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Gertz RJ, Gerhardt F, Pienn M, Lennartz S, Kröger JR, Caldeira L, Pennig L, Schömig TH, Hokamp NG, Maintz D, Rosenkranz S, Bunck AC. Dual-layer dual-energy CT-derived pulmonary perfusion for the differentiation of acute pulmonary embolism and chronic thromboembolic pulmonary hypertension. Eur Radiol 2024; 34:2944-2956. [PMID: 37921925 PMCID: PMC11126515 DOI: 10.1007/s00330-023-10337-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/18/2023] [Accepted: 10/03/2023] [Indexed: 11/05/2023]
Abstract
OBJECTIVES To evaluate dual-layer dual-energy computed tomography (dlDECT)-derived pulmonary perfusion maps for differentiation between acute pulmonary embolism (PE) and chronic thromboembolic pulmonary hypertension (CTEPH). METHODS This retrospective study included 131 patients (57 patients with acute PE, 52 CTEPH, 22 controls), who underwent CT pulmonary angiography on a dlDECT. Normal and malperfused areas of lung parenchyma were semiautomatically contoured using iodine density overlay (IDO) maps. First-order histogram features of normal and malperfused lung tissue were extracted. Iodine density (ID) was normalized to the mean pulmonary artery (MPA) and the left atrium (LA). Furthermore, morphological imaging features for both acute and chronic PE, as well as the combination of histogram and morphological imaging features, were evaluated. RESULTS In acute PE, normal perfused lung areas showed a higher mean and peak iodine uptake normalized to the MPA than in CTEPH (both p < 0.001). After normalizing mean ID in perfusion defects to the LA, patients with acute PE had a reduced average perfusion (IDmean,LA) compared to both CTEPH patients and controls (p < 0.001 for both). IDmean,LA allowed for a differentiation between acute PE and CTEPH with moderate accuracy (AUC: 0.72, sensitivity 74%, specificity 64%), resulting in a PPV and NPV for CTEPH of 64% and 70%. Combining IDmean,LA in the malperfused areas with the diameter of the MPA (MPAdia) significantly increased its ability to differentiate between acute PE and CTEPH (sole MPAdia: AUC: 0.76, 95%-CI: 0.68-0.85 vs. MPAdia + 256.3 * IDmean,LA - 40.0: AUC: 0.82, 95%-CI: 0.74-0.90, p = 0.04). CONCLUSION dlDECT enables quantification and characterization of pulmonary perfusion patterns in acute PE and CTEPH. Although these lack precision when used as a standalone criterion, when combined with morphological CT parameters, they hold potential to enhance differentiation between the two diseases. CLINICAL RELEVANCE STATEMENT Differentiating between acute PE and CTEPH based on morphological CT parameters is challenging, often leading to a delay in CTEPH diagnosis. By revealing distinct pulmonary perfusion patterns in both entities, dlDECT may facilitate timely diagnosis of CTEPH, ultimately improving clinical management. KEY POINTS • Morphological imaging parameters derived from CT pulmonary angiography to distinguish between acute pulmonary embolism and chronic thromboembolic pulmonary hypertension lack diagnostic accuracy. • Dual-layer dual-energy CT reveals different pulmonary perfusion patterns between acute pulmonary embolism and chronic thromboembolic pulmonary hypertension. • The identified parameters yield potential to enable more timely identification of patients with chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Roman Johannes Gertz
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - Felix Gerhardt
- Department of Cardiology, Heart Center, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Michael Pienn
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Simon Lennartz
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan Robert Kröger
- Department of Radiology, Neuroradiology and Nuclear Medicine, Ruhr University Bochum, Johannes Wesling University Hospital, Bochum, Germany
| | - Liliana Caldeira
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lenhard Pennig
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thomas Henning Schömig
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nils Große Hokamp
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David Maintz
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Alexander Christian Bunck
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Fulton B, Bashir R, Weinberg MD, Lakhter V, Rali P, Pugliese S, Giri J, Kobayashi T. Advanced Treatment of Hemodynamically Unstable Acute Pulmonary Embolism and Clinical Follow-up. Semin Thromb Hemost 2023; 49:785-796. [PMID: 37696292 DOI: 10.1055/s-0043-1772840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
High-risk acute pulmonary embolism (PE), defined as acute PE associated with hemodynamic instability, remains a significant contributor to cardiovascular morbidity and mortality in the United States and worldwide. Historically, anticoagulant therapy in addition to systemic thrombolysis has been the mainstays of medical therapy for the majority of patients with high-risk PE. In efforts to reduce the morbidity and mortality, a wide array of interventional and surgical therapies has been developed and employed in the management of these patients. However, the most recent guidelines for the management of PE have reserved the use of these advanced therapies in scenarios where thrombolytic therapy plus anticoagulation are unsuccessful. This is due largely to the lack of prospective, randomized studies in this population. Stemming from this, the approach to treatment of these patients varies widely depending on institutional experience and resources. Furthermore, morbidity and mortality remain unacceptably high in this population, with estimated 30-day mortality of at least 30%. As such, development of a standardized approach to treatment of these patients is paramount to improving outcomes. Early and accurate risk stratification in conjunction with a multidisciplinary team approach in the form of a PE response team is crucial. With the advent of novel therapies for the treatment of acute PE, in addition to the growing availability of and familiarity with mechanical circulatory support systems, such a standardized approach may now be within reach.
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Affiliation(s)
- Brian Fulton
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Mitchell D Weinberg
- Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, New York
| | - Vladimir Lakhter
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Steve Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jay Giri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
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Shah IK, Merfeld JM, Chun J, Tak T. Pathophysiology and Management of Pulmonary Embolism. Int J Angiol 2022; 31:143-149. [PMID: 36157092 PMCID: PMC9507564 DOI: 10.1055/s-0042-1756204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Pulmonary embolism (PE) is one of the most common etiologies of cardiovascular mortality. It could be linked to several risk factors including advanced age. The pathogenesis of PE is dictated by the Virchow's triad that includes venous stasis, endothelial injury, and a hypercoagulable state. The diagnosis of PE is difficult and is often missed due to the nonspecific symptomatology. Hypoxia is common in the setting of PE, and the degree of respiratory compromise is multifactorial and influenced by underlying cardiac function, clot location, and ability to compensate with respiratory mechanics. Right ventricular dysfunction/failure is the more profound cardiovascular impact of acute PE and occurs due to sudden increase in afterload. This is also the primary cause of death in PE. High clinical suspicion is required in those with risk factors and presenting signs or symptoms of venous thromboembolic disease, with validated clinical risk scores such as the Wells, Geneva, and pulmonary embolism rule out criteria in estimating the likelihood for PE. Advancement in capture time and wider availability of computed tomographic pulmonary angiography and D-dimer testing have further facilitated the rapid evaluation and diagnosis of suspected PE. Treatment is dependent on clinical presentation and initially involves providing adequate oxygenation and stabilizing hemodynamics. Anticoagulant therapy is indicated for the treatment of PE. Treatment is guided by presence or absence of shock and ranges from therapeutic anticoagulation to pharmacologic versus mechanical thrombectomy. The prognosis of patients can vary considerably depending on the cardiac and pulmonary status of patient and the size of the embolus.
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Affiliation(s)
- Ishan K. Shah
- Department of Family Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
| | - John M. Merfeld
- Department of Family Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
| | - Jimy Chun
- Department of Nephrology, Mayo Clinic, La Crosse, Wisconsin
| | - Tahir Tak
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, Wisconsin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester. Minnesota
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Kong AHS, Woo PYM, Choo WMY, Wong DKK. Acute Pulmonary Edema with Paradoxical Desaturation after Salbutamol due to Venous Air Embolism during an Awake Craniotomy: A Diagnostic Challenge. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1744403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Amy H. S. Kong
- Department of Anaesthesiology and Operating Theatre Services, Kwong Wah Hospital, Hong Kong
| | | | - Wilson M. Y. Choo
- Department of Anaesthesiology and Operating Theatre Services, Kwong Wah Hospital, Hong Kong
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Samhouri B, Venkatasaburamini M, Paz Y Mar H, Li M, Mehra R, Chaisson NF. Pulmonary artery hemodynamics are associated with duration of nocturnal desaturation but not apnea-hypopnea index. J Clin Sleep Med 2021; 16:1231-1239. [PMID: 32267224 DOI: 10.5664/jcsm.8468] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
STUDY OBJECTIVES Sleep-disordered breathing and nocturnal hypoxia are prevalent among patients with precapillary pulmonary hypertension (PAH). The rationale for these associations remains unclear and these relationships have not been well studied in other forms of pulmonary hypertension (PH). We hypothesized that severity of sleep-disordered breathing and nocturnal hypoxia are associated with worsening pulmonary hemodynamics, regardless of hemodynamic profile. METHODS Four hundred ninety-three patients were divided into 4 groups: 1) no PH, 2) postcapillary pulmonary hypertension, 3) PAH, and 4) mixed PAH/postcapillary pulmonary hypertension. The relationship between right heart catheterization measurements and apnea-hypopnea index or the percentage of sleep time spent with oxygen saturation < 90% (T90) was calculated using multiple linear regression. Analysis of variance was used for between-group comparisons. Statistical models were adjusted for known confounders. RESULTS Apnea-hypopnea index did not differ between hemodynamic subgroups (P = .27) and was not associated with right atrial pressure (.11 ± .19, P = .55), cardiac index (.25 ± 1.64, P = .88), mean pulmonary artery pressure (-.004 ± .09, P = .97), or pulmonary artery occlusion pressure (.16 ± .14, P = .26). While patients with PH had a higher T90 than those without (mean 24.2% vs 11.7%, P < .001), there was no difference in T90 between individual PH subgroups (P = .70). T90 was associated with mean pulmonary artery pressure (.55 ± .10, P < .0001), PVR (1.61 ± .49, P = .001), and right atrial pressure (.50 ± .20, P = .01), but not cardiac index (-.76 ± 1.73, P = .66), or pulmonary artery occlusion pressure (.23 ± .15, P = .13). CONCLUSIONS Increased PH severity was associated with longer duration of nocturnal hypoxia regardless of hemodynamic subgroup.
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Affiliation(s)
| | | | - Hugo Paz Y Mar
- Pulmonary, Critical Care and Sleep Medicine Division, MetroHealth Medical Center, Cleveland, Ohio
| | - Manshi Li
- Department of Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Reena Mehra
- Sleep Disorders Center, Neurologic Institute, Respiratory Institute, Heart and Vascular Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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Affiliation(s)
- Robin Cherian
- Department of Cardiology, National University Heart Centre Singapore, Singapore
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Lyhne MD, Schultz JG, Kramer A, Mortensen CS, Nielsen-Kudsk JE, Andersen A. Right ventricular adaptation in the critical phase after acute intermediate-risk pulmonary embolism. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 10:2048872620925253. [PMID: 32436719 DOI: 10.1177/2048872620925253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/21/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The haemodynamic response following acute, intermediate-risk pulmonary embolism is not well described. We aimed to describe the cardiovascular changes in the initial, critical phase 0-12 hours after acute pulmonary embolism in an in-vivo porcine model. METHODS Pigs were randomly allocated to pulmonary embolism (n = 6) or sham (n = 6). Pulmonary embolism was administered as autologous blood clots (20 × 1 cm) until doubling of mean pulmonary arterial pressure or mean pulmonary arterial pressure was greater than 34 mmHg. Sham animals received saline. Cardiopulmonary changes were evaluated for 12 hours after intervention by biventricular pressure-volume loop recordings, invasive pressure measurements, arterial and central venous blood gas analyses. RESULTS Mean pulmonary arterial pressure increased (P < 0.0001) and stayed elevated for 12 hours in the pulmonary embolism group compared to sham. Pulmonary vascular resistance and right ventricular arterial elastance (right ventricular afterload) were increased in the first 11 and 6 hours, respectively, after pulmonary embolism (P < 0.01 for both) compared to sham. Right ventricular ejection fraction was reduced (P < 0.01) for 8 hours, whereas a near-significant reduction in right ventricular stroke volume was observed (P = 0.06) for 4 hours in the pulmonary embolism group compared to sham. Right ventricular ventriculo-arterial coupling was reduced (P < 0.05) for 6 hours following acute pulmonary embolism despite increased right ventricular mechanical work in the pulmonary embolism group (P < 0.01) suggesting right ventricular failure. CONCLUSIONS In a porcine model of intermediate-risk pulmonary embolism, the increased right ventricular afterload caused initial right ventricular ventriculo-arterial uncoupling and dysfunction. After approximately 6 hours, the right ventricular afterload returned to pre-pulmonary embolism values and right ventricular function improved despite a sustained high pulmonary arterial pressure. These results suggest an initial critical and vulnerable phase of acute pulmonary embolism before haemodynamic adaptation.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Cardiology and Department of Clinical Medicine, Aarhus University Hospital, Denmark
| | | | - Anders Kramer
- Department of Cardiology and Department of Clinical Medicine, Aarhus University Hospital, Denmark
| | | | - Jens Erik Nielsen-Kudsk
- Department of Cardiology and Department of Clinical Medicine, Aarhus University Hospital, Denmark
| | - Asger Andersen
- Department of Cardiology and Department of Clinical Medicine, Aarhus University Hospital, Denmark
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Abstract
Pulmonary embolism (PE) is caused by emboli, which have originated from venous thrombi, travelling to and occluding the arteries of the lung. PE is the most dangerous form of venous thromboembolism, and undiagnosed or untreated PE can be fatal. Acute PE is associated with right ventricular dysfunction, which can lead to arrhythmia, haemodynamic collapse and shock. Furthermore, individuals who survive PE can develop post-PE syndrome, which is characterized by chronic thrombotic remains in the pulmonary arteries, persistent right ventricular dysfunction, decreased quality of life and/or chronic functional limitations. Several important improvements have been made in the diagnostic and therapeutic management of acute PE in recent years, such as the introduction of a simplified diagnostic algorithm for suspected PE as well as phase III trials demonstrating the value of direct oral anticoagulants in acute and extended treatment of venous thromboembolism. Future research should aim to address novel treatment options (for example, fibrinolysis enhancers) and improved methods for predicting long-term complications and defining optimal anticoagulant therapy parameters in individual patients, and to gain a greater understanding of post-PE syndrome.
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Akizuki M, Serizawa N, Ueno A, Adachi T, Hagiwara N. Effect of Balloon Pulmonary Angioplasty on Respiratory Function in Patients With Chronic Thromboembolic Pulmonary Hypertension. Chest 2016; 151:643-649. [PMID: 27746200 DOI: 10.1016/j.chest.2016.10.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 09/10/2016] [Accepted: 10/05/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) in chronic thromboembolic pulmonary hypertension (CTEPH) improves hemodynamics and exercise capacity. However, its effect on respiratory function is unclear. Our objective was to investigate the effect of BPA on respiratory function. METHODS We enrolled patients with inoperable CTEPH who underwent BPA primarily in lower lobe arteries (first series) and upper and middle lobe arteries (second series). We compared changes in hemodynamics and respiratory function between different BPA fields. RESULTS Sixty-two BPA sessions were performed in 13 consecutive patients. Mean pulmonary arterial pressure and pulmonary vascular resistance significantly improved from 44 ± 8 to 23 ± 5 mm Hg and 818 ± 383 to 311 ± 117 dyne/s/cm-5. The percent predicted diffusion capacity of lung for carbon monoxide (Dlco) decreased after BPA in the lower lung field (from 60% ± 8% to 54% ± 8%) with no recovery. Percent Dlco increased after BPA in the upper middle lung field (from 53% ± 6% to 58% ± 6%) and continued to improve during the follow-up (from 58% ± 6% to 64% ± 11%). The ventilation/Co2 production (V˙e/V˙co2) slope significantly improved after BPA in the lower lung field (from 51 ± 13 to 41 ± 8) and continued to improve during the follow-up (from 41 ± 8 to 35 ± 7); however, the V˙e/V˙co2 slope remained unchanged after BPA in the upper/middle lung field. Changes in % Dlco and the V˙e/V˙co2 slope differed significantly between lower and upper/middle lung fields. CONCLUSIONS The effect of BPA on respiratory function in patients with CTEPH differed depending on the lung field.
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Affiliation(s)
- Mina Akizuki
- Department of Rehabilitation, Tokyo Women's Medical University, Tokyo, Japan; Department of Internal Medicine and Rehabilitation, Science Disability Science, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Naoki Serizawa
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Atsuko Ueno
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Taku Adachi
- Department of Rehabilitation, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
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Retrograde lung perfusion in the treatment of massive pulmonary embolism. A randomised porcine study. Thromb Res 2014; 135:410-4. [PMID: 25523344 DOI: 10.1016/j.thromres.2014.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/23/2014] [Accepted: 12/01/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The treatment of massive pulmonary embolisms with an associated cardiac arrest is controversial; however, surgical thrombectomy with extracorporeal circulation (ECC) is an option for treatment. It is difficult to remove all thromboembolic material. Theoretically, retrograde blood perfusion through the lungs may be beneficial. OBJECTIVES To investigate whether retrograde blood perfusion through the lungs during a thrombectomy is beneficial. METHODS Twelve pigs were prepared for ECC. Repetitive injections of preformed blood thrombi into the right atrium resulted in cardiac arrests. ECC was established after 10 minutes of cardiac arrest, and after a sternotomy, the main pulmonary artery was incised and as much thrombotic material as possible was removed from the pulmonary arteries. The pigs were randomised to ECC for one hour either with or without retrograde perfusion in the pulmonary circulation. After one hour, the released material was removed from the pulmonary arteries, and the incision was sutured. The pigs were weaned from the ECC. After sacrificing the pigs, they were autopsied with special attention to the amount of remaining thrombi. Additional histological analyses were performed with special attention to microembolisms, atelectases, and signs of tissue damage. RESULTS All of the pigs were weaned from the ECC. The amount of the embolic material removed varied considerably, as did the amount removed after the retrograde or antegrade perfusion, and there was no significant difference between the two treatment modalities. There were no signs of tissue damage in the lungs. CONCLUSIONS Retrograde lung perfusion was not generally beneficial in the treatment of massive pulmonary embolism in this setup; however, it may be an option if only a modest amount of material is accessible in the pulmonary artery.
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