Archives des maladies du coeur et des vaisseaux
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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.
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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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In general, there are two types of right heart thrombi diagnosed by echocardiography: mobile and non-mobile thrombi, more often located in the atrium than in the ventricle and a potential source of pulmonary embolism. However, they differ in several points: clinical context, clinical and echocardiographic presentations, embolic potential, prognosis and treatment. The result of peripheral venous thrombosis, mobile thrombus it is usually diagnosed during echocardiographic investigation of pulmonary embolism. ⋯ It decreases or disappears with anticoagulant therapy and the outcome is usually good. The differential diagnosis between a mobile thrombus and a Chiari network, or between an adherent thrombus and a vegetation on a intracardiac pacing wire may be difficult and requires transoesophageal echocardiography. The investigation of pulmonary embolism requires systematic echocardiography, one of the objectives of which is to search for right sided thrombi.