Archives des maladies du coeur et des vaisseaux
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The prognosis of thromboembolic disease depends, to a large degree, on the deep venous thrombosis. It is located in the legs in nearly 80% of cases and proximal to the popliteal vein in one out of two patients. It is the cause of recurrence and at longer term, of post-thrombotic disease, the frequency of which contrasts with the rarity of chronic post-embolic cor pulmonale. ⋯ Conversely, distal deep vein thrombosis only requires heparin therapy. Interruption of the inferior vena cava is essential when embolism complicates well-treated deep vein thrombosis or when the thrombosis becomes more extensive despite effective treatment. It is also advisable when pulmonary sequellae are severe, long-term anticoagulant therapy is contra-indicated or when the aetiology of the thromboembolism cannot be determined.
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Arch Mal Coeur Vaiss · Nov 1995
[Cerebral protection by selective cerebral perfusion during surgery on the aortic arch].
The aim of this study was to evaluate the technique of cerebral protection by selective cerebral perfusion with moderate hypothermia during surgery of the transverse aortic arch. Twenty-three patients were operated for partial or total replacement of the transverse aortic arch between January 1987 and December 1993 by the technique of selective cerebral perfusion by bilateral carotid cannulation. There were 12 cases of aneurysm of the ascending aorta and/or transverse aortic arch, one aneurysm of the innominate artery and 10 Stanford type A aortic dissections. ⋯ The perioperative mortality was 13%; the causes of death were not neurological (3 haemorrhages). The neurological morbidity was 10% (one brachial monoparesis and one bulbar tetraparesis). This is therefore a useful technique of cerebral protection which avoids the complications of deep hypothermia with circulatory arrest and does not limit the time of aortic repair.
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Transthoracic echocardiography rarely confirms a diagnosis of pulmonary embolism by visualizing a thrombus in the pulmonary artery or right heart chambers. However, easily observed morphological and Doppler abnormalities may result from acute pulmonary hypertension: dilatation of the right heart chambers, a very sensitive and reliable sign of severe pulmonary embolism when the ratio of the right/left ventricular dimension > 0.6: abnormal interventricular septal contraction, a very specific sign of massive pulmonary embolism, and increased systolic pulmonary artery pressure. ⋯ The investigation is rapid and can be carried out at the bedside, allowing confirmation of the diagnosis in two thirds of cases and the institution of thrombolytic or surgical therapy without the need for pulmonary angiography. Doppler echocardiography is also useful for following up the haemodynamic changes and the regression of acute cor pulmonale after thrombolysis.
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Arch Mal Coeur Vaiss · Nov 1995
[Pulmonary embolectomy in pulmonary embolism: surgery and endoluminal techniques].
Since Trendelenburg's first attempts in 1908, the techniques of embolectomy have progressed considerably. The reference method remains embolectomy under cardiopulmonary bypass, the development of which has reduced the operative mortality to 30-40% instead of 60% when embolectomy was performed without cardiopulmonary bypass. ⋯ These procedures are difficult to initiate, little experimented in humans or still at the experimental stage in animals. Advances in the medical treatment of massive acute pulmonary embolism have reduced the indications of embolectomy which has become the exception reserved for the most seriously ill patients in whom the other methods are contraindicated or have failed.
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Arch Mal Coeur Vaiss · Nov 1995
Review[Indications of partial interruption of the inferior vena cava in pulmonary embolism].
Forty years after the first implantation of caval filters, there is still no indication for implantation validated by a controlled clinical trial. This fact may be explained by our poor understanding of the evolution of thromboembolic disease, especially in certain groups of patients. The absolute contra-indications to heparin therapy would seem to be a logical indication for a caval filter. ⋯ The implantation of a filter would seem to be justified in patients with chronic cor pulmonale after pulmonary embolectomy. The value of a temporary caval filter during thrombolysis has not been demonstrated; there are hopes that temporary filters "of long duration" will provide filtration of the vena cava during vulnerable periods. The results of the first controlled trial (PREPIC) are eagerly awaited and should rationalise the indications of inferior vena cava filters.