Unsuspected pulmonary emboli adversely impact survival in patients with cancer undergoing routine staging multi-row detector computed tomography scanning. J Thromb Haemost 2011; 9: 305-11.Summary. Background: While symptomatic venous thromboembolism adversely impacts survival among cancer patients, the outcome of cancer patients with unsuspected pulmonary embolism (UPE) found on routine cancer staging multi-row detector computed tomography (MDCT) scans is unknown. Objective: To determine whether UPE detected on routine staging MDCT scans impacts overall survival among cancer patients. Patients and methods: We performed a matched cohort study of cancer patients diagnosed with UPE on routine staging scans between May 2003 and August 2006. Two controls (n = 137) were individually matched by age (± 5 years), cancer type and stage for each UPE patient (n = 70). We used CoxÕs proportional hazard models to compare the mortality between UPE patients and their matched controls. Results: The hazard ratio (HR) for death among UPE patients was 1.51 (95% CI 1.01-2.27, P = 0.048). Compared with their matched controls, patients with UPE more proximal than the subsegmental arterial branches had a HR for death at 6 months of 2.28 (95% CI 1.20-4.33, P = 0.011) and an overall HR of 1.70 (95% CI 1.06-2.74, P = 0.027). Survival among UPE patients with isolated subsegmental PE (ISSPE) was not significantly different than that of matched controls (HR 1.04 95% CI 0.44-2.39, P = 0.92). Conclusions: UPE identified more proximal than the subsegmental arterial branches has a significant negative impact on survival among cancer patients.
PRESENCE OF PACEMAKER and intracardiac defibrillator leads as well as tricuspid annuloplasty ring or bioprosthetic tricuspid valve by transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), due to reverberation artifact produced by the catheter and prosthetic valve material.Identification of location of the vegetation on the lead versus prosthetic valve has therapeutic implications, particularly in patients with multiple prior cardiac surgeries in whom repeat surgery is not desirable. Cardiac magnetic resonance is currently not a feasible imaging option in patients with prosthetic devices. Real-time 3-dimensional transesophageal echocardiography (RT3D TEE) is able to demonstrate precise relationships among various anatomical structures and is also able to visualize intracardiac catheters, including catheter tip, without artifact associated with TTE and conventional TEE.The utility of RT3D TEE in suspected right-sided endocarditis in patients with pacemaker or intracardiac leads and bioprosthetic tricuspid valve or a tricuspid annuloplasty ring is described in this report. It is to be emphasized that lack of demonstrable vegetations by RT3D TEE may not necessarily imply lack of infection of the device.RT3D TEE allows evaluation of precise location of vegetation on prosthetic devices such as intracardiac defibrillator (ICD) leads, pacemakers, or tricuspid valve prostheses. Precise delineation of location of vegetation in these patients allows therapeutic medical and surgical treatment decisions. Absence of demonstrable vegetations by RT3D TEE however does not entirely exclude endocarditis, which ultimately remains a clinical diagnosis.
Background: While symptomatic venous thromboemboli (VTE) clearly have an adverse impact on survival among cancer patients, the outcome of cancer patients with unsuspected pulmonary emboli (PE) found on routine cancer staging multi-row detector CT (MDCT) scans is unknown. In order to evaluate survival among cancer patients with unsuspected PE, we expanded on a previous study (O’Connell, JCO2006; 24:4928) of such patients. Methods: We performed a retrospective chart review of cancer patients with unsuspected PE found on routine cancer staging MDCT scans between May, 2003 and August, 2006. Two patients matched for age, cancer type and stage (“controls”) were identified for each patient with unsuspected PE (“cases”). Patients with known VTE, patients already receiving anticoagulation for any reason and patients with multiple active cancers were excluded. We recorded cancer characteristics, signs and symptoms typical of PE, risk factors, presence of PE on subsequent staging scans, time to death, and cause of death. We used conditional logistic regression analysis to compare the baseline characteristics. To evaluate the impact of unsuspected PE and other covariates on survival, we used stratified Cox proportional hazard analysis and the logrank test. Results: Seventy patients with unsuspected PE and 137 matched controls were evaluated. There were no significant differences between the groups in terms of matching factors, gender, or sites of metastases. Cases were more likely to have had prior VTE and to have had surgery within the previous 2 months than were controls (p=0.008, p=0.0002, respectively). There were no differences in the time from cancer diagnosis to the index MDCT scan, use of erythropoietin, exposure to chemotherapy, presence of central lines, hormonal therapy or use of antiplatelet medication between cases and controls. As previously reported in the smaller series, cases were more likely to actually have complained to someone on the medical team of shortness of breath and fatigue than were control patients (p =0.0009, p=0.001, respectively); case patients were also more likely than control patients to complain of cough (p=0.019). There were no statistically significant differences in other signs or symptoms such as hypoxia, fever, limb pain or swelling, chest pain or tachycardia. Of the 70 patients with unsuspected PE, 17 (24.3%) had isolated subsegmental clots and 53 (75.7%) had more proximal clots. Fifty-nine of the 70 patients (84.3%) with PE received some form of anticoagulation as treatment. Using a stratified analysis adjusting for the presence of brain, liver and lung metastases and for use of erythropoietin we found that proximal unsuspected PE conferred a hazard ratio for death of 1.79 (95% CI 1.10–2.90, p =0.018) (Kaplan-Meier curves, Figure 1). Symptomatic patients with unsuspected proximal PE, in particular, had poorer overall survival than matched controls (5 months vs. 14 months, p=0.009, logrank test). Use of erythropoietin, metastases to lung, liver or lymph nodes, gender, and active treatment with chemotherapy had no significant impact on survival; brain metastases, however, conferred poorer overall survival (20.5 vs. 61 months, p=0.003) independent of PE. Conclusion: These data support our previous findings in the smaller series that patients with unsuspected PE detected on routine staging MDCT scans are more likely to be symptomatic than are matched control patients, particularly with shortness of breath, fatigue and cough. Unsuspected PE have a significant adverse impact on overall survival among cancer patients; this impact is more pronounced among those patients reporting PE-related symptoms. Figure SEQ Figure \* ARABIC 1. Overall survival among cancer patients with unsuspected PE and matched controls Figure. SEQ Figure \* ARABIC 1. Overall survival among cancer patients with unsuspected PE and matched controls
Trauma inflicted by sharp penetrating objects can cause unusual and complex injuries to the heart. We present a case where penetrating trauma caused an unusual ventricular laceration that filleted the ventricular septum into two separate sections creating an artificial chamber in between. The ventricular septal defect was clearly displayed with echocardiography and required special cardiac surgical intervention.
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