The effects of recombinant tissue plasminogen activator (rt-PA) and urokinase on patency and early reocclusion of infarct-related coronary arteries were investigated in a single blind, randomized multicenter trial in 246 patients with acute myocardial infarction of less than 6 h duration. Both 70 mg of single chain rt-PA with an initial bolus of 10 mg and 3 million units of urokinase with an initial bolus of 1.5 million units were given intravenously over 90 min. The first angiographic study at the end of the infusion revealed a patent infarct-related artery (Thrombolysis in Myocardial Infarction trial [TIMI] grade 2 or 3) in 69.4% of 121 patients given rt-PA versus 65.8% of 117 patients given urokinase (p = NS). Among patients treated within 3 h from symptom onset a patent infarct-related artery was found in 63.9% of 72 patients given rt-PA versus 70% of 70 patients given urokinase (p = NS). There were five cardiac deaths in each group and one fatal intracranial hemorrhage in the rt-PA group. The in-hospital reinfarction rate was 8.9% versus 13.2% for patients treated with rt-PA and urokinase, respectively. There was no difference in left ventricular function at baseline and follow-up catheterization studies. Both drugs were well tolerated and there was no significant difference in cardiovascular or bleeding complications between the two groups. It is concluded that rt-PA and urokinase in the dosages used provide similar efficacy and safety in the treatment of acute myocardial infarction. Reocclusion during the first 24 h may be less frequent after urokinase treatment.
With the increasing use of cross-sectional echocardiography in patients with overt or suspected pulmonary thromboembolism in the emergency rooms, more and more right atrial thrombi are detected. These are so-called "transitthrombi" from the venous system on their way to the pulmonary arteries and they are a severe presentation of thromboembolic disease. They appear as an imminent pulmonary embolism and usually coexists with an already massive embolism. In patients were a right atrial thrombus is associated with a patent foramen ovale, paradoxical arterial embolism has been observed. Right sided heart thrombi have a high mortality rate and need immediate treatment. In our hospital we have seen 14 patients with right atrial thrombi and pulmonary embolism in a period of 6 years. Three patients had cardiac arrest with a massive pulmonary embolism, seven patients presented with a submassive embolism. All patients were treated immediately after echocardiographic diagnosis without pulmonary angiography. In about half of the cases transesophageal echocardiography was done additionally for diagnosis and monitoring. Therapeutic options were thrombectomy, fibrinolysis or anticoagulants. We treated one of our patients with thrombectomy, eleven patients with fibrinolysis and two patients with anticoagulants.
Transoesophageal sonography is an excellent addition to the already well established staging methods in staging lung cancer. This examination clearly has advantages over the conventional methods (CT scan) for the diagnosis of vessel involvement, extrinsic compression of the heart, and for the recognition of lymph node metastases. The limitation of this examination is the restriction to the paraoesophageal area and reduced effectiveness in areas filled with air and other nonconductive structures.
Introduction of air into the arterial circulation can cause cerebral air embolism, leading to severe neurological deficits. A case is reported on a patient suffering from fatal cerebral air embolism after a subclavian vein catheter had been inserted. The risks associated with inserting and removing central venous catheters are described. Apart from the pathogenesis of a paradoxical air embolism in a patient with a right-to-left shunt due to a patent foramen ovale, air embolism can occur if a large amount of air traverses the pulmonary circulation. The ability of the pulmonary vasculature to filter air may be exceeded by a bolus injection of more than 30 ml air. Air embolism is suspected if acute neurological symptoms occur after inserting a central venous catheter. Echocardiography, especially transoesophageal echocardiography. Is highly sensitive in detecting air emboli in the ventricles. Treatment is effected with hyperbaric oxygen and standard measures of intensive-care medicine.
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