- Email: [email protected]
Surgical management of paradoxical embolism
106
Letters to the Editor
I˙smail Demirtas¸, MD Department of Pediatric Surgery Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine Van, Turkey Hasan Yılmaz, MD Department of Parasitology Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine Van, Turkey Serdar Ugˇ ras¸, MD Department of Pathology Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine Van, Turkey Dursun Odabas¸, MD Department of Pediatrics Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine Van, Turkey PII S0736-4679(02)00426-7
This work has been carried out in the Department of Pediatrics, Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine, Van, Turkey
REFERENCES 1. Weissman SB, Salata RA. Amebiasis. In: Behrman RE, Kliegman RM, Jenson HB, eds. Textbook of pediatrics (16th ed). Philadelphia: WB Saunders; 2000:1035– 6. 2. Strickland AD. Entamoeba histolytica. In: Feign RD, Cherry JD, eds. Textbook of pediatric infectious diseases (3rd ed). Philadelphia: WB Saunders; 1992:2003–10. 3. Chong SK, Blackshaw AJ, Morson CB, Williams CB, WalkerSmith JA. Prospective study of colitis in infancy and early childhood. J Pediatr Gastroenterol Nutr 1986;5:352– 8. 4. Ulshen M. Inflammatory bowel disease. In: Behrman RE, Kliegman RM, Jenson HB, eds. Textbook of pediatrics (16th ed). Philadelphia: WB Saunders; 2000:1150 – 8.
e Surgical Management of Paradoxical Embolism: The Vol. 19, No. 1, 2000 issue of The Journal of Emergency Medicine contains two case reports of the rare clinical condition of paradoxical embolism (1,2). The optimal treatment modality for this condition is controversial, and the choice between surgical and non-surgical treatment strategies can be difficult. The 74-year-old patient of Mirarchi et al. did not have surgical treatment because of age, a history of cardiovascular accident and chronic obstructive pulmonary disease (1). For most of these same reasons, this patient should have had surgical intervention.
We recently managed a 72-year-old man with pulmonary embolism (PE), patent foramen ovale (PFO), and paradoxical embolism. He presented with sudden onset acute central chest pain and dyspnea (NYHA grade III), having had atrial fibrillation, left-leg thrombophlebitis, and recurrent episodes of transient ischemic attacks 6 weeks previously. Past investigations had demonstrated normal carotid arteries and a 4-cm abdominal aortic aneurysm. He was obese, tachypneic (respiratory rate of 26 breaths per minute), with an oxygen saturation of 88% on room air and in atrial fibrillation. He had a blood pressure of 130/70 mm Hg, and his jugular venous pressure was not raised. An electrocardiogram confirmed atrial fibrillation with a ventricular response rate of 120 beats per minute without evidence of ischemic changes. The arterial blood gases were; PO2 of 54 mm Hg and PCO2 of 52 mm Hg, and he had a normal cardiac enzyme profile. A transthoracic and later transesophageal echocardiogram revealed a right atrial thrombus projecting through a patent foramen ovale. The cardiac valves and left ventricular function were normal. A spiral computed tomography (CT) scan showed a left PE. Intravenous heparin was commenced and emergency pulmonary and bi-atrial embolectomy was performed using cardiopulmonary bypass. The right atrium was explored, and a serpeginous embolus was found trapped in the PFO and propagating into the left atrium (Figure 1). Cardiopulmonary endoscopy was performed through the PFO and the main pulmonary artery as we have previously described (3). The PFO was closed by direct suturing. The patient made an uneventful recovery but remained in AF postoperatively. He is doing well 12 months after surgery on long-term anticoagulation and awaiting review of his abdominal aortic aneurysm. Surgical therapy should not be denied a septuagenarian with fulminant PE on the grounds of age. The decision on patient management should be based on clinical considerations. Massive PE with hemodynamic compromise (fulminant PE) is an indication for immediate surgical treatment (4,5). Unfortunately, the patient of Mirarchi et al. did not have a CT scan of the chest, but the large right atrial embolus projecting through the PFO on transesophageal echocardiography and the clinical presentation of the patient are evident of fulminant PE. The presence of an old embolic cerebral infarct on CT scan of the head should not be regarded as a contraindication to surgery. Massive PE greatly reduces the respiratory reserve by altering the ventilation/perfusion equilibrium. In a patient with chronic obstructive pulmonary disease (COPD) (with an already diminished respiratory reserve), requiring rapid intubation because of further respiratory compromise by massive PE, the best chance of respiratory recovery is the expeditious removal of the emboli. Surgery offers the most predictable means of achieving this. The addition of car-
The Journal of Emergency Medicine
107
Figure 1. Photograph of an impending paradoxical embolus taken at surgery. It demonstrates bicaval cannulation of the right atrium and the interior of the right atrium. A serpiginous embolus can be seen projecting into a patent foramen ovale.
diopulmonary endoscopy enables complete embolectomy without extensive cardiac and pulmonary incisions. Moreover, by retrieving emboli from the left ventricle, further systemic embolization and embolic cardiovascular accident are prevented. Surgical treatment for PE, with or without paradoxical embolism, is indicated when the cardiorespiratory status of the patient is severely compromised. When an embolus is projecting through the PFO (impending paradoxical embolism), emergency surgery should be performed (3,6). The decision for surgical intervention should be made early in the appropriate scenario, and treatment should not be delayed. Resort to surgery, after failed medical therapy, accounts for the high mortality that is sometimes associated with acute pulmonary embolectomy. Finally, I wish to observe that the title of the case report is misleading (1). The foramen ovale, a feature of the fetal circulation, closes anatomically in the first year of life. Anatomic persistence beyond this age occurs in 27.3%, and is not usually associated with physiological activity (7). However, alterations in the hemodynamics resulting in atrial pressure changes can
allow interatrial shunts. PE is associated with increase in right atrial pressure leading to a right-to-left shunt through the PFO. A PFO, therefore, cannot be regarded as a condition complicating PE. Dumbor Laateh Ngaage, MB, BS, FRCS, FWACS Department of Cardiothoracic Surgery Yorkshire Heart Center Leeds General Infirmary Leeds, West Yorkshire LS1 3EX UK. PII S0736-4679(01)00446-2 REFERENCES 1. Mirarchi FL, Hecker J, Kramer CM. Pulmonary embolism complicated by patent foramen ovale and paradoxical embolization. J Emerg Med 2000;19:27–30. 2. Islam MA, Khalighi K, Goldstein JE, Raso J. Paradoxical embolism—report of a case involving four organ systems. J Emerg Med 2000;19:31– 4. 3. Ngaage DL, Shah R, Sanjay SP, Cale ARJ. Cardioplumonary endoscopy: an effective and low risk method for examining the cardiopulmonary system during cardiac surgery. Eur J Cadiothorac Surg 2001;19:152–5.
108 4. Doerge H, Schoendube FA, Voss M, Seipelt R, Messmer BJ. Surgical therapy of fulminant pulmonary embolism: early and late results. Thorac Cardiovasc Surg 1999;47:9 –13. 5. Clarke DB, Abrams LD. Pulmonary embolectomy: a 25 year experience. J Thorac Cardiovasc Surg 1986;92:442–5. 6. Cheng TO. Paradoxical embolism. A diagnostic challenge and its detection during life. Circulation 1976;53:565– 8. 7. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59: 17–20.
e Dipstick Urinalysis and the Accuracy of the Clinical Diagnosis of Urinary Tract Infection The Australian evaluation of dipstick urinalysis (DU) for an accurate diagnosis of urinary tract infection in adult patients in an Emergency Department (ED) revealed DU combined with a clinical evaluation to be superior to an exclusively clinical evaluation1. A concurrent evaluation of any antimicrobial activity (AM) in urine would have been still more useful. Both bacterial counts and DU would be fallacious if there was AM in the urine. Bacteriuria is common in routine and emergency practice. Among 112 patients at an ED in Taiwan, AM was evident in 55.2% patients2. Furthermore, AM was also recorded in 25.1% of internal medicine outpatients, 7.6% of high-school students, and 7.4% of 202 people at a senior citizen center. There was no correlation between the bacterial counts and sterility of a specimen and its AM. Traces of antibiotics, numerous non-antibiotics, and therapeutic agents for non-urinary infections exert antibacterial activity in urine (Table 1). Conventionally, the residual antibacterial activity in urine is detected by seeding urine samples onto cultures of the standard strains of Bacillus stearothermophilus, Escherchia coli, and Streptococcus pyogenes4. Of course, that would be of little value to the clinician in an ED. Nevertheless, technological modifications in the existing dipstick formats to record urinary AM instantaneously should guide the clinician in this connection in the ED itself1. The exclusive assay for bacteria in urine in an individual on chemotherapy might be erroneous and misleading. If appropriate chemotherapy were initiated with very high bacterial count, the number of drug-sensitive organisms would decline rapidly. On the contrary, inadequate therapy with an antibiotic that is only partially sensitive against the bacteria would support selection of a resistant population. The outcome would not differ with an insufficient dose of an efficient chemotherapeutic. Such failures would be accompanied by an initial fall in bacterial count in urine to be followed by a subsequent rise. The gold standard for a successful outcome of therapeutic interventions in urinary tract infections should be
Letters to the Editor Table 1. Antimicrobial Activity of Non-antibiotics in Urine ● Direct antibacterial activity of non-antibiotics Resistance-reversing agents Resistance-inducing agents ● Agents with antibacterial and anti-parasitic activity Psychotropic Antihistaminic Antineoplastics Hyperbaric oxygen ● Indirect antibacterial activity Agents modifying urinary pH Modification of antibiotic pharmacokinetic parameters by non-antibiotics ● Indirect anti-infectious activity of non-antibiotics Host defense Immunity and inflammation ● Use of non-antibiotics to decrease toxicity of anti-infectious agents Source: Neuman M. The antimicrobial activity of non-antibiotics: interaction with antibiotics. APMIS 1992;30(suppl):15–23.
sterile urine with no residual AM. That could be accomplished by repeated DU rather than cultural examinations of urine during the course of treatment. When the first specimen was collected before starting chemotherapy, the subsequent samples would reveal whether therapy had been effective, partly effective, or ineffective. Alternatively, in a patient already on antibiotics, initial DU or culture would indicate if the bacteria were sensitive or resistant to that drug. Nevertheless, subsequent samples would be necessary to establish a clearance of infection. Sterile DU or cultures or exceedingly low DU readings or bacterial counts in the presence of AM can be misleading. The negative report would produce a false satisfaction. Bacterial counts lower than 104/mL are not likely to be taken seriously. False-negative reports leading to an inadvertent underprescription of antibiotics would be unfortunate. That would mislead the clinician. A sterile culture without any AM should emerge as the ultimate goal of any therapy. There is considerable morbidity and chronicity in urinary infections among patients with urogenital congenital abnormalities, prolonged in situ catheterization, frequent instrumentation, renal transplants, and immunosuppression. A DU format that would not miss AM in urine should instantly pick up any therapeutic inefficacy of chemotherapeutic agents or emergence of resistant bacteria.
Subhash C. Arya Centre for Logistical Research and Innovation New Delhi, India [email protected] PII S0736-4679(01)00447-4
Letters to the Editor
I˙smail Demirtas¸, MD Department of Pediatric Surgery Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine Van, Turkey Hasan Yılmaz, MD Department of Parasitology Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine Van, Turkey Serdar Ugˇ ras¸, MD Department of Pathology Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine Van, Turkey Dursun Odabas¸, MD Department of Pediatrics Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine Van, Turkey PII S0736-4679(02)00426-7
This work has been carried out in the Department of Pediatrics, Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine, Van, Turkey
REFERENCES 1. Weissman SB, Salata RA. Amebiasis. In: Behrman RE, Kliegman RM, Jenson HB, eds. Textbook of pediatrics (16th ed). Philadelphia: WB Saunders; 2000:1035– 6. 2. Strickland AD. Entamoeba histolytica. In: Feign RD, Cherry JD, eds. Textbook of pediatric infectious diseases (3rd ed). Philadelphia: WB Saunders; 1992:2003–10. 3. Chong SK, Blackshaw AJ, Morson CB, Williams CB, WalkerSmith JA. Prospective study of colitis in infancy and early childhood. J Pediatr Gastroenterol Nutr 1986;5:352– 8. 4. Ulshen M. Inflammatory bowel disease. In: Behrman RE, Kliegman RM, Jenson HB, eds. Textbook of pediatrics (16th ed). Philadelphia: WB Saunders; 2000:1150 – 8.
e Surgical Management of Paradoxical Embolism: The Vol. 19, No. 1, 2000 issue of The Journal of Emergency Medicine contains two case reports of the rare clinical condition of paradoxical embolism (1,2). The optimal treatment modality for this condition is controversial, and the choice between surgical and non-surgical treatment strategies can be difficult. The 74-year-old patient of Mirarchi et al. did not have surgical treatment because of age, a history of cardiovascular accident and chronic obstructive pulmonary disease (1). For most of these same reasons, this patient should have had surgical intervention.
We recently managed a 72-year-old man with pulmonary embolism (PE), patent foramen ovale (PFO), and paradoxical embolism. He presented with sudden onset acute central chest pain and dyspnea (NYHA grade III), having had atrial fibrillation, left-leg thrombophlebitis, and recurrent episodes of transient ischemic attacks 6 weeks previously. Past investigations had demonstrated normal carotid arteries and a 4-cm abdominal aortic aneurysm. He was obese, tachypneic (respiratory rate of 26 breaths per minute), with an oxygen saturation of 88% on room air and in atrial fibrillation. He had a blood pressure of 130/70 mm Hg, and his jugular venous pressure was not raised. An electrocardiogram confirmed atrial fibrillation with a ventricular response rate of 120 beats per minute without evidence of ischemic changes. The arterial blood gases were; PO2 of 54 mm Hg and PCO2 of 52 mm Hg, and he had a normal cardiac enzyme profile. A transthoracic and later transesophageal echocardiogram revealed a right atrial thrombus projecting through a patent foramen ovale. The cardiac valves and left ventricular function were normal. A spiral computed tomography (CT) scan showed a left PE. Intravenous heparin was commenced and emergency pulmonary and bi-atrial embolectomy was performed using cardiopulmonary bypass. The right atrium was explored, and a serpeginous embolus was found trapped in the PFO and propagating into the left atrium (Figure 1). Cardiopulmonary endoscopy was performed through the PFO and the main pulmonary artery as we have previously described (3). The PFO was closed by direct suturing. The patient made an uneventful recovery but remained in AF postoperatively. He is doing well 12 months after surgery on long-term anticoagulation and awaiting review of his abdominal aortic aneurysm. Surgical therapy should not be denied a septuagenarian with fulminant PE on the grounds of age. The decision on patient management should be based on clinical considerations. Massive PE with hemodynamic compromise (fulminant PE) is an indication for immediate surgical treatment (4,5). Unfortunately, the patient of Mirarchi et al. did not have a CT scan of the chest, but the large right atrial embolus projecting through the PFO on transesophageal echocardiography and the clinical presentation of the patient are evident of fulminant PE. The presence of an old embolic cerebral infarct on CT scan of the head should not be regarded as a contraindication to surgery. Massive PE greatly reduces the respiratory reserve by altering the ventilation/perfusion equilibrium. In a patient with chronic obstructive pulmonary disease (COPD) (with an already diminished respiratory reserve), requiring rapid intubation because of further respiratory compromise by massive PE, the best chance of respiratory recovery is the expeditious removal of the emboli. Surgery offers the most predictable means of achieving this. The addition of car-
The Journal of Emergency Medicine
107
Figure 1. Photograph of an impending paradoxical embolus taken at surgery. It demonstrates bicaval cannulation of the right atrium and the interior of the right atrium. A serpiginous embolus can be seen projecting into a patent foramen ovale.
diopulmonary endoscopy enables complete embolectomy without extensive cardiac and pulmonary incisions. Moreover, by retrieving emboli from the left ventricle, further systemic embolization and embolic cardiovascular accident are prevented. Surgical treatment for PE, with or without paradoxical embolism, is indicated when the cardiorespiratory status of the patient is severely compromised. When an embolus is projecting through the PFO (impending paradoxical embolism), emergency surgery should be performed (3,6). The decision for surgical intervention should be made early in the appropriate scenario, and treatment should not be delayed. Resort to surgery, after failed medical therapy, accounts for the high mortality that is sometimes associated with acute pulmonary embolectomy. Finally, I wish to observe that the title of the case report is misleading (1). The foramen ovale, a feature of the fetal circulation, closes anatomically in the first year of life. Anatomic persistence beyond this age occurs in 27.3%, and is not usually associated with physiological activity (7). However, alterations in the hemodynamics resulting in atrial pressure changes can
allow interatrial shunts. PE is associated with increase in right atrial pressure leading to a right-to-left shunt through the PFO. A PFO, therefore, cannot be regarded as a condition complicating PE. Dumbor Laateh Ngaage, MB, BS, FRCS, FWACS Department of Cardiothoracic Surgery Yorkshire Heart Center Leeds General Infirmary Leeds, West Yorkshire LS1 3EX UK. PII S0736-4679(01)00446-2 REFERENCES 1. Mirarchi FL, Hecker J, Kramer CM. Pulmonary embolism complicated by patent foramen ovale and paradoxical embolization. J Emerg Med 2000;19:27–30. 2. Islam MA, Khalighi K, Goldstein JE, Raso J. Paradoxical embolism—report of a case involving four organ systems. J Emerg Med 2000;19:31– 4. 3. Ngaage DL, Shah R, Sanjay SP, Cale ARJ. Cardioplumonary endoscopy: an effective and low risk method for examining the cardiopulmonary system during cardiac surgery. Eur J Cadiothorac Surg 2001;19:152–5.
108 4. Doerge H, Schoendube FA, Voss M, Seipelt R, Messmer BJ. Surgical therapy of fulminant pulmonary embolism: early and late results. Thorac Cardiovasc Surg 1999;47:9 –13. 5. Clarke DB, Abrams LD. Pulmonary embolectomy: a 25 year experience. J Thorac Cardiovasc Surg 1986;92:442–5. 6. Cheng TO. Paradoxical embolism. A diagnostic challenge and its detection during life. Circulation 1976;53:565– 8. 7. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59: 17–20.
e Dipstick Urinalysis and the Accuracy of the Clinical Diagnosis of Urinary Tract Infection The Australian evaluation of dipstick urinalysis (DU) for an accurate diagnosis of urinary tract infection in adult patients in an Emergency Department (ED) revealed DU combined with a clinical evaluation to be superior to an exclusively clinical evaluation1. A concurrent evaluation of any antimicrobial activity (AM) in urine would have been still more useful. Both bacterial counts and DU would be fallacious if there was AM in the urine. Bacteriuria is common in routine and emergency practice. Among 112 patients at an ED in Taiwan, AM was evident in 55.2% patients2. Furthermore, AM was also recorded in 25.1% of internal medicine outpatients, 7.6% of high-school students, and 7.4% of 202 people at a senior citizen center. There was no correlation between the bacterial counts and sterility of a specimen and its AM. Traces of antibiotics, numerous non-antibiotics, and therapeutic agents for non-urinary infections exert antibacterial activity in urine (Table 1). Conventionally, the residual antibacterial activity in urine is detected by seeding urine samples onto cultures of the standard strains of Bacillus stearothermophilus, Escherchia coli, and Streptococcus pyogenes4. Of course, that would be of little value to the clinician in an ED. Nevertheless, technological modifications in the existing dipstick formats to record urinary AM instantaneously should guide the clinician in this connection in the ED itself1. The exclusive assay for bacteria in urine in an individual on chemotherapy might be erroneous and misleading. If appropriate chemotherapy were initiated with very high bacterial count, the number of drug-sensitive organisms would decline rapidly. On the contrary, inadequate therapy with an antibiotic that is only partially sensitive against the bacteria would support selection of a resistant population. The outcome would not differ with an insufficient dose of an efficient chemotherapeutic. Such failures would be accompanied by an initial fall in bacterial count in urine to be followed by a subsequent rise. The gold standard for a successful outcome of therapeutic interventions in urinary tract infections should be
Letters to the Editor Table 1. Antimicrobial Activity of Non-antibiotics in Urine ● Direct antibacterial activity of non-antibiotics Resistance-reversing agents Resistance-inducing agents ● Agents with antibacterial and anti-parasitic activity Psychotropic Antihistaminic Antineoplastics Hyperbaric oxygen ● Indirect antibacterial activity Agents modifying urinary pH Modification of antibiotic pharmacokinetic parameters by non-antibiotics ● Indirect anti-infectious activity of non-antibiotics Host defense Immunity and inflammation ● Use of non-antibiotics to decrease toxicity of anti-infectious agents Source: Neuman M. The antimicrobial activity of non-antibiotics: interaction with antibiotics. APMIS 1992;30(suppl):15–23.
sterile urine with no residual AM. That could be accomplished by repeated DU rather than cultural examinations of urine during the course of treatment. When the first specimen was collected before starting chemotherapy, the subsequent samples would reveal whether therapy had been effective, partly effective, or ineffective. Alternatively, in a patient already on antibiotics, initial DU or culture would indicate if the bacteria were sensitive or resistant to that drug. Nevertheless, subsequent samples would be necessary to establish a clearance of infection. Sterile DU or cultures or exceedingly low DU readings or bacterial counts in the presence of AM can be misleading. The negative report would produce a false satisfaction. Bacterial counts lower than 104/mL are not likely to be taken seriously. False-negative reports leading to an inadvertent underprescription of antibiotics would be unfortunate. That would mislead the clinician. A sterile culture without any AM should emerge as the ultimate goal of any therapy. There is considerable morbidity and chronicity in urinary infections among patients with urogenital congenital abnormalities, prolonged in situ catheterization, frequent instrumentation, renal transplants, and immunosuppression. A DU format that would not miss AM in urine should instantly pick up any therapeutic inefficacy of chemotherapeutic agents or emergence of resistant bacteria.
Subhash C. Arya Centre for Logistical Research and Innovation New Delhi, India [email protected] PII S0736-4679(01)00447-4