These are among the first measures of transferase mRNA expression in primary human tissue. More samples should be examined to extend these observations.
Strokes may be delayed following cardiac surgery perhaps because of ongoing risk of embolism or a hypercoagulable state. A surprisingly high proportion of patients have lacunar syndromes or small-deep infarcts shown on computed tomography. Early computed tomographic imaging may be useful to exclude hemorrhage if anticoagulation is considered, but is not without risk in these potentially unstable patients. Greater understanding of risk factors for stroke, timing, and subtypes may ultimately allow identification of patients at particularly high risk for perioperative stroke.
1,2 This procedure has been associated with excessive mortality rates, persistent right heart failure, intra-alveolar and interstitial pulmonary edema, and massive parenchymal and intrabronchial hemorrhage.1-3 It is not surprising, then, that the mainstay treatment in recent times has been nonsurgical therapy.Although most studies show historically high mortality rates (32% on the basis of pooled data from 30 studies and 1,047 patients from 1961 through 1984), recent increases in the effectiveness of surgical techniques have resulted in lower mortality rates for pulmonary embolectomies. 4,5 For example, a surgical approach described by Aklog and colleagues 6 resulted in an 11% mortality rate among 29 patients, over a 3-year period of study. All patients had anatomically extensive embolism and moderate-to-severe right ventricular (RV) dysfunction. Other investigators have shown similar results. For example, Lehnert and associates, in 33 patients who underwent embolectomy, achieved a 30-day mortality rate of 6% and a 12-year survival rate of 80%.7 Kadner and coworkers also produced a low mortality rate of just 8% in 25 patients over a 7-year period. Schoepf and colleagues' study of patients with RV enlargement showed a 30-day mortality rate of 15.6%, compared with 7.7% when RV enlargement was not present.
9The American College of Chest Physicians Evidence-Based Clinical Practice Guidelines recommend surgical pulmonary embolectomy in patients with acute pulmonary embolism (PE) associated with hypotension, if 1) patients have contraindications to thrombolysis; 2) patients have undergone failure of thrombolysis or catheter-assisted embolectomy; or 3) patients are in a state of shock that is likely to result in death before thrombolysis can take effect; and 4) the surgeon possesses appropriate expertise, and obtainable or accessible resources are ready for use.
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