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Lactate concentration gradient from right atrium to pulmonary artery
Guillermo Gutierrez, Lakhmir S Chawla, Michael G Seneff, Nevin M Katz, Hasan Zia
Critical Care , 2005, DOI: 10.1186/cc3741
Abstract: A prospective, sequential, observational study was conducted in a medical-surgical intensive care unit. We enrolled 45 critically ill adult individuals of either sex requiring pulmonary artery catheters (PACs) to guide fluid therapy. Immediately following the insertion of the PAC, one paired set of blood samples per patient was drawn in random order from the PAC's proximal and distal ports for measurement of hemoglobin concentration, O2 saturation (SO2) and [Lac]. We defined Δ[Lac] as ([Lac]ra - [Lac]pa), ΔSO2 as (SraO2 - SpaO2) and the change in O2 consumption (ΔVO2) as the difference in systemic VO2 calculated using Fick's equation with either SraO2 or SpaO2 in place of mixed venous SO2. Data were compared by paired Student's t-test, Spearman's correlation analysis and by the method of Bland and Altman.We found SraO2 > SpaO2 (74.2 ± 9.1 versus 69.0 ± 10.4%; p < 0.001) and [Lac]ra > [Lac]pa (3.9 ± 3.0 versus 3.7 ± 3.0 mmol.l-1; p < 0.001). Δ[Lac] correlated with ΔVO2 (r2 = 0.34; p < 0.001).We found decreases in [Lac] from the RA to PA in this sample of critically ill individuals. We conclude that parallel decreases in SO2 and [Lac] from the RA to PA support the hypothesis that these gradients are produced by mixing RA with coronary venous blood of lower SO2 and [Lac]. The present study is a preliminary observation of this phenomenon and further work is needed to define the physiological and clinical significance of Δ[Lac].Pulmonary artery (PA) blood comprises the mixed venous effluent from all organs, with the notable exception of the lungs. PA O2 saturation (SpaO2) has been promoted as an index of tissue oxygenation [1,2] because it is thought to be related to the average end capillary blood PO2 [3].In a prior study [4], we measured the O2 saturation (SO2) of right atrial blood (SraO2) and SpaO2 in samples drawn from the proximal and distal ports of PA catheters (PACs) placed in critically ill patients. We noted that SpaO2 was consistently lower than SraO2 by appr
The concentration of oxygen, lactate and glucose in the central veins, right heart, and pulmonary artery: a study in patients with pulmonary hypertension
Guillermo Gutierrez, Anthony Venbrux, Elizabeth Ignacio, Jonathan Reiner, Lakhmir Chawla, Anish Desai
Critical Care , 2007, DOI: 10.1186/cc5739
Abstract: This was a prospective, sequential, observational study of hemodynamically stable individuals with pulmonary artery hypertension (n = 9) who were about to undergo right heart catheterization. Catheters were advanced under fluoroscopic guidance into the IVC, SVC, right atrium, right ventricle, and pulmonary artery. Samples were obtained at each site and analyzed for SO2, [Lac], and glucose concentration ([Glu]). Analysis of variance with Tukey HSD test was used to compare metabolite concentrations at each site.There were no differences in SO2 or [Lac] between IVC and SVC, both being greater than their respective pulmonary artery measurements (P < 0.01 for SO2 and P < 0.05 for [Lac]). SO2 and [Lac] in right atrium, right ventricle, and pulmonary artery were similar. ΔSO2 was 4.4 ± 1.4% (mean ± standard deviation) and Δ[Lac] was 0.16 ± 0.11 mmol/l (both > 0; P < 0.001). Δ[Glu] was -0.19 ± 0.31 mmol/l, which was not significantly different from zero, with SVC [Glu] being less than IVC [Glu].Mixing of SVC with IVC blood does not account for the development of ΔSO2 and Δ[Lac] in hemodynamically stable individuals with pulmonary artery hypertension. An alternate mechanism is mixing with coronary sinus blood, implying that ΔSO2 and Δ[Lac] may reflect changes in coronary sinus SO2 and [Lac] in this patient population.Blood oxygen saturation (SO2) in the superior vena cava (SVC) is approximately 2% to 5% higher than that in the pulmonary artery [1,2]. This SVC-pulmonary artery gradient in SO2 varies considerably among individuals, or even within the same person when it is measured at different times [3]. Declines in blood lactate concentration ([Lac]) from right atrium to pulmonary artery (Δ[Lac]) have also been reported [4]. The SO2 and [Lac] gradients (ΔSO2 and Δ[Lac]) probably develop as SVC blood mixes with blood from the inferior vena cava (IVC) or from the heart's venous drainage, comprised of blood emanating from the coronary sinus and Thebesian veins; alternatively (a
Traveling Thrombus in the Right Atrium: Is It the Final Destination?  [PDF]
Maneesh Bhargava,Erhan Dincer
Case Reports in Pulmonology , 2012, DOI: 10.1155/2012/378282
Abstract: Right heart thrombus is rare in structurally normal heart. Here, we report a 74-year-old man with a right atrial thrombus who presented with shortness of breath. 1. Introduction Right heart thrombus in the absence of structural heart disease, atrial fibrillation, or catheter located in the heart is rare and usually represents a traveling clot from the venous system to the lung, known as right heart thrombi-in-transit (RHThIT). The optimal therapy for RHThIT remains controversial. We elected surgical thromboembolectomy for our patient. However, the thrombus in the right atrium had migrated to the pulmonary circulation during the surgery. 2. Case Report A 74-year-old man presented to our ER with shortness of breath. He had a recent history of air and car travel lasting seven hours. His past medical history was remarkable for DVT, prostate cancer, obstructive sleep apnea, hypertension, and chronic kidney disease stage 1. His examination was unremarkable except for mild tachycardia and hypoxemia at rest. Laboratory studies showed an elevated D-dimer, troponin, and BNP. An occlusive thrombus extending from the mid-thigh to the mid-calf on the right was seen on a Doppler study. A CT angiogram of the chest was not performed due to high creatinine but ventilation-perfusion scan showed a high probability for pulmonary embolism. Trans-thoracic echocardiography (TTE) revealed a large mobile mass extending from the right atrium through the tricuspid valve into the right ventricle (Figure 1). Right ventricle was mildly dilated with decreased systolic function. Figure 1: Transthoracic echocardiography showing a large right atrial thrombus (white arrow) extending into the right ventricle. A retrievable IVC Tulip filter was placed. After consultation with cardiology, pulmonary medicine, and cardiovascular surgery, it was decided to pursue surgical exploration with thrombectomy. The presence of the right atrial mass was confirmed by TTE prior to surgery. Right atrial exploration demonstrated no masses. A 2?cm incision was made in the pulmonary artery and a large thrombus was removed from the orifice of the left pulmonary artery (Figure 2). Pathologic examination showed laminated thrombus confirming diagnosis of pulmonary embolism. Figure 2: The thrombus removed from the left pulmonary artery. Postoperatively in the ICU, the patient needed cardio-pulmonary resuscitation for pulseless electrical activity on two separate occasions within hours of surgery. Next four days, he required high degree of supportive care with pressors, ionotropes, mechanical ventilation, and
Lipoma of the right atrium
Silveira, Wilson Luiz da;Nery, Max Weyler;Soares, Erica Coelho Garcia;Leite, Adélio Ferreira;Nazzetta, Hernando;Batista, Márcia Andery Ludovico;Oliveira, Cacilda Pedrosa de;Oliveira, Vilmondes Gon?alves de;
Arquivos Brasileiros de Cardiologia , 2001, DOI: 10.1590/S0066-782X2001001000006
Abstract: the patient is a 54-year-old asymptomatic male with a tumor in the right atrium that was diagnosed on transesophageal echocardiography and confirmed as a lipoma of the right atrium on computerized tomography. the patient underwent surgical repair with extracorporeal circulation. the tumor was resected, and its base of implantation in the atrium was repaired with a flap of bovine pericardium. the diagnosis of lipoma was confirmed on histopathological examination. locating of the tumor with the aid of transesophageal echocardiography was very useful in the strategy of cannulation of the venae cava for installation of the circuit of extracorporeal circulation. the patient had a good postoperative evolution.
Lipoma of the right atrium
Silveira Wilson Luiz da,Nery Max Weyler,Soares Erica Coelho Garcia,Leite Adélio Ferreira
Arquivos Brasileiros de Cardiologia , 2001,
Abstract: The patient is a 54-year-old asymptomatic male with a tumor in the right atrium that was diagnosed on transesophageal echocardiography and confirmed as a lipoma of the right atrium on computerized tomography. The patient underwent surgical repair with extracorporeal circulation. The tumor was resected, and its base of implantation in the atrium was repaired with a flap of bovine pericardium. The diagnosis of lipoma was confirmed on histopathological examination. Locating of the tumor with the aid of transesophageal echocardiography was very useful in the strategy of cannulation of the venae cava for installation of the circuit of extracorporeal circulation. The patient had a good postoperative evolution.
Acute pressure overload of the right ventricle. Comparison of two models of right-left shunt. Pulmonary artery to left atrium and right atrium to left atrium: experimental study
Mihalis Argiriou, Dimitrios Mikroulis, Timothy Sakellaridis, Vasilios Didilis, Apostolos Papalois, George Bougioukas
Journal of Cardiothoracic Surgery , 2011, DOI: 10.1186/1749-8090-6-143
Abstract: Thirty, male Large White pigs weighting in average 21.3 kg ± 0.7 (SEM) were divided into two groups (15 pigs per group): In group 1, banding of the pulmonary artery and a pulmonary artery to left atrium shunt with an 8 mm graft (PA-LA) was performed and in group 2 banding of the pulmonary artery and right atrial to left atrial shunt (RA-LA) with a similar graft was performed. Hemodynamic parameters and blood gases were measured from all cardiac chambers in 10 and 20 minutes, half and one hour interval from the baseline (30 min from the banding). Cardiac output and flow of at the left anterior descending artery was also monitored.In both groups, a stable RVF was generated. The PA-LA shunt compared to the RA-LA shunt has better hemodynamic performance concerning the decreased right ventricle afterload, the 4 fold higher mean pressure of the shunt, the better flow in left anterior descending artery and the decreased systemic vascular resistance. Favorable to the PA-LA shunt is also the tendency - although not statistically significant - in relation to central venous pressure, left atrial filling and cardiac output.The PA-LA shunt can effectively reverse the catastrophic effects of acute RVF offering better hemodynamic characteristics than an interatrial shunt.Pulmonary hypertension and right ventricular dysfunction are associated with poor survival. Management of patients with acute decompensate RV failure is largely empiric and targeted towards treating underlying precipitants while optimizing conditions of RV preload, afterload and contractility.However, right-sided heart failure remains a major problem in the long-term follow-up, leading to impairment of functional status, severe arrhythmia, and premature death. Treatment consists of pulmonary vasodilator therapy, long-term oxygen therapy, anticoagulation, and lung transplantation, or, at times, heart-lung transplantation. Management strategies for patients who develop acute refractory right ventricular failure are:
Renal Angiomyolipoma with Fatty Thrombus Extending to the Right Atrium: An Exceptional Presentation  [PDF]
Yassine Nouira,Yousri Kallel,Mourad Gargouri,Ahmed Sellami,Rami Boulma,Jalel Ziedi,Mohamed Chelif,Sami Ben Rhouma,Taoufik Kalfat,Adel Khayati
Case Reports in Urology , 2013, DOI: 10.1155/2013/120383
Abstract: This paper reports the case of 34-year-old woman who presented with bilateral renal angiomyolipomas (AMLs). On the right side, there was a large AML with a fatty thrombus extending to the right atrium. The treatment consisted of right nephrectomy and complete thrombectomy with extracorporeal circulation and right atriotomy. Postoperatively, the patient was septic and died on postoperative day 7 because of septic shock. 1. Introduction Renal angiomyolipomas (AMLs) are benign renal tumors that warrant only excision when symptomatic or large. The major known complication of these tumors is rupture and retroperitoneal bleeding that may be massive and threatens the patient’s life [1]. Herein, we report a case depicting the dangerousness of these tumors with a fatty thrombus of the inferior vena cava extending to the right atrium. This is a rare and serious presentation of renal AML. 2. A Case Report A 34-year-old woman, with unremarkable medical history, presented with right lumbar pain beginning two weeks previously. Physical examination revealed a 20?cm tender right lumbar mass with no fever. No skin lesions were noted, and blood pressure was 120/70?mmHg. CT scan showed multiple bilateral AML with various sizes with one 8?cm perihilar lesion with a fatty thrombus extending into the inferior vena cava to the right atrium. Also, there was evidence of old hematoma in the renal fossa extending in the pelvis (Figure 1). Figure 1: (a) Coronal CT scan showing renal AML (*) with inferior vena cava thrombus (arrow). (b) The thrombus extends up to right atrium. Note the presence of a large perirenal infected hematoma due to an old bleeding from lower pole AML (**). Given this unusual extension of the tumor and the risk that a part of the thrombus may detach and cause pulmonary embolism, rapid surgical intervention was decided. The patient was first operated through a chevron incision, the right colon was reflected, and the whole right kidney was dissected. The right renal artery was ligated, and the kidney was left attached only by the renal vein with the thrombus inside. At the level of the lower pole of the kidney, there was a 15?cm infected hematoma that was evacuated and cleaned. A sternotomy was then performed, and extracorporeal circulation was installed; the right atrium was opened, and the distal part of the thrombus was visualized. A circumferential incision of the renal vein was done, and the kidney was extracted along with the fatty thrombus attached (Figure 2) under visual control from the right atrium (Figure 3). Figure 2: (a) Operative specimen showing
Inflammatory Myofibroblastic Tumor of the Right Atrium
Neerod K. Jha,Michel Trudel,Gregory P. Eising,Peter Lange,Awatif Al Sousi,Wael Al Mahmeed,Javed A. Khan,Moataz A. Saleh,Friederike Von Canal,Virendra K. Misra,Norbert Augustin
Case Reports in Medicine , 2010, DOI: 10.1155/2010/695216
Abstract: Cardiac inflammatory myofibroblastic tumor (IMT) is a rare entity and is associated with distinct clinical, pathological and molecular features. The clinical behavior, natural history, biological potential, management and prognosis of such tumors are unclear. We present herewith an adolescent girl who presented with similar entity involving the junction of the right atrium and the inferior vena cava (IVC) in association with thrombocytosis and IVC thrombosis leading to obstruction of blood flow. Diagnostic tools included imaging and immuno-histopathology studies. Surgical management included resection of the tumor and thrombo-embolectomy of the IVC under cardiopulmonary bypass. This case is unique due to association of complete obstruction of IVC caused by the strategic location of the tumor, thrombosis of vena cava and association of thrombocytosis. These features have not been reported yet in relation to the cardiac IMT. This report will help in better understanding and management of similar cases in terms of planning cannulation of femoral veins or application of total hypothermic circulatory arrest during cardiopulmonary bypass and prompt us to look for recurrence or metastasis during follow up using echocardiography and laboratory investigations. The possibility of IMT should be kept in the differential diagnosis of cardiac tumors especially in children and adolescents.
Do right atrium to mixed venous oxygen saturation gradients mirror heart oxygen uptake?
AJ Pereira, P Rehder, C Dias, L Figueiredo, E Silva
Critical Care , 2009, DOI: 10.1186/cc7806
Abstract: Sixteen large white pigs, weight 35 kg, in general anesthesia (isofluorane, fentanyl, pancuronium), fully monitored (electrocardiography, etCO2, invasive pressure, pulmonary artery catheter, portal vein Doppler ultrasound flow, small bowel tonometry), were studied. Fifteen pigs were submitted to fecal peritonitis sepsis (1 g/kg feces plus 150 ml warm saline) after fluoroscopy-guided coronary sinus catheterization and the last one was the sham. Laboratory data (blood samples collected from the coronary sinus, right atrium, pulmonary artery) and hemodynamic data were registered hourly. After the experiments, pigs were sacrificed with a sedative overdose and KCl 19.1% injection.Central to mixed venous SvO2 curve distances vary along time (hours) (Figure 1) more in septic pigs than in the sham (Figure 2). Measurements of SvO2 from the coronary sinus reach extremely low values (Figure 3).Absolute SvO2 gradient variations along time, in sepsis, may be the consequence of coronary sinus contribution, considering the extremely low values observed. Further studies should explore whether these gradient variations may be an indicator of myocardial oxygenation status.
Primary right atrium angiosarcoma mimicking pericarditis
Marina Kontogiorgi, Demetrios Exarchos, Christos Charitos, Ioannis Floros, Demetra Rontogianni, Charis Roussos, Christina Routsi
World Journal of Surgical Oncology , 2007, DOI: 10.1186/1477-7819-5-120
Abstract: We present a case of a young male who was transferred to our hospital because of shock and multiple organ failure after a complicated pericardial biopsy. During the previous seven months he presented with recurrent episodes of pericardial effusions and tamponade. Chest computed tomography revealed a mass in the right atrium, infiltrating the myocardium and pericardium. During emergency surgery that followed, the patient died because of uncontrolled hemorrhage. Autopsy revealed the mass of the right atrium, which was identified on histological examination as primary cardiac angiosarcoma.This case highlights the difficulties both in early diagnosis and in the management of patients with cardiac angiosarcoma.Primary tumors of the heart are extremely rare and the majority of them are benign [1-7]. Angiosarcoma is the most common primary malignant tumor in adults. It is a highly aggressive tumor characterized by a predilection in the right side of the heart, a short clinical course and a fatal outcome. Because of nonspecific clinical presentation early diagnosis is difficult. We report a case of right atrial angiosarcoma that presented with recurrent pericardial effusions and cardiac tamponade.A 29-year-old male patient was transferred to our Intensive Care Unit (ICU) from another hospital, because of shock and multiple organ failure after a complicated pericardial biopsy. Seven months before, after a syncopal episode, he had been diagnosed with cardiac tamponade diagnosed by a transthoracic echocardiogram (TEE). Subxiphoidal drainage of 700 ml hemorrhagic fluid was performed resulting in hemodynamic stabilization. Cytologic examination of the fluid was negative for malignancy. Pericarditis was diagnosed caused by chlamydia; azithromycin and anti-inflammatory drugs were administered. For the next four months the patient was relatively well except for complain of easy fatigue. From that point on, he gradually presented dyspnea on exertion, along with pain in the back and
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