Prognostic factors in medically treated patients with chronic pulmonary embolism.

OBJECTIVE: To evaluate risk factors in medically treated patients with chronic pulmonary embolism (CPE) who are not suitable candidates for definitive surgical therapy. STUDY DESIGN: A total of 53 consecutive patients with angiographically confirmed CPE were involved. Four patients underwent pulmonary endarterectomy, and 49 patients received continuous anticoagulation therapy and were followed up over an average period of 18.7 months (range, 6 to 72 months). RESULTS: Sixteen patients died during the follow-up period, mostly from progressive right ventricle failure. Among the nonsurvivors, 12.5% had distal CPE and 87.5% had proximal CPE (p = 0.03). The survivors had a higher (mean +/- SD) level of PaO(2) (59.3 +/- 11 mm Hg) than the nonsurvivors (50.8 +/- 9 mm Hg; p = 0.02), a lower mean pulmonary artery pressure (mPAP; 30.3 +/- 15 mm Hg vs 51 +/- 21 mm Hg; p = 0.0004), a lower hematocrit value (40.0 +/- 6 vs 44.2 +/- 6; p = 0.03), and better exercise tolerance (4.8 +/- 3 multiples of resting O(2) consumption [METs] vs 2.5 +/- 1 METs; p = 0.02) achieved during the maximal symptom-limited exercise. The patients with coexisting COPD had a higher mortality rate (62.5%) than those without COPD (37.5%; p = 0.04). Independent risk factors in the Cox analysis were as follows: mPAP (p = 0.04), exercise tolerance (p = 0.02), and COPD (p = 0.04). In the Kaplan-Meier analysis, the patient group with lower mortality achieved > 2 METs (p = 0.02) and had mPAP < 30 mm Hg (p = 0.04). CONCLUSION: The prognosis for the medically treated CPE patients, particularly those with pulmonary hypertension, was unfavorable. The prognostic factors for these patients were mPAP, coexistence of COPD, and severe exercise intolerance.

[Diagnosis of chronic pulmonary embolism in patients with advanced chronic obstructive pulmonary disease]. / Rozpoznawanie przewleklej zatorowosci plucnej u chorych z zaawansowana POCHP.

The coexistence of chronic obstructive pulmonary disease (COPD) and chronic pulmonary embolism (PE) worsens prognosis and requires complex therapeutic procedures. However, the diagnosis COPD + PE is difficult because of similar clinical symptomatology. Pulmonary angiography was performed in 20 patients aged 60.9 (37-75) years with COPD and with clinical suspicion of chronic pulmonary embolism (PE). Of 13 patients with PE 8 had proximal PE and in 5 patients peripheral PE was found. Both groups of patients did not differ with regard to their age 60.2 +/- 7 vs 59 +/- 10 years (NS), FEV1 0.9 +/- 0.3 vs 1.1 +/- 0.4 l (NS) as well as platelet cells count, fibrinogen, hematocrit and hemoglobin. Patients with COPD + PE compared to patients with COPD had higher pH 7.38 +/- 0.05 vs 7.32 +/- 0.03 (p = 0.01), and tendency to lower PaCO2 44.3 +/- 12 vs 52.0 +/- 7 mmHg(NS), and higher mean pulmonary artery pressure 48 +/- 17 vs 36.3 +/- 9 mmHg(NS). Patients with COPD+ proximal PE compared to COPD patients had higher pH 7.4 +/- 0.05 vs 7.3 +/- 0.03 (p = 0.004) and lower paCO2 39.6 +/- 10 vs 52 +/- 7 mmHg (p = 0.03).

[Value of classical and new criteria of electrocardiography in diagnosis of hypoxic cor pulmonale evaluated by hemodynamics tests]. / Wartosc klasycznych i nowych kryteriów elektrokardiograficznych rozpoznawania hipoksyjnego serca plucnego oceniana badaniami hemodynamicznymi.

Electrocardiogram is commonly used in the diagnosis of cor pulmonale in patients with chronic obstructive pulmonary disease (COPD). Pulmonary hemodynamics being the definite method for diagnosis the disease can be used to vary the ecg criteria for diagnosis cor pulmonale. After excluding patients with old myocardial infarction and with pulmonary wedge pressure > 12 mm Hg in 66 patients aged 65.2 with advanced COPD (FEV1 0.78 +/- 0.3 litre) pulmonary hemodynamics and ecg were performed at the same time. The signs of right ventricular hypertrophy were sought for using 3 sets of criteria: the World Health Organisation criteria, new compiled Lehtonen et al. Criteria and right ventricular precordial leads. WHO criteria had a specificity and sensitivity of 50% and 57.6%, the modified right precordial leads-53% and 64.5% and compiled Lehtonen's criteria -57% and 59% respectively. In 32 patients with mild pulmonary hypertension (20-29 mm Hg) sensitivity of WHO criteria was 46.8%, right precordial leads -51.6%, and Lethonen and co. Criteria -50%, in 10 patients with moderate pulmonary hypertension (30-39 mm Hg) 59%-62.5%-50%, in 9 patients with severe hypertension (> or = 40 mm Hg) 100%-100%-100% respectively. Our studies confirm the poor sensitivity and of ecg criteria for diagnosis of cor pulmonale (pulmonary hypertension) in COPD. However, in mild and moderate pulmonary hypertension, sensitivity of ecg diagnosis of cor pulmonale is improved if right modifieds precordial leads are used. New, compiled Lehtonen's criteria failed to improved diagnosis of diagnosis of cor pulmonale. All studied sets of criteria are highly sensitive in COPD patients with severe pulmonary hypertension.

[Effect of acute exercise on cardiac arrhythmias in the course of chronic obstructive pulmonary disease]. / Wplyw ostrego wysilku na niemiarowosc serca w przewleklej obturacyjnej chorobie pluc.

It is suggested that ventricular arrhythmias may be the reason of sudden death in stable patients with COPD. Strenuous effort might provoke danger ventricular arrhythmias in those patients. The impact of maximal exercise test on cardiac ventricular arrhythmias was studied in 24 patients with advanced chronic obstructive pulmonary disease (COPD). The treadmill, self limited exercise test according to Bruce protocol and accompanied by pulse oximetry was performed during 24 hour Holter monitoring. We found ventricular extrasystoles in all patients, in an average 492 +/- 770, complex ventricular extrasystoles in 17 patients and nonsustained ventricular tachycardia in 8 patients. 81% of all ventricular extrasystoles, 80% complex ventricular extrasystoles and 70% nonsustained ventricular tachycardia occurred during the test and up to 2 hour after the test. Patients with complex ventricular arrhythmias were younger and mostly achieved more MET during exercise, but they did not differ in advancing of COPD as measured by spirometry, gas measurements and echocardiography. Although maximal exercise test enhances ventricular arrhythmias it produced no sustained, symptomatic ventricular arrhythmias in patients with advanced and stable COPD.

[Constrictive pericarditis in a patient following prosthetic aortic valve replacement caused by postpericardiotomy syndrome]. / Zaciskajace zapalenie osierdzia u chorego po wszczepieniu sztucznej zastawki aortalnej powiklanym zespolem po perikardiotomii.

A case of a 53-year old man is presented who developed postpericardiotomy syndrome and subsequently constrictive pericarditis following prosthetic aortic valve replacement due to severe aortic stenosis. The diagnosis was based on clinical picture and confirmed invasively. Nearly total excision of thickened fibrous pericardium resulted in a slow but full disappearance of constriction signs.

[Chronic thromboembolic pulmonary hypertension--observation of personal case reports]. / Nadcisnienie plucne na tle przewleklej zatorowosci do duzych naczyn plucnych--obserwacja wlasnych przypadków.

The clinical picture, differential diagnosis and prognosis in chronic thromboembolic pulmonary hypertension (CTEPH) is being discussed on the basis of a dozen of the authors' cases. The clinical course of CTEPH in 2 patients fulfilling the main criterium for pulmonary thromboendarterectomy and undergoing one year anticoagulation is examined. As a result patient with one large pulmonary vessel occlusion (a. lobaris superior sinistra) improved his clinical status as well as hemodynamic and echocardiographic outcome. In patient with multivessel pulmonary occlusion gradual clinical aggravation and hemodynamic-echocardiographic progression of CTEPH was observed.

[Chronic obstructive lung disease: does accompanying arrhythmia have any clinical significance?]. / Przewlekla obturacyjna choroba pluc. Czy towarzyszaca arytmia ma znaczenie kliniczne?

Clinical significance of cardiac arrhythmias in patients with advanced and stable chronic obstructive pulmonary disease was assessed 22-24 hour Holter monitoring revealed supraventricular and ventricular arrhythmias in all 65 patients. There was a great variation of arrhythmia quality and quantity in the study group. Among others, 1808 complex ventricular extrasystoles in 33 patients and 302 episodes of nonsustained ventricular tachycardia in 19 patients were recorded. No sustained symptomatic ventricular arrhythmias were observed. We found no correlation between the intensity of ventricular and supraventricular extrasystoles and clinical parameters as assessed by echocardiography, spirometry and gasometry. However, patients with complex ventricular arrhythmias had larger right ventricular diameter in echocardiography. Of 65 studied patients, 14 (21%) died during follow-up ranging from 1 month to 3.2 years, mean 12.2 months. Two outpatients died suddenly. These 14 patients had larger right ventricle and left atrial dimension, more pronounced PaO2 decrease as well as lowered FEV1 as compared to the survivors. No differences in the incidence of cardiac arrhythmias were noted. Summarizing, despite the great prevalence of cardiac arrhythmias in patients with advanced stable COPD we found no life-threatening ventricular arrhythmias during approximately 1500 hours of holter monitoring. Cardiac arrhythmias seem not to influence the prognosis in these patients.

[Enalapril improves hemodynamics and exercise tolerance in pulmonary heart disease caused by obstructive lung disease]. / Enalapril poprawia hemodynamike i tolerancje wysilku w zespole plucno-sercowym spowodowanym przewlekla obturacyjna choroba pluc.

Chronic enalapril therapy was assessed in 11 patients with cor pulmonale due to chronic obstructive pulmonary disease. Enalapril was added to the maintenance dose of diuretics and digitalis and when clinical stabilisation was achieved haemodynamics, spirometry, blood gases and maximal treadmill exercise test accompanied by +pulse oximetry were performed before and after 30 days, 10-20 mg a day, enalapril therapy. Haemodynamic study showed moderate but significant decrease in mean pulmonary artery pressure, from 24 +/- 3 to 21 +/- 5 mmHg (p = 0.05). There were no substantial differences in cardiac output as well as in blood gases and spirometry after enalapril therapy. Slight decrease in oxygen delivery, on an average from 9157 +/- 3808 to 8074 +/- 3574 (p = NS), was accompanied by a concomitant fall in haemoglobin. We noted significant improvement of maximal exercise test results after enalapril therapy. Maximal workload achieved and the time of exercise increased. It was accompanied by subjective improvement as assessed by Borg scale. We observed no adverse effects of enalapril during one month therapy in patients with cor pulmonale and COPD.

[Respiratory rehabilitation of patients with chronic obstructive lung diseases in the subjective and objective evaluation]. / Rehabilitacja oddechowa u chorych z przewlekla obturacyjna choroba pluc w ocenie subiektywnej i obiektywnej.

An intensive 14 day respiratory rehabilitation program was carried out in 24 COPD patients of mean age 66.0 +/- 10.0 yrs (FVC 1.56 +/- 0.52 L, FEV1 0.94 +/- 0.4 L/s). A statistically objective improvement was seen measured by the 100 meter tread mill test (p = 0.001) which was not seen in spirometric analysis. Seventeen patients reported a subjective improvement in their clinical state. The authors have demonstrated usefulness of the 100 meter walk test in analysis of rehabilitation processes.

[Clinical and hemodynamic evaluation of 6-week treatment of pulmonary hypertension in chronic obstructive lung diseases (COLD) with low dose of prazosin]. / Kliniczna i hemodynamiczna ocena 6 tygodniowego leczenia nadcisnienia plucnego wystepujacego w przebiegu przewleklej obturacyjnej choroby pluc (p.o.ch.p.) niewielka dawka prazosyny.

The value of vasodilatatory treatment of pulmonary hypertension due to chronic obturative pulmonary disease (c.o.p.d.) is still controversial. However in patients with c.o.p.d. causal treatment as well as chronic domestic oxygen therapy have a wide range of limitations. Among vasodilator alpha-1 blockers show less vasodilator-related adverse effects, and as known from acute trials they exert a potent effect on pulmonary circulation in patients with pulmonary hypertension and c.o.p.d. Prazosin was studied in 11 patients (10 men, 1 women) aged 63 +/- 7 years with advanced c.o.p.d. (FVC 1.8 +/- 0.41, FEV1 0.99 +/- 0.55 l) (s) after their clinical stabilisation. In 4 of them prazosin was added to the maintenance dose of diuretics and digitalis. Subjective status, NYHA functional class, spirometric (FVC, FEV1) and gaseous (PaO2, PCO2) parameters, weight, systemic blood pressure, and heart rate were noted. During Swan-Ganz catheterization mean pulmonary artery pressure (MPAP), right ventricular end-diastolic pressure (RVEDP), pulmonary wedge pressure (PCWP), cardiac output (CO), systemic (SVR) and pulmonary (PVR) vascular resistance were measured. The acute trial with 1 mg prazosin taken orally was followed by 2- and 6-week of 3 mg prazosin treatment assessment. After a single dose of 1 mg prazosin there was a significant decrease in MPAP from 36 +/- 9 to 28 +/- 10 (p = 0.001) and 44% decrease in RVEDP (p = 0.05). CO increased by 16% (p = 0.01). The fall in PVR (30%, p = 0.01) exceeded that in SVR (17%, NS). No adverse effects were observed. During 2-week 3 mg a day prazosin therapy 2 patients were excluded following dyspnea and systemic hypotonia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Giant thrombus of mitral valve prosthesis diagnosed by two-dimensional and Doppler echocardiography and confirmed by autopsy]. / Rozpoznany echokardigrafia dwuwymiarowa i dopplerowska, potwierdzony sekcyjnie ogromny zakrzep sztucznej zastawki mitralnej.

Authors presented intravitally diagnosed and well echocardiographically supplied documentary evidence for a huge thrombus positioned in the left atrioventricular ostium in a 52 years old woman within two months of Björk-Shiley mitral valve replacement because of a mitral valve disease.