RESUMO
Management of acute decompensated heart failure patients presenting with cardiogenic shock (CS) is not straightforward, as few data are available from clinical trials. Stabilization before left ventricle assist device (LVAD) or heart transplantation (HTx) is strongly advocated, as patients undergoing LVAD implant or HTx in critical status have worse outcomes. This was a multicenter phase II study with a Simon 2-stage design, including 24 consecutive patients treated with low-moderate epinephrine doses, whose refractory CS prompted implantation of intra-aortic balloon pump (IABP) which was subsequently upgraded with peripheral venoarterial extracorporeal membrane oxygenation. At admission, patients had severe left ventricular dysfunction and overt CS, 7 patients could be managed only with inotropic therapy, and 16 patients were transitioned to IABP and 1 to IABP and venoarterial extracorporeal membrane oxygenation; the median duration of epinephrine therapy was 7â¯days (interquartile range 6-15), and the median dose was 0.08 µg/kg/min (interquartile range 0.05-0.1); 21 patients (87.5%) survived at 60â¯days (primary outcome); among them, 13 (61.9%) underwent LVAD implantation, 2 (9.5%) underwent HTx, and 6 (28.6%) improved on medical treatment, indicating that early and intensive treatment of CS in chronic advanced heart failure patients with low-dose epinephrine and timely short-term mechanical circulatory support leads to satisfactory outcomes.
Assuntos
Agonistas Adrenérgicos beta/uso terapêutico , Epinefrina/uso terapêutico , Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca/complicações , Balão Intra-Aórtico , Choque Cardiogênico/terapia , Vasoconstritores/uso terapêutico , Agonistas Adrenérgicos beta/efeitos adversos , Idoso , Algoritmos , Terapia Combinada , Epinefrina/efeitos adversos , Feminino , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Choque Cardiogênico/etiologia , Resultado do Tratamento , Vasoconstritores/efeitos adversosRESUMO
Palliation of malignant tracheobronchial stenosis is challenging. Published experience with self-expanding Y-shaped stents is limited and it seems necessary to evaluate whether they improve clinical results with respect to alternative prostheses. We present a retrospective case series of 20 consecutive patients with malignant tracheobronchial stenosis that underwent placement of a single-unit, Y-shaped covered metallic stent. Outcomes were: safety of the procedure, palliation of dyspnea, complications, and survival. All stents were safely and easily placed using a rigid tracheoscope within 24hours of admission. Dyspnea was effectively palliated in all patients, and no early or late adverse stent-related events were observed. Thirty-day mortality was 40%. Median survival was 12.2 weeks. Placement of Y-shaped self-expanding stents is a safe and effective procedure for the palliation of malignant tracheobronchial stenosis, and is currently our stent of choice for this subgroup of patients.
Assuntos
Obstrução das Vias Respiratórias/terapia , Broncopatias/terapia , Neoplasias Brônquicas/secundário , Carcinoma/complicações , Stents , Neoplasias da Traqueia/secundário , Estenose Traqueal/terapia , Idoso , Idoso de 80 Anos ou mais , Obstrução das Vias Respiratórias/etiologia , Obstrução das Vias Respiratórias/cirurgia , Broncopatias/etiologia , Broncopatias/cirurgia , Neoplasias Brônquicas/complicações , Broncoscopia , Constrição Patológica/etiologia , Constrição Patológica/cirurgia , Constrição Patológica/terapia , Desenho de Equipamento , Feminino , Humanos , Terapia a Laser , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/métodos , Radiografia Intervencionista , Estudos Retrospectivos , Neoplasias da Traqueia/complicações , Estenose Traqueal/etiologia , Estenose Traqueal/cirurgiaRESUMO
AIMS: Mitral valve reoperations due to failing bioprostheses, in patients affected by multiple comorbidities, are associated with high morbidity and mortality. Transcatheter techniques may evolve as complementary approaches to surgery in these patients at high risk for surgery. METHODS AND RESULTS: We describe a case of Direct Flow 25 mm transcatheter valve implantation as valve-in-valve in a degenerated mitral bioprosthesis through a transapical approach in a 63-year-old man affected by dilated cardiomyopathy. The patient was affected by Carpentier-Edwards 29 mm severe regurgitation. The 25 mm Direct Flow bioprosthesis was advanced through the mitral bioprosthesis into the left atrium and then positioned using the three independent positioning wires. Transoesophageal echocardiography evidenced normal Direct Flow function with no paravalvular regurgitation and a low transmitral gradient of 4 mmHg. CONCLUSIONS: Our successful experience, characterised by a Heart Team approach and multidisciplinary patient care, demonstrated the technical feasibility and procedural safety of Direct Flow valve-in-valve mitral implantation.