Dr. Goldhaber - I couldn't agree with you more on the recovery and return to "normalcy" that Serena has shown.  However, I wanted to point out that grass courts (the ones used at Wimbledon) are in fact the FASTEST of all the tennis court services requiring very quick reflexes and athleticism.  Just another reason to be inspired by her recovery and return to tennis elite.  I hope she can be an inspiration to patients world-wide.

Dear Dr Golhaber,

I had a slightly knotty problem that I should be glad to have your viewpoint on.  A young male operated for a glioma 2 weeks back has been diagnosed to have a massive PTE (spiral CT: Rt PA cut off Lt PA significant obstruction). The odd thing is that his PA pressure are very high (RAP + 80 mm Hg) suggesting chronic PTE. Is there any role for thrombolysis (local or IV) in this scenario?

Regards 

Dr Ajay

Dear Dr. Ajay:

Thank you for sharing this patient with us.  I've seen young patients with large first-time PE generate PE systolic pressures as high as 80 mm Hg.  Because of the glioma, thrombolysis is contraindicated, both systemic and local thrombolysis (peripheral IV and catheter-based).

 A retrievable filter makes sense at this point because a second PE during this early recovery period could be fatal.

 It's probably OK to give full IV heparin, as soon as your neurosurgeon agrees.

 If more aggressive treatment is needed, and it might not be, the next step to consider is open surgical embolectomy. 

Please let us know how you decide to manage the patient and let us know, too, how the patient is doing clinically.

Best regards, SZG

Dear Dr Goldhaber,

Thank you very much for your kind and comprehensive reply.

The patient has already had a retrievable filter placed and is on continuous heparin being overlapped with warfarin. (We prefer an infusion of unfractionated heparin in acute patients at risk of bleeding as we do not have facilities to monitor anti Xa levels.)

He is presently stable and seems to be improving.He is now about 4 days post filter placement and on warfarin.

I was wondering, quite apart from the world of clinical trials, how good is local thrombolysis as compared to systemic?

Once again thank you for your kind reply.

Regards

Dr Ajay