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Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. Systemic anticoagulation remains the recommended treatment for low-risk PE. Systemic thrombolysis is the recommended treatment for PE with hemodynamic compromise (massive/high-risk PE). A significant number of patients are not candidates for systemic thrombolysis due to the bleeding risk associated with thrombolytics. Historically, surgical pulmonary embolectomy (SPE) was recommended for massive PE with hemodynamic compromise for these patients. In the last decade, catheter-directed thrombolysis (CDT) has largely replaced SPE in the patient population with intermediate risk PE (submassive), defined as right heart strain (as evidenced by right ventricle enlargement on echocardiogram and/or computed tomography, usually along with elevation of troponin or B-type natriuretic peptide). Use of CDT increased in the last few years due to high incidence of PE in hospitalized patients with coronavirus disease 2019 pneumonia, and the use of mechanical thrombectomy (initially reserved for those with contraindications to thrombolysis) has also grown. In this article, we discuss the value of the PE response team, our approach to management of submassive (intermediate risk) and massive (high risk) PE with systemic thrombolytics, CDT, mechanical thrombectomy, and surgical embolectomy.

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Repeat operations involving the aortic root, ascending aorta, and arch (proximal aorta) are technically challenging. These procedures are associated with higher operative mortality and morbidity. A dedicated surgical team with special skill set is essential to manage these complex patients. Redo root and proximal aortic procedures can be done with acceptable risk in most patients with attention to details involving the surgical procedure, patient selection, and perioperative management.

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Primary hyperparathyroidism from a parathyroid adenoma is common. Ectopic parathyroid glands have been reported in numerous locations, including the chest. We present a single case report of an intrapericardial parathyroid gland found after failed bilateral neck exploration. The patient presented with severe, recurrent nephrolithiasis and acute renal failure prior to his surgical intervention. Repeat imaging identified a parathyroid adenoma in the mediastinum that was localized to the aortopulmonary window. After attempts at minimally invasive thoracotomy and posterolateral thoracotomy, a median sternotomy was ultimately required to identify the adenoma.

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Atrial arrhythmias (AAs) after noncardiac thoracic surgery may be associated with increased mortality, length of stay (LOS), and health care expenditures. A retrospective analysis of adult patients who underwent thoracotomy at our institution from January 2002 to June 2008 was performed. Of 820 patients identified, 112 (14%) developed an AA. Overall mortality was 7.14% in the AA group and 3.11% in the non-AA group (relative risk, 2.30; 95% confidence interval, 1.06-4.91; P = 0.035). Median intensive care unit (ICU) LOS and total LOS were 4.0 and 7.0 days in the AA group and 3.0 and 5.0 days in the non-AA group (ICU LOS P < 0.01 and total LOS P < 0.001). Median health care expenditures in the AA group were approximately $37,000 versus $28,000 in the non-AA group (P < 0.001). The development of an AA in this patient population may be associated with increased mortality, ICU and total LOS, and health care expenditures.

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BACKGROUND: Lifestyle modification and appropriate medical therapy improve long-term outcomes following coronary artery bypass grafting (CABG). Our institutional experience suggested that evidence-based recommendations were not being followed postdischarge after CABG. We undertook this study to document our rate of compliance with evidence-based guidelines and to correct deficiencies in our discharge practices. METHODS: Seven evidence-based interventions were studied after CABG: (1) institution of beta-blocker therapy, (2) angiotensin-converting enzyme (ACE) inhibitor therapy, (3) aspirin, (4) lipid-lowering therapy, (5) smoking cessation intervention, (6) heart-healthy diet therapy, and (7) physical activity recommendations. The rate of compliance with guidelines in 50 control patients was measured at discharge. A multidisciplinary team including cardiac surgeons, nurses, dieticians, physical therapists, and clinical pharmacists evaluated the guideline compliance in the control group and developed interventions to assure guideline compliance at the time of discharge. A subsequent study group of 50 patients was then assessed prospectively to measure the guideline compliance after institution of intervention programs. The multidisciplinary team agreed on predefined acceptable compliance limits as follows: (1) >80% of patients receive ACE inhibitors at discharge, (2) 100% of patients receive beta-blockers, aspirin, and lipid-lowering agents at discharge, and (3) 100% of patients receive lifestyle modification counseling at discharge. Compliance with guidelines was defined as documentation in the medical record of provision of medications and lifestyle counseling at the time of discharge. RESULTS: In the control group, the rate of guideline compliance was surprisingly low. Rates of compliance with guidelines increased significantly after the multidisciplinary interventions were undertaken. CONCLUSIONS: We conclude that compliance with guidelines known to improve long-term outcome is suboptimal after CABG. A multidisciplinary intervention program can improve compliance with currently accepted guidelines and quality indicators in patients following CABG.

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A 56-year-old man with heparin-induced thrombocytopenia with thrombosis syndrome (HITTS) received anticoagulation with recombinant hirudin (lepirudin) for emergency coronary artery bypass graft (CABG) surgery and aortic valve replacement. The patient experienced life-threatening refractory bleeding that was successfully treated with recombinant factor VIIa. He had a history of infective endocarditis that resulted in severe aortic insufficiency, three-vessel coronary artery disease, and acute renal failure requiring hemodialysis. The patient was transferred from another hospital for the emergency surgery, but before his transfer, he developed HITTS secondary to therapeutic heparin for a deep vein thrombosis of the lower extremity. The presence of HITTS, the urgent nature of the case, and the availability of the direct thrombin inhibitor led the surgical team to select lepirudin for anticoagulation to facilitate cardiopulmonary bypass. After separation from cardiopulmonary bypass, the patient was in a coagulopathic state due to the inability to reverse the lepirudin and the slowed elimination of the drug secondary to inadequate renal function. As a result, the patient experienced excessive generalized oozing that was unresponsive to traditional therapies and blood product transfusions. Recombinant factor VIIa 35 microg/kg was given as rescue therapy. The bleeding slowed, which allowed placement of chest tubes and closing of the sternum. The patient was transferred to the intensive care unit in stable condition with no evidence of thrombosis in the freshly placed bypass grafts or on the bioprosthetic valve. Recombinant factor VIIa appears to be a suitable option as salvage therapy in patients with refractory bleeding secondary to anticoagulation with a direct thrombin inhibitor during cardiac surgery.

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Cardiac surgery often is associated with a significant disruption of the coagulation system, particularly in high risk patients such as those undergoing placement of ventricular assist devices. This type of severe coagulopathy can lead to life threatening bleeding that can require massive transfusions to restore hemostasis. Recently, recombinant activated factor VII (rFVlla) has been +used as an alternative to massive transfusion for the treatment of refractory bleeding in several patient populations, including cardiac surgery patients. In the case reported here, the patient's risk was compounded by multiple operations in a short period of time and circulatory collapse that was initially managed with a shortterm left ventricular assist device. After multiple failed attempts at weaning the patient from circulatory assistance, he was taken back to the operating room for conversion to a chronic, implantable device. This procedure was complicated by a severe coagulopathy secondary to a myriad of factors commonly encountered after the use of cardiopulmonary bypass. The administration of rFVlla resulted in a rapid cessation of bleeding without thrombotic complications. This is the first case reported involving an acute to chronic bridge patient. Despite the anecdotal success of rFVlla, further clinical research is needed to establish both the safety and economic feasibility of this agent.

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OBJECTIVE: To report a case of successful use of recombinant factor VIIa (rFVIIa) for the treatment of refractory bleeding in a patient undergoing orthotopic heart transplantation. CASE SUMMARY: A 57-year-old white male with idiopathic cardiomyopathy was taken to the operating room for explantation of his left-ventricular assist device and orthotopic heart transplantation. He experienced excessive generalized oozing that required transfusions of multiple units of blood products and significant amounts of Cellsaver (washed red blood cells via autotransfusion) without achieving adequate hemostasis. After ruling out any obvious surgical sources of bleeding and attempting to correct all coagulation deficiencies, the clinicians administered rFVIIa 90 microg/kg. The oozing rapidly declined to a negligible level, chest tubes and sternal wires were placed, and the chest was closed. The patient was on minimal inotropic support and was transferred to the intensive care unit in stable condition. DISCUSSION: Cardiac surgery is often associated with significant disruption of the coagulation system, particularly in high-risk patients, such as those undergoing removal of a ventricular assist device and subsequent orthotopic heart transplantation. This can lead to life-threatening bleeding that can require multiple hemostatic agents and significant transfusions to restore hemostasis. Recently, rFVIIa has been utilized as an alternative to massive transfusion for treatment of refractory bleeding in several patient populations, including some cardiac surgery patients. CONCLUSIONS: rFVIIa appears to be a viable option as rescue therapy for treatment of refractory bleeding following orthotopic heart transplantation. Despite the anecdotal success of rFVIIa in this setting, further clinical research is needed.

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