Is surgery indicated in massive pulmonary embolism?

Massive pulmonary embolism is a life-threatening occurrence with significant morbidity and mortality. Surgical embolectomy (via thoracotomy, suction catheter, or balloon catheter) is a potentially life-saving procedure. Attempts at medical therapy may waste precious time and, if unsuccessful, almost certainly result in a fatal outcome. On the other hand, many patients with massive pulmonary embolism die within the first hour of presentation (before surgical services can be mobilized); medical therapy is highly effective if instituted quickly; and results of surgical embolectomy are not impressive. Surgical embolectomy therefore should be reserved for rare cases when the diagnosis is irrefutable, medical therapy has failed or is contraindicated, and surgical intervention can be performed immediately.

What are the typical presenting symptoms in patients with pulmonary hypertension?

Dyspnea on exertion is most common. Because this symptom is nonspecific, patients are often thought to have some other respiratory or cardiac disorder. Other symptoms include chest pain, presyncope or syncope, and edema.

What are the usual physical findings in patients with pulmonary hypertension?

By the time most patients present, pulmonary hypertension is already severe. Findings on physical examination might include:

Loud pulmonic valve closure sound (P2)

Right ventricular heave

Murmur of tricuspid regurgitation (a systolic murmur over the left lower sternal border) Murmur of pulmonic insufficiency (a diastolic murmur over the left sternal border)

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