Abhijat Sheth

Thrombolysis for massive pulmonary embolism in pregnancy - A report of three cases and follow up over a two year period

We read with interest the recent literature review submitted by te Raa et al regarding treatment options in massive pulmonary embolism during pregnancy [1]. As highlighted venous thromboembolism is a leading cause ofmaternal mortality in the UK [2]. Treatment options for pregnant patients that develop pulmonary embolism are often considered high risk with possible effects to both mother and foetus. We describe our total experience of thrombolysis for the treatment of massive PE in pregnancy over the last 5 years.

A retrospective review to evaluate the safety of right heart catheterization via the internal jugular vein in the assessment of pulmonary hypertension.

Right heart catheterization (RHC) is important in the evaluation of pulmonary hypertension, but is not without risk.

Successful Endobronchial Seal of Surgical Bronchopleural Fistulas Using BioGlue

Postoperative bronchopleural fistula is uncommon, but it is associated with a high mortality and morbidity, and a prolonged hospital stay. Surgical treatment is gold standard, but it can prove challenging especially in the presence of infection. We describe three cases of bronchopleural fistula that developed after surgery for lung cancer in 1 patient and for bronchiectasis in 2 patients. All were successfully treated endoscopically by direct application of albumin-glutaraldehyde tissue adhesive (BioGlue; Cryolife Inc, Kennesaw, GA) through a rigid bronchoscope. Complete resolution was obtained in each patient within 24 hours.

Removal of Long-Term Tracheal Stents With Excellent Tracheal Healing

Covered metallic endobronchial stents are increasingly used in the management of diverse large airway pathology and once deployed they are considered permanent. Long-term complications of stent fracture and airway granulation tissue formation may necessitate stent removal. We describe successful endoscopic removal of the Ultraflex expandable tracheal metallic stents (Microvasive; Boston Scientific, Natick, MA) in 5 patients at 105, 84, 50, 38, and 21 months after deployment, with excellent tracheal healing and clearance of granulation tissue noted at 6 weeks after removal in each patient.

Sildenafil therapy in secondary pulmonary hypertension: Is there benefit in prolonged use?

BACKGROUND Sildenafil is of benefit to selected patients with pulmonary hypertension due to parenchymal lung or cardiac disease. We present data from patients with secondary pulmonary hypertension, comparing their right heart catheter results and six minute walking distance to time on treatment. METHODS 25 patients with symptomatic secondary pulmonary hypertension received sildenafil 50 mg tds in a 5-year period. Underlying causes were chronic inoperable thromboembolic disease (11), COPD (6), interstitial lung disease (5) and valvular heart disease (3). Their cardio-pulmonary haemodynamics were measured with right heart catheterization prior to treatment, post-treatment at 2, 6 and 12 months and subsequently depending upon clinical need. Six-minute walk distance was also measured. RESULTS Patient age range was 40 to 83 (median 70.5) years. Time of treatment to latest right heart catheter was 2 to 60 (median 17) months and 8 to 61 (median 34) months to clinic follow-up or death. There was a significant reduction in six-minute walk distance from baseline to long term (>12 months) follow-up (p=0.002). Pulmonary vascular resistance was significantly reduced from baseline to 12 months (p=0.049). The mean pulmonary arterial (PA) pressure was significantly reduced at long-term follow-up (p=0.009). 20 patients had an improved PA pressure with treatment. In those with a worsening PA pressure, two had an improvement in cardiac output and six minute walk distance, two had stable cardiac output at 20 and 21 months, and one had measurements taken during a significant illness. Three patients, who had a reduction in PA pressure, subsequently died of progression of underlying illness at 8 months, from myocardial infarction at 34 months, and from aspergillus pneumonia at 59 months. CONCLUSION Long-term use of sildenafil in patients with secondary forms of pulmonary hypertension is associated with a sustained improvement in cardio-pulmonary haemodynamics. Lack of improvement may be attributed to other factors apart from treatment failure, such as underlying disease progression or unrelated concurrent illness at time of assessment.

A novel approach to the management of acute tracheal tear.

OBJECTIVE We describe the emergency use of a covered, expandable, removable tracheal stent in a patient who developed a large posterior tracheal tear complicating endobronchial therapy for large airway obstruction. METHOD Case report and review of the literature concerning management of acute tracheal tear. RESULTS AND CONCLUSION Our patient demonstrates that endotracheal stenting is an option for managing acute large airway tear. Moreover, the use of a removable stent allows not only for rapid closure of the defect but also removal once the defect has healed, thus avoiding long-term complications of stent deployment.

An approach to tracheostomy in a patient with an expandable metallic tracheal stent.

With increasing use of expandable metallic stents to manage patients with a variety of endobronchial pathologies, some will have a subsequent need for tracheostomy insertion. We describe a successful technique to insert a tracheostomy using rigid and fibre-optic bronchoscopy in a patient who had an 8 cm expandable metallic tracheal stent deployed previously on account of tracheomalacia.