Surgical embolectomy for high-risk acute pulmonary embolism is standard therapy.

OBJECTIVES: Acute massive pulmonary embolism (AMPE) is a life-threatening condition that often induces rapid haemodynamic deterioration. The mortality of surgical embolectomy is still poor in patients with preoperative cardiopulmonary arrest (CPA). We analysed the outcome of surgical pulmonary embolectomy for haemodynamically unstable patients. METHODS: Thirty-one patients underwent surgical embolectomy for haemodynamically unstable AMPE. The indications for surgical embolectomy were (i) <7 days from onset, (ii) haemodynamically unstable, (iii) massive clots in bilateral pulmonary arteries or unilateral pulmonary artery occlusion with a floating clot in the main pulmonary artery or right atrium and (iv) right ventricular dilatation in transthoracic echocardiography. Eight (25.8%) patients had cardiopulmonary arrest. Nine (29.0%) patients received preoperative percutaneous cardiopulmonary support (PCPS). The mean original Pulmonary Embolism Severity Index (PESI) and simplified PESI scores were 158 ± 51 and 2.4 ± 0.9, respectively. RESULTS: The hospital mortality rate was 12.9% (n = 4). Two patients died of hypoxia. Multiorgan failure occurred by sepsis and by right ventricular failure in 1 patient each. No hospital deaths occurred in patients with preoperative PCPS (n = 9). The mean follow-up period was 47.7 ± 35.9 months (range, 3 - 134 months) and the 5-year survival rate was 83.2 ± 6.9%. Postoperative pulmonary artery pressure significantly decreased from 52.7 to 25.8 mmHg. CONCLUSIONS: Surgical embolectomy for high-risk AMPE patients has an excellent operative mortality and long-term outcome. Preoperative PCPS may lead to an immediate stable haemodynamic state and improve surgical embolectomy results, especially in high-risk patients (e.g. those with preoperative CPA). Surgical embolectomy for AMPE is an established operation and considered as the first-line therapy.

[Beating mitral valve surgery in patients with poor left ventricular function].

Mitral valve surgery is usually performed under the arrested heart condition. However, cardioplegic arrest techniques will inevitably produce some degree of reperfusion injury. We expected that keeping heart beating decrease the reperfusion injury in patients with poor left ventricular function. The present study compared the results of beating heart technique and conventional mitral valve surgery to demonstrate the merit of this technique. Thirty six patients with low left ventricular function[ ejection fraction (EF)≤35%] who underwent mitral valve surgery between April 2004 and July 2012 were enrolled in this study. On-pump beating mitral valve surgery were performed in 21 patients (beating group). Fifteen patients underwent conventional mitral valve surgery with cardiac arrest using blood cardioplegia (arrest group). Postoperative cardiac events in the beating group were less than that in the arrest group. However, this difference in both groups was not statistically significant. The visual field of the beating heart was equal to that of conventional surgery, and technical accuracy was not compromised. To decrease postoperative cardiac events, beating-heart mitral valve surgery may be suitable surgical option for patients with poor left ventricular function.

Evaluation of percutaneous endoscopic gastrostomy in elderly patients with silicosis and co-morbidities.

To clarify the indications and usefulness of Percutaneous endoscopic gastrostomy (PEG) in patients with Silicosis and some co-morbidities, we analyzed eight cases of silicosis, who suffered from dysphagia and had received a PEG for tube feeding during the period from 1998 to 2002. The characteristics, and clinical course, of each case were statistically analyzed before and during PEG usage. All cases were bed-ridden males, with a mean age of 80 years. The profusion rate (PR) grade of silicosis was for five cases in category 2, and for three cases in category 4. Most of the co-morbidities were dementia (five cases), and chronic heart failure (four cases). There were no significant improvements in the measured nutrition criteria (albumin, lymphocytes) nor in respiratory function (arterial O2) between before and during PEG usage. Tube feeding through the PEG was not performed in three cases because of repeated aspiration pneumonia. The mean duration of PEG usage was 9 months, ranging from 5 to 20 months. Five cases died of the co-morbidities. Furthermore, there was significant deterioration in the bacteriological data (p = 0.001), suggesting a worsening of the swallowing disturbances during PEG usage, or the emergence of more resistant organisms as a result of empirical antibiotic therapy. The present results suggest that the indications of PEG in cases of severe chronic obstructive pulmonary disease (COPD) such as silicosis, associated with other morbidities, and with dysphagia, are somewhat limited. The patient's general condition should be an important factor in deciding whether or not this technique should be used.

Treatment of secondary spontaneous pneumothorax complicating silicosis and progressive massive fibrosis.

To clarify the management and treatment for the refractory cases of secondary spontaneous pneumothorax (SSP), we analyzed the clinical features in SSP complicating three cases of advanced silicosis, and discussed the available treatment. All three cases were males of age ranging from 60 to 70 years, and had silicosis with massive progressive fibrosis (PMF), classified as type 4 (PR4) according to the ILO guidelines. There was no correlation between the onset of SSP and the smoking habit, or the duration of the occupational exposure to silica. In a total of ten episodes of SSP, a refractory episode occurred in each of the three patients. No surgical treatment was possible because of some complications. Therefore, we administered conservative treatments under mechanical ventilation. The conservative treatments used were tube drainage with suction in each episode and pleurodesis by the combination of minocycline and OK-432 in one case. Approximately one month was the average time required for the air leak cessation. A significant decline in arterial oxygen tension (PaO2) was observed after the treatment of one case, suggesting further respiratory deterioration. These results imply that the more aggressive treatments for refractory SSP should be limited because of the patient status and progression. More information might be required before performing these options safely and effectively.