Detection of right pulmonary artery thrombosis by two-dimensional echocardiography.


Proof of decreased mortality requires a demonstration that the length of survival is increased. I am, of course, delighted that after a decade of widespread use of pulmonary vasodilators, their safety and efficacy will at last be tested. If you have any influence on these clinical trials, could you suggest that: 1) workup deaths (deaths resulting from catheterization, recatheterization, open lung biopsy and drug titration, etc.) be included in the final statistics; 2) patients be informed that premature death is one of the possible outcomes; 3) sequential analysis be performed so that as few patients as possible are exposed to the hazards of the trial; and 4) an estimate of quality of life in the treated vs untreated group be included so that if there is a significant subgroup which is improved, this will not be overlooked. The New York Heart Association classification could be used for this purpose. Details concerning patient protection during clinical trials can be found in Silverman's book,5 a complex treatment by Feinstein,6 and a simplified account by me.7 I did not claim personal rigorous honesty. The words in my column say, "the candidates are provided rigorously honest informed choices about the procedure (heart-lung transplantation)." The honesty is provided by my surgical and medical colleagues who frequently serve as my medical conscience. Judging by the lack of understanding manifested by some patients with PPH during treatment with pulmonary vasodilators, perhaps the more general use of surrogate consciences might not be a bad idea.' The data which I used from the PPH Registry were provided in the form of periodic printed reports from the Registry, by my direct communication with Drs. S. Rich and P. Levy (who were very forthcoming as was I), and by a definitive publication in the Annals of Internal Medicine,4 I do plan to discuss the PPH Registry report in a future column. I believe the term "vilify" to be doubly inaccurate. It is inaccurate from the semantic standpoint and it does not describe my state of mind. However, as my mindset has become an issue, let me describe it as accurately as I can. For this purpose, perhaps the word "appalled" would be the most accurate term. It is difficult for me to accept the fact that patients died during the course of being worked up for a registry. I have been informed that there were deaths clearly related to drug titration and probably to open lung biopsy. The latter issue became sharp enough so that open lung biopsy was explicitly removed as a requirement for inclusion in the Registry. The final report equivocates with respect to this issue as follows: " . . . ten reported adverse reactions from the catheterization (not including drug testing)."4 Does this mean that there were no adverse reactions during drug testing (I know that there were), or does this mean that there were deaths during drug testing but, if the patient died at that stage, he/she no longer qualified for the Registry and was excluded from the data? If the latter is true, as I have been led to believe, this is surely one of the most ironic literary treatments of human death since Gogol's "Dead Souls".' And were there no deaths during Registry workups from (surrounding) open lung biopsy? If my information is wrong and no patient died during the peri-workup period, then I will issue a public apology in my column on the Registry report. I will predict that no apology will be required. I do not agree that past therapeutic efforts in PPH is the process by which "more pieces will be yielded until the mystery of PPH is ultimately solved." As noted above, there are well defined processes for establishing the safety and efficacy of therapeutic modalities in medicine.57 These have not been used. As a result, what has taken place does not even resemble jigsaw puzzle solving. It has been more like using a Ouija board to come up with answers. I realize that in an exchange which is this sharp, the original letter writer does not have the chance for a final rebuttal. In consideration of this, I invite Dr. Rubin to submit a column for Chest on "the risks benefits of pulmonary vasodilators in pulmonary hypertension" so that you can present your ideas in greater detail and without a rebuttal by me. Eugene D. Robin, M.D., Stanford University, Stanford, CA

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Cite this paper

@article{Thompson1988DetectionOR, title={Detection of right pulmonary artery thrombosis by two-dimensional echocardiography.}, author={Ross W Thompson and P W Waytz and Tommy Cheng and Richard W. Asinger}, journal={Chest}, year={1988}, volume={93 4}, pages={895-6} }