KOMPLİKASYONLAR & İLGİNÇ OLGULAR

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1 KOMPLİKASYONLAR & İLGİNÇ OLGULAR Prof. Dr. Ender SEMİZ Medical Park Gebze Hastanesi

2 49 yaşında, erkek hasta Dışarda gezerken senkop atağı, kafa travması Götürüldüğü hastanede EKG değişikliği ve TR: 0.14 >>> Q dalgasız MI tanısıyla sevk Acil servise getirildiğinde genel durumu iyi, obez, kan basıncı cmhg, kalp-akciğer muayenesi normal Özgeçmişinde NIDDM, hipertansiyon Senkop ve kafa travması nedeni ile acil serviste BBT çekimi

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4 Koroner yoğun bakıma yatırılan hastada ilk laboratuvar değerleri: Hg: 14.4gm, lökosit: , trombosit: , Tr I: 0.19, CK-MB: 9.8, Kreatinin: 0.8 mg, ALT: 45, AST: 23 Yoğun bakımda bulantı-kusma, bilinç kaybı tekrarı, ventriküler takikardi, kardiyovasküler arrest Başarılı canlandırmayı takiben acil koroner anjiyografi

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13 ASA 300 mg, Fraxiparin 2x0.6cc, Metoprolol 50 mg, Amiodaron infüzyonu, O2 tedavisi Hg: 13gm, lökosit: 9620, trombosit: , Tr I: 0.32, CK-MB: 13, kreatinin: 1.1, ALT: 40, AST: 20, Na: 139, K: 4.5 Epigastrik duyarlılık nedeni ile genel cerrahi konsültasyonu >> akut gastrit

14 Bradikardi ve kusmanın devam etmesi, tekrarlayan arrest nedeni ile >>> Nöroloji konsültasyonu: Fizik muayene normal. Kafa travması öyküsü nedeniyle nöroşirürji bölümünce de görülmesi. Acil serviste çekilen BBT >> Normal. Öncelikli olarak vazo-vagal senkop düşünüldü. Kardiyak neden yok ise, EEG de çekilmek üzere Nöroloji polikliniğine kontrol Takipte genel durumu iyi, yakınması yok. EKG Holteri ve gerekirse EFÇ uygulanmak üzere 4 gün sonra taburcu

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16 Taburcu olduktan 6 gün sonra tekrarlayan senkop atakları ile tekrar yatırıldı. Genel durumu iyi. Kan basıncı normal, hafif takikardik ve takipneik. Kalp muayenesinde ek ses ya da üfürüm yok. Hg: 12.4gm, lökosit: 6930, trombosit: , kreatinin: 0.9, Na: 139, K: 4.3, arteriyel kanda ph: 7.496, po2: 52 mmhg, pco2: 25.2 mmhg, %so2: 90.1 HCO3: 19.5mmol

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24 Pulmoner emboli tanısı ile hastaya sistemik 100 mg tpa tedavisi uygulandı ( ) Heparin 1000 Ü/saat Bilateral alt ekstremite venöz Doppler: Sol popliteal vende total tromboz ile uyumlu akım kaybı, çapta artış ve kompresyona yanıtsızlık

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32 Ekosonic 106cm 40 cm endovascular device EKOS Corporation

33 Ekosonic 106cm 40 cm endovascular device EKOS Corporation

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37 Aegisy vena cava filtresi Lifetech Scientific (Shenzhen) Co.

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42 Pulmonary Embolism Annual incidence United States: >600,000; Europe >1,000,000 Up to 200,000 deaths in the US annually More die of PE in the US than AIDS, motor vehicle accidents & breast cancer combined PE categories High Risk Intermediate Risk Massive (5% of PE patients): 58% 90-day mortality rate Patients present in hemodynamic collapse with cardiogenic shock; high early mortality rate due in part to right ventricular failure Sub-massive (40% of PE patients): 22% 90-day mortality rate Presenting with thrombosis usually in one or both of the left and right pulmonary arteries, hemodynamic compensation and maintenance of adequate systolic arterial blood pressure albeit with right heart strain consistent with imminent right heart failure Minor (55% of PE patients): 15% 90-day mortality rate Presenting with small clots in the distal pulmonary vessels, pleuritic chest pain, mild tachycardia and possibly hemoptysis Goldhaber SZ, Visani L, De Rosa M, et al. for ICOPER. Acute pulmonary embolism; clinical outcomes in the International Cooperative Pulmonary Embolism Registry. Lancet 1999;353:

43 The Challenge why Thrombus Is So Difficult To Dissolve Plasminogen receptor sites are embedded into thrombus during formation Speed of lysis depends on ability of lytic to access plasminogen receptor sites** Tightly wound fibrin strands prevent lytic from penetrating the thrombus, limiting access to plasminogen receptor sites ** Francis, Charles W. et al. Ultrasound Accelerates Transport of Recombinant Tissue Plasminogen Activator into Clots. Ultrasound in Medicine and Biology 21.3 (1995):

44 Ultrasound accelerated Mechanism of Action Ultrasound energy causes fibrin strands to thin and loosen, exposing plasminogen receptor sites thrombolysis (Science studied over 4 decades) WITHOUT ULTRASOUND ENERGY Thrombus permeability and thrombolytic penetration are dramatically increased WITH ULTRASOUND ENERGY Ultrasonic pressure waves force drug deep into the clot and keep it there Drug acts faster, clearing clot sooner with reduced bleeding complications, & ULTRASONIC ENERGY & THROMBOLYTIC No hemolysis No valve or wall damage Very low risk of embolization

45 Ultrasound mechanism of action Standard Infusion Catheter Plasma Clot EkoSonic Endovascular Device Plasma Clot Spread of Stained t-pa Spread of Stained t-pa Thrombus exposed to ultrasound absorbed 48% more t-pa in one hour, 84% more t-pa in two hours and 89% more t-pa in 4 hours than thrombus not exposed to ultrasound pressure. 7 7 Francis, CW, et al. Ultrasound Accelerates Transport of Recombinant Tissue Plasminogen Activator into Clots. Ultrasound in Medicine and Biology 21.3 (1995):

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49 Submassive Pulmonary Emboli, An Unrecognized And Often Fatal Condition: Incidence, Diagnosis And Treatment With Ultrasonic Thrombolysis Tod C. Engelhardt, MD Chair, Cardiovascular and Thoracic Surgery Division, East Jefferson General Hospital, Metairie, LA, USA 38th Annual VEITHsymposium, New York, NY November 17, 2011

50 East Jefferson General Hospital New Orleans Presenter Disclosure Financial: T. Engelhardt is a consultant for EKOS Corporation Approved Uses: The device used in this presentation has received European approval (CE Mark) for the treatment of pulmonary embolism (PE) The device discussed in this presentation has been cleared by the US FDA for placement in the PA for use with solutions Unapproved/Unlabeled Uses: This presentation includes information on uses of drug and device that have not been approved or cleared by the US FDA for PE treatment

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