Right-heart pulmonary emboli-in-transit

Volume Number

124 6

Letters to the Editor

of a calf pericardium mitral valve. In as much as this case was published after our report was submitted for publication, it eluded our literature search. We do not believe that the mechanism by which valve area is increased after valvuloplasty of bioprosthetic valves is leaflet tearing and fracturing as those investigators indicated. Such a mechanism would not result in the remarkable generalized increase in valve mobility observed after valvuloplasty. Also mitral regurgitation would invariably result from leaflet tears and fractures, and this has not been universally observed after valvuloplasty of bioprosthetic mitral valves. Mitral valve obstruction develops in only a few patients with degeneration of mitral bioprosthetic valves. In these patients, commissural fusion is seen and valvuloplasty is successful. Another possible contributing factor in mitral obstruction is gradually increasing rigidity and stiffness of the leaflets. Here valvuloplasty may stretch and increase the flexibility and mobility of the valve leaflets. It is not certain whether in vitro studies in which valves are stored and preserved for long periods of time, as in the report cited by Drs. Chandra bose Reddy and Ziady,’ relate to the clinical situation. Nonetheless, two of the eight valves included in that report had commissural fusion and apparently responded to balloon dilatation with commissural splitting. Recently Waller et al.’ also described in vitro results of valvuloplasty in porcine bioprosthetic valves. In 18 stenotic valves, commissural splitting was the mechanism by which stenosis was relieved. In only three of these valves major cuspal fractures and fragmentation occurred. Finally, we agree that long-term clinical observation of this important invasive procedure is warranted. Richard

D. Spellberg, MD Guy 5’. Mayeda, MD Julio N. Flores, MD 1045 Atlantic Ave., Suite 912 Long Beach, CA 90813 REFERENCES

1. Velasco LM, Vasquez RV, Acosta JL, et al. Valvuloplasty with ballooncatheter in biologic protheses. Reality or illusion. Arch Inst Cardiol Mex 1989;59:69-71. 2. Waller BF, McKay C, Van Tassel J, Allen M. Catheter balloon valvuloplasty of stenotic porcine bioprosthetic valve. Part Il. Mechanisms, complications and recommendations for clinical use. Clin Cardiol 1991:14:765-72.

while awaiting unnecessary additional investigations and planned surgery. Immediate cardiopulmonary bypass and removal of the clot from the right side of the heart and the pulmonary artery are in order. When pulmonary embolism is suspected, two-dimensional echocardiography may be the most expedient and economical method of establishing a diagnosis. Any delay in treatment might be disastrous for the patient. Michael Shechtcr, MD The Heart Institute Sheba Medical Center Sackler Faculty of Medicine

Tel-Auiu Tel-Hashomer

University 52621,

Israel

REFERENCES

1. Redberg RF, Hecht SR, Berger M. Echocardiographic detection of transient right heart thrombus: now you see it, now you don’t. Al\i~ HEART J 1991;122:862-3. 2. Farfel Z, Shechter M, Vered Z, Rath S, Goor D, Gafni J. Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management. AM H~~~~J1987;113:171-8. 4/8/41816

REPLY To the Editor:

I appreciate Dr. Shechter’s confirmation of our conclusion that right-heart thrombus detected by two-dimensional echocardiography requires immediate treatment because it identifies a lifethreatening situation. His group wrote one of several excellent case reports and reviews of the literature that we studied, and they all came to similar conclusions.‘-‘j However, before our report no study had been able to document the transit time of a right-heart thromhus from the peripheral to the pulmonary circulation. We were surprised at the very rapid transit time (25 minutes) in the case we observed. We believe that this additional information of very rapid transit times of right-heart thrombi emphasizes the need for urgent therapy when they are visualized by two-dimensional echocardiography.

4/8/4181!5

Rita F. Redberg, MD Laboratory, M342A Division of Cardiology San Francisco, Medical Center San Francisco, CA 94143-0214

Echocardiography University

RIGHT-HEART TRANSIT

1663

PULMONARY

EMBOLI-IN-

To the Editor:

I refer to the article by Redberg et al.’ in a recent issue of the JOURNAL. In 1987 a report from Sheba Medical Center was published discussing echocardiographically diagnosed right-heart entrapment of pulmonary emboli-in-transit with emphasis on management.2 We had previously stated that two-dimensional echocardiography is a noninvasive technique that allows detection of large thromboemboli at a critical moment in their evolution while they are traversing the right-heart chambers en route to the pulmonary arteries. The echocardiographic picture of entrapped thromboemboli seems highly specific and identifies patients in a precarious, life-threatening situation. We then concluded that several patients died after two-dimensional echocardiography

of California,

REFERENCES

1. Farfel Z, Sheeter M, Vered Z, Rath S, Goor D, Gafni J. Review of echocardiographicallv diagnosed right heart entraoment of pulmonary emboli-in-transit with emphasis on management. AM HEART J 1987;113:171-8. 2. Crowell RH, Adams GS, Koilpallai CJ, NcNutt EJ, Montague TJ. In vivo right heart thrombus: precursor of life-threatening pulmonary embolism. Chest 1988;94:1236-9. 3. Kumar A, Rose SJ, Reid CL, Perera PF, Michael TA, Chandraratna AN. Echocardiographic demonstration of pulmonary embolism as it evolves through the right heart chambers. Am J Med 1985;79:538-40. 4. Torbicki A, Pasierski T, Uchman B, Miskiewicz A. Right atria1 mobile thromboemboli: two dimensional echocardiographic . diagnosis and clinical outcome. Cor Vasa 1987;29:293-303. 5. Saner HE, Asinger RW, Daniel JA, Elsperger KJ. Two dimensional echocardiographic detection of right sided car-