Pulmonary embolism is sudden occlusion of pulmonary arteries, usually by a clot arising in the lower limb veins. The majority of pulmonary emboli are silent, and it is only when the embolus burden is substantial that the patient becomes symptomatic. Mortality after an acute, major thromboembolic episode is significantly high. Pulmonary embolism which causes hemodynamic instability is usually associated with occlusion of more than 50% of the pulmonary vasculature. Associated severe pulmonary hypertension may cause cardiac arrest. The precipitation of RV failure is also affected by the degree of preexisting right ventricular hypertrophy or dilatation, tricuspid valve regurgitation, and the presence of coronary artery disease. Aggressive therapy is needed in this subgroup of patients. Unfortunately, surgical embolectomy is seldom even entertained as an option in the management of these patients. A critical assessment of the data reveals that there is in fact a definite place for surgical therapy in the management of massive pulmonary embolism.
Part of the book: Embolic Diseases
The management of infections of the cardiac structures—specifically native heart valves—remains a difficult clinical challenge. Patients often present with a systemic infection that is made worse by embolic complications, such as strokes, along with pathophysiologic sequelae of acute valvular dysfunction. The timing of interventions has a significant impact on short- and long-term outcomes. The challenges and management decisions are even more complex when the infection involves a prosthetic valve—as risks of reoperative cardiac surgery can be substantial. The goal of this chapter is to discuss the history of prosthetic valve endocarditis, review the current literature on the management of specific valvular involvement (i.e., aortic and/or mitral), and illustrate the challenging problems and outcomes that drive clinical decision making. While many of the indications for surgery are similar to those associated with native valve infections, there is increased risk with reoperative surgery, often difficulties in clearing infection due to prosthetic material being in place. Unfortunately, antibiotics alone are not always effective, and frequent communications between the cardiac surgeon and infectious disease physicians are often necessary to find the “sweet spot” to perform the surgery.
Part of the book: Advanced Concepts in Endocarditis