![]() The diagnosis of heart failure is suspected on both clinical and radiographic grounds. Esterl, in Essential Emergency Medicine, 2007 Diagnosis 147,148 Pulmonary dysfunction associated with inhalation injury is discussed in a separate chapter. As a result, clinical studies of burn-injured patients suggest that, in the absence of inhalation injury, the lungs do not typically develop edema. Furthermore, lung lymph flow may increase considerably to counteract interstitial fluid accumulation. 146 Analysis of lung lymph sampled in large animal models after 40% TBSA burn injury showed no evidence of increased microvascular permeability. However hypoproteinemia may be the greatest contributing factor to postburn pulmonary edema. It is likely that some degree of left heart failure also contributes to the increased capillary pressure. 54,145 By increasing capillary pressure, venular constriction may contribute to pulmonary edema. Pulmonary wedge pressure is increased more than left atrial pressure after experimental burn injury due to postcapillary venular constriction. 7,54 In contrast to the systemic circulation, however, pulmonary edema is unusual and typically does not occur until after the fluid resuscitation phase is complete. In large burns there is a pronounced increase in PVR that corresponds with the increased SVR. Kramer, in Total Burn Care (Fifth Edition), 2018 Pulmonary Circulation and Lung Edema Therefore, in most patients, the possibility of sudden death from a cardiac source is greater than the risk of prosthetic valve infection, and valve replacement should proceed if warranted. In patients who present with severe aortic insufficiency resulting from endocarditis, aortic valve replacement during active infection comes with <10% chance of infection. Persons with a preoperative ejection fraction < 35% have a 10-year postoperative survival rate of 41% with an ejection fraction of 35–49%, the 10-year postoperative survival rate is 56% and if the ejection fraction is 50% or more, the 10-year postoperative survival rate is 70%. In general, aortic valve surgery should be considered before the ejection fraction falls below 55% or the end-systolic dimension becomes greater than 55 mm. In asymptomatic persons with aortic insufficiency, surgical intervention is warranted if frank left ventricular enlargement or moderate dysfunction is present. Persons who are without contraindications to surgery should proceed to early valve surgery because waiting until severe symptoms develop has been associated with excess mortality. In these instances, the acute process should be treated and the need for valve replacement considered after recovery based on symptoms and left ventricular function. In patients with chronic aortic regurgitation, acute illness can lead to decompensation. This is particularly so when left ventricular pressures have increased to the point of mitral valve preclosure. Schulman MD, in Critical Care Secrets (Fourth Edition), 2007 27 When is surgery indicated in aortic regurgitation?Įarly surgical intervention is indicated when patients present with heart failure resulting from valve dysfunction. ![]()
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