well as total and partial rupture of the postero-medial papillary muscle in the other two patients. Two patients were submitted to mitral valve replacement, and the surgical findings confirmed the transesophageal echo conclusions. One of them died in the immediate pos-operative period, whereas the other was discharged from the hospital and is doing well. The third patient died before operation. Differential diagnosis of acute mitral regurgitation due to papillary muscle dysfunction or rupture was not possible by left ventriculography or by transthoracic echo. Transesophageal echo was the only exam to clearly confirm papillary muscle rupture, as should be done promptly after clinical suspicion of this severe condition arises
Subject(s)
Humans , Male , Female , Middle Aged , Echocardiography, Doppler , Echocardiography, Transesophageal , Papillary Muscles , Heart Rupture, Post-Infarction , Diagnosis, Differential , Mitral Valve Insufficiency/etiology , Heart Rupture, Post-Infarction/complicationsABSTRACT
Mulher de 17 anos com prolapso de valvas mitral e tricúspide com sinais de degeneraçäo mixomatosa apresentou infecçäo puerperal por Staphylococcus aureus, com sepse e múltiplas embolias sépticas (órbita e globo ocular direitos, polegar esquerdo, baço, flegmäo em gastrocnêmio esquerdo), resultando histerectomia total dno 10§ dia pós-parto e enucleaçäo do globo ocular direito no 16§. Foram diagnosticadas endocardite infecciosa e insuficiência mitral aguda e realizada substituiçäo mitral no 13§ dia pós-parto, ocorrendo bloqueio átrio-ventricular total (BAVT) - necessitando de utilizaçäo de estimulaçäo artificial temporária - no 14§ dia pós-parto, bem como endocardite e insuficiência na tricúspide no 46§ dia pós-parto. A paciente recebeu alta no 62§ dia pós-parto em boas condiçöes clínicas, após término da antibioticoterapia
A 17-year-old woman with mitral and tricuspid valve prolapse and mizomatous degeneration presented puerperal infection by Staphylococcus aureus with clinical picture of sepsis and multiple septic embolism (right eye, left thumb, spleen, and left calf). She underwent total hysterectomy on the 10th day postdelivery and right eye enucleation on the 16th. Temporary total AV block occurred on the 14th day with temporary external pacing during the next couple of days. Acute endocarditis with acute mitral regurgitation was diagnosed on the 13th day, demanding immediate valve replacement. On the 46th day she developed moderate tricuspid valve regurgitation due to another episode of endocarditis. Final clinical discharge took place on the 62nd day after antibiotic therapy completion.