John A. Paraskos

Resolution Rate of Acute Pulmonary Embolism in Man

Abstract In 15 patients with definite angiographic evidence of embolism involving both lungs, and treated with heparin or venous ligation or both, sequential studies showed only minimal angiographic and hemodynamic signs of resolution at seven days. By 10 to 21 days, pressures in the right side of the heart had decreased to near normal levels, and there was unmistakable angiographic evidence of resolution. Complete resolution, with normal angiograms and hemodynamics, was noted in three patients at 14, 15 and 34 days. In other patients angiographic and hemodynamic abnormalities persisted weeks after embolism.

Pulmonary Embolism, Pulmonary Hemorrhage and Pulmonary Infarction

We compared 41 patients with angiographic proof of pulmonary embolism and clinical signs of pulmonary infarction (as evidenced by an infiltrate on x-ray study and pleuritic pain in the area of the embolus) with 24 patients with pulmonary embolism but without infarction. Only 18 of the 41 patients with pulmonary infarction had associated heart disease. Pulmonary infarction was uncommon when emboli obstructed central arteries but frequent when distal arteries were occluded. Follow-up x-ray examination showed that the infiltrates resolved in the patients with pulmonary infarction without heart disease, but persisted when heart disease was present. We suggest that obstruction of distal arteries results in pulmonary hemorrhage owing to an influx of bronchial arterial blood at systemic pressure. Hemorrhage causes symptoms and x-ray changes usually attributed to pulmonary infarction. However, hemorrhage resolves without infarction in patients without, but progresses to infarction in those with, heart disease.

The hemodynamic and respiratory effects of diazepam (Valium).

Diazepam, 5–10 rag, was given intravenously to treat anxiety occurring during cardiac catheterization in 15 patients. Anxiety was effectively relieved in 11 patients. Hemodynamic and ventilatory parameters were assessed before, and ten and 30 minutes after diazepam. The cardiac index decreased significantly in only three patients, each of whom had a control cardiac index in the high-normal range. No significant changes occurred in patients whose control cardiac indexes were below normal. Systolic blood pressure decreased by more than 10 mm Hg in eight patients. Pulmonary arterial pressure, heart rate, stroke volume and pulmonary and systemic resistance did not change significantly. Hypoventilation occurred in all patients. Ten minutes after diazepam minute ventilation had decreased by 28 per cent and tidal volume by 23 per cent. Paco2 increased by 5 mm Hg and Pao2 decreased by 10 mm Hg. The observed changes in blood pressure and ventilation were without clinical correlates and did not require therapy.

Late Prognosis of Acute Pulmonary Embolism

Abstract Sixty consecutive patients who survived an episode of acute pulmonary embolism documented by pulmonary angiography were assessed one to seven years later (average follow-up period, 29 mont...

Fatal pulmonary hemorrhage after use of the flow-directed balloon-tipped catheter.

The flow-directed balloon-tipped catheter is extensively used in intensive care units, catheterization laboratories, operating rooms, and emergency wards. Major complications associated with its use have not been frequently reported. In a recent 2-year period in four hospitals, we identified five cases of fatal pulmonary hemorrhage resulting from balloon-tipped catheters. We review here four additional cases previously cited in the literature and discuss possible mechanisms and predisposing factors associated with this complication and guidelines for safe use of these catheters. Pulmonary artery rupture is probably commoner than previously reported.

Relationship of quality of life and perceived control with posttraumatic stress disorder symptoms 3 to 6 months after myocardial infarction

PURPOSE This study examined whether psychological variables were associated with posttraumatic stress disorder (PTSD) symptoms 3 to 6 months after myocardial infarction. METHODS The sample included 52 patients with myocardial infarction. A structured interview was used to obtain information about PTSD symptoms, quality of life, and ratings of perceived control, danger, and predictability, as well as information about stressful events that occurred during hospitalization. RESULTS Four patients (7.7%) met criteria for the diagnosis of PTSD. Elevated PTSD scores were associated with poorer quality of life (r = -0.32 to -0.79). Lower perceived control was associated with higher PTSD symptom scores (r = -0.30 to -0.52). Finally, PTSD scores were significantly correlated with the number of times patients were readmitted to the hospital (r = 0.35-0.57). CONCLUSIONS Approximately 8% of patients experienced PTSD 3 to 6 months following MI. Increasing levels of PTSD symptoms were correlated with poorer quality of life. Perceived lack of control during the MI and multiple hospitalizations may be related to the severity of PTSD symptoms.

Impact of thrombolytic therapy on left ventricular mural thrombi in acute myocardial infarction

Abstract Left ventricular (LV) mural thrombi have long been recognized as a complication of acute myocardial infarction (AMI). Recent echocardiographic studies suggest an incidence of 2 to 18% in patients with AMI. Anterior infarctions are found to have a much higher incidence of mural thrombus than inferior infarctions. 1 Previous reports have noted conflicting results regarding the effect of thrombolysis on the formation of LV mural thrombi after AMI. 2–4 The aim of this study was 2-fold: to examine if systemic thrombolytic therapy using either tissue plasminogen activator or streptokinase reduces the incidence of LV mural thrombi early after AM1 compared with conventional treatment, and to determine if reperfusion of the infarct-related artery was associated with a lower incidence of LV mural thrombi.

Studies of systolic mechanics and diastolic behavior of the left ventricle in the trained racing greyhound

SummaryDespite much interest in the effects of exercise on the myocardium, and the need to develop animal models which mimic conditions leading to cardiac hypertrophy, little attention has been focused on the trained racing greyhound. The current study compared two groups of anesthetized trained racing greyhounds (a total of 20 animals, 12 of whom were maintained for serial studies and 8 of whom were sacrificed for anatomic correlations) with 3 detrained greyhounds and 6 comparably sized mongrels. Systemic blood pressures, right and left heart pressures, ventricular mechanics and indices of diastolic behavior were compared. All measured indices of contractility (dp/dt, dp/dtDP40, Vce and Vmax) were lower in trained racing greyhounds than in mongrels although none achieved statistical significance. No significant difference in diastolic behavior was found between trained greyhounds and mongrels. While caution should be applied because of the small numbers of animals and the use of anesthesia, the lower than expected contractility found in trained racing greyhounds may reflect increased parasympathetic tone in the immediate post-training period. The normal diastolic behavior of the trained greyhound left ventricle contrasts to abnormal diastolic behavior found in models of chronic pressure overload.ZusammenfassungBisher hat man dem trainierten Windhund als Versuchstier wenig Aufmerksamkeit geschenkt, trotz des vielen Interesses für den Einfluß, welchen das Trainieren auf das Myokard ausübt, und trotz des Mangels an Tiermodellen, welche die zur Herzhypertrophie führenden Umstände imitieren. Vorliegende Untersuchung vergleicht zwei Gruppen betäubter trainierter Windhunde (insgesamt 20 Tiere, von denen 12 mehrmals untersucht wurden, 8 aber zwecks pathologischer Untersuchung geopfert wurden) mit 3 abtrainierten Windhunden und 6 ungefähr gleichgroßen Mischhunden. Die arteriellen Blutdrücke, Rechts- und Linksherzdrücke, mechanische Funktion und Indizes der diastolischen Aktivität wurden verglichen. Alle gemessenen Indizes der Kontraktilität (dP/dt, dP/dtDP40, Vce und Vmax) waren bei den trainierten Windhungen niedriger als bei den Mischhunden, obwohl kein Index für sich von statistischer Bedeutung war. Bei diastolischer Funktion wurden zwischen den trainierten Windhunden und den Mischhunden kein Unterschied von Bedeutung gefunden. Wegen der kleinen Anzahl von Versuchstieren und wegen des Gebrauchs von einem Betäubungsmittel ist bei der Interpretation der Resultate Vorsicht geboten. Nichtsdestoweniger ist es möglich, daß die unerwartet niedrige Kontraktilität, die man in den trainierten Windhunden vorgefunden hat, einen gesteigerten parasympathischen Einfluß in der Nachtrainingsperiode darstellt. Die normale diastolische Funktion des linken Ventrikels im trainierten Windhund steht im Gegensatz zur anormalen diastolischen Funktion von Modellen chronischen Überdrucks.

Transient right atrial thrombus resulting in pulmonary embolism detected by two-dimensional echocardiography

Development of sophisticated techniques for detecting thrombus in the lower extremities has lead to the understanding that the vast majority of pulmonary emboli originate in the deep venous system of the legs. We recently treated a patient in whom a thrombus originated in the lower extremities, was transiently entrapped in the right atrium, and ultimately embolized to the pulmonary circulation. The presence of a large coiled thrombus in the right atrium was initially detected by two-dimensional

The effect of maximal treadmill exercise on the axis and amplitude of the ventricular depolarization wave

Summary Forty-five normal subjects (36 control subjects, four wrestlers and five cross country runners) and 21 patients with symptoms of cardiovascular disease (11 without and 10 with significant arteriographic evidence for coronary artery disease (CAD) underwent maximal exercise treadmill tests. Twelve lead ECGs were recorded and the voltage amplitude of the ventricular depolarization wave (ΣR), the frontal plane axis (FPA) and horizontal plane axis (HPA) were measured immediately before exercise in the supine (SP) and standing positions (ST), during exercise at a heart rate of 120 bpm (120), at peak exercise (MX), and in the supine position 1 minute after the completion of exercise (1R). In normal subjects (controls and athletes) there was a decrease in ΣR (p Athletes involved in intense aerobic activity have increased R wave amplitude as compared with other normal subjects, but they otherwise react normally to exercise by diminishing R wave amplitude above a heart rate of 120. The R wave amplitude changes with exercise are accompanied by posterior axis shifts of the R wave in the horizontal plane in all subjects. Patients with CAD do not demonstrate an exercise-induced decrease in R wave amplitude even though they shift their R wave axis posteriorly. The presence or absence of significant coronary disease by coronary arteriography or ischemic ST segment depression did not influence the results in this small group of patients.