We investigated hemodynamic and respiratory changes in 19 postoperative patients who had undergone thromboendarterectomy for chronic pulmonary thromboembolism (CPTE) between 1986 and 1993 and were managed in our ICU. The postoperative hemodynamic and respiratory studies revealed reduced mean pulmonary arterial pressure (mean PAP), increased cardiac index (CI), and a resultant significant reduction in pulmonary vascular resistance (PVR) compared to their preoperative values. However, arterial oxygen tension (PaO₂) deteriorated and the respiratory index (RI) increased on the admission to ICU. We classified these patients into two groups according to the duration of ventilatory support: group A required 5 or more days for weaning from the ventilator and group B were weaned from the ventilator within 5 days. The percent changes in mean PAP and PVR were greater in group A than in group B. The deteriorations in respiratory condition observed during the immediate postoperative period were supposed due to the ventilation-perfusion imbalance following the sudden reliease of mechanical obstruction caused by the removal of the thromboemboli. However, the patients' postoperative respiratory condition gradually improved in both groups and the difference had vanished by the 7th postoperative day. The preoperative hemodynamic findings, especially PVR, were worse in the non-survivors than that in the survivors, indicating that the preoperative PVR is a determinant factor of outcome.

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We investigated the efficacy of thrombolytic therapy with recombinant tissue plasminogen activator (t-PA) from the standpoint of changes in hemodynamics and pulmonary oxygenation in 9 patients suffering from massive pulmonary embolism. Eight of the 9 patients presented with shock symptoms, and 4 of them required cardiopulmonary resuscitation. We immediately administered 20 million units of t-PA over the course of an hour. Systolic blood pressure (SBP), heart rate (HR), central venous pressure (CVP), systolic pulmonary arterial pressure (SPAP), PaO₂/FiO₂ ratio (P/F ratio), cardiac index (CI) and pulmonary vascular resistance (PVR) were recorded before and after t-PA administration. After t-PA infusion, HR, SPAP, CI and PVR showed significant improvement, but SBP and CVP did not change significantly.
The results demonstrated the rapid thrombolytic capability of t-PA, and as early as possible administration seemed crucial to saving the lives of patients with massive pulmonary embolism complicated by shock. Since t-PA infusion did save critically ill pulmonary embolism patients without any side effects, we believe that early thrombolytic therapy with t-PA is a life saving treatment for massive pulmonary embolism.

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Airway bleeding is one of the complications of cardiac surgery for cyanotic congenital heart disease. Sometimes conservative therapy is ineffective and death results. However, there are no definitive indications for invasive therapy. We retrospectively analyzed 53 cases of airway bleeding after cardiac surgery for cyanotic congenital heart disease between 1983 and 1993 at our institution. The greatest number of patients were suffering from pseudotruncus arteriosus. We classified the patients on the basis of efficacy of conservative therapy as follows: group 1, effective; group 2, ineffective. The mean duration of airway bleeding in group 2 (6.8 days) was significantly longer than in group 1 (2.9 days). In group 1 more than 80% of the patients stopped bleeding within 3 days, and it persisted over 5 days in only 10%. We attempted invasive therapy to treat the intractable airway bleeding in two patients by bronchial artery embofization, in two patients by pulmonary lobectomy, and in one patient compression with a Fogarty catheter. Airway bleeding was stopped in every patient except one who died intraoperatively. We conclude that invasive therapy should be considered in patients in which airway bleeding lasts more than 5 days.

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Two cases of thrombotic thrombocytopenic purpura (TTP) secondary to sepsis are reported. The pentad of consumptive thrombocytopenia, microangiopathic hemolytic anemia, fluctuating neurologic signs, fever, and renal disease appeared after sepsis in both patients. Except for thrombocytopenia, hemostatic studies were normal in one patient but prothrombin time was prolonged and fibrin/fibrinogen degradation products were slightly elevated in the other patient. Compelling evidence from the clinical, laboratory and pathologic findings suggests that disseminated intravascular coagulation (DIC) and TTP are separate entities. However, patients with TTP following sepsis may simultaneously develop DIC. We therefore emphasize the differential diagnosis of TTP and DIC in septic patients.

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This paper reports the successful treatment of a left ventricular thrombus detected and treated using transesophageal echocardiography (TEE) in an acute myocardial patient implanted with a left ventricular assist device (LVAD).
The patient underwent LVAD implantion because of severe left heart failure after coronary artery bypass grafting and anticoagulant therapy was performed by heparin administration via an indwelling catheter in the left ventricle space. On 4th day after implantation, a mobile, pedunculated, protruding left ventricular thrombus was detected by TEE, and subsequent thrombolytic therapy with urokinase infusion failed. Thus, on the 6th day surgical removal was attempted. During surgery, the thrombus was removed using a wall-sucker under TEE guidance.
We conclude that TEE is useful not only in the diagnosis of left ventricular thrombus, but also in its treatment.

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A case of severe pulmonary hypertension effectively treated with amrinone is reported. A 66-year-old man was admitted to our hospital with a diagnosis of bladder tumor, and antineoplastic chemotherapy with cisplatin, methotrexate, vinblastine and pirarubicin was initiated. Two weeks after start of the chemotherapy, pancytopenia developed. Following administration of granulocyte colony stimulating factor, chemotherapy was discontinued. One month after admission, acute respiratory failure developed and tracheal intubation was performed. The patient was admitted to the ICU with severe hypoxemia and hypercapnea (PaO₂ 48.2mmHg, PaCO₂ 49.7mmHg) and was placed on mechanical ventilation with 2cm H₂O of positive endexpiratory pressure and FIO₂=1.0. Although blood pressure and heart rate were stable, pulmonary hypertention (mean pulmonary arterial pressure 30mmHg) and interstitial pneumonia were present. Despite administration of antibiotics, steroids and urinastatin, the pulmonary hypertention was progressed. Dobutamine was administered, but the pulmonary hypertension did not improve. Amrinone was then administered intravenously in addition to dobutamine. Pulmonary arterial pressure and pulmonary vascular resistance decreased gradually without any change in pulmonary capillary wedge pressure or cardiac output, and both oxygenation and CO₂ elimination improved following amrinone administration. Amrinone induces direct pulmonary vasodilatation and has positive inotropic and afterload-reducing effects. In the present case, amrinone improved pulmonary hypertension, oxygenation and CO₂ elimination probably via direct pulmonary vasodilatation.

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