RESUMO
Tension hydrothorax is a rare complication of pneumonectomy for pleural mesothelioma and an exceptionally rare cause of heart failure. We describe a patient who had undergone extrapleural pneumonectomy, chemotherapy, and radiation for pleural mesothelioma and who developed heart failure symptoms within months of the completion of treatment. Investigation showed a massive left pleural effusion resulting in tension hydrothorax, mediastinal shift, and evidence of right heart failure with constrictive physiology and low cardiac output. Therapeutic thoracentesis resulted in increase in cardiac output and symptomatic improvement.
Assuntos
Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Mesotelioma/cirurgia , Neoplasias Pleurais/cirurgia , Pneumonectomia/efeitos adversos , Pneumotórax/etiologia , Pneumotórax/terapia , Idoso , Humanos , Masculino , Mesotelioma/complicações , Neoplasias Pleurais/complicações , Resultado do TratamentoRESUMO
We studied 31 patients with prosthetic valves (PVs) using two-dimensional and three-dimensional transthorathic echocardiography (2DTTE and 3DTTE, respectively) in order to determine whether 3DTTE provides an incremental value on top of 2DTTE in the evaluation of these patients. With 3DTTE both leaflets of the St. Jude mechanical PV can be visualized simultaneously, thereby increasing the diagnostic confidence in excluding valvular abnormalities and overcoming the well-known limitations of 2DTTE in the examination of PVs, which heavily relies on Doppler. Three-dimensional transthorathic echocardiography provides a more comprehensive evaluation of PV regurgitation than 2DTTE with its ability to more precisely quantify PV regurgitation, in determining the mechanism causing regurgitation, and in localizing the regurgitant defect. Furthermore, 3DTTE is superior in identifying, quantifying, and localizing PV thrombi and vegetations, in addition to the unique feature of providing a look inside mass lesions by serial sectioning. These preliminary results suggest the superiority of 3DTTE over 2DTTE in the evaluation of PVs and that it provides incremental knowledge to the echocardiographer.
Assuntos
Ecocardiografia Tridimensional/métodos , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/cirurgia , Próteses Valvulares Cardíacas , Interpretação de Imagem Assistida por Computador/métodos , Idoso , Idoso de 80 Anos ou mais , Sistemas Computacionais , Análise de Falha de Equipamento/métodos , Feminino , Humanos , Aumento da Imagem/métodos , Masculino , Pessoa de Meia-Idade , Prognóstico , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Resultado do TratamentoRESUMO
OBJECTIVE: Our objective was to compare the utility of combined two-dimensional (2D) transthoracic echocardiography (TTE) and three-dimensional (3D) TTE versus 2D transesophageal echocardiography (TEE) in evaluation of the left atrium (LA) and LA appendage (LAA) for clot. BACKGROUND: 2DTEE, usually performed to visualize the LAA, is semi-invasive and not without risks. With improved technology the LAA has been increasingly visualized by 2DTTE and 3DTTE in many patients. METHODS: We compared combined 2DTTE and 3DTTE with 2DTEE in evaluating the LA/LAA for a thrombus. Ninety-two patients underwent 2DTTE, 3DTTE, and 2DTEE. An additional 20 patients, in whom TEE could not be performed, underwent 2DTTE and 3DTTE. RESULTS: LA and LAA could be visualized in all patients. Of 92 patients studied, 74 had no thrombus and 7 had thrombus in the LAA by all modalities. Eleven patients, 9 with atrial fibrillation (AF), had a suspected thrombus by 2DTEE, but 3DTTE cropping clearly showed these to be prominent pectinate muscles which were seen in short axis on 2DTEE as rounded echo dense masses and therefore mimicked thrombi. These 9 patients with AF underwent successful cardioversion without any complications. Of the 20 patients in whom TEE could not be performed, 19 had no thrombus in the LA/LAA and 1 had a clot in the LAA. These 19 patients underwent successful cardioversion without complications. CONCLUSIONS: Our preliminary study suggests that combined 2DTTE and 3DTTE has comparable accuracy to TEE in evaluating the LA and LAA for thrombus. In some patients TEE, but not 3DTTE, may misdiagnose pectinate musculature as thrombus.
Assuntos
Apêndice Atrial/diagnóstico por imagem , Ecocardiografia Tridimensional/métodos , Ecocardiografia/métodos , Átrios do Coração/diagnóstico por imagem , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Adulto JovemRESUMO
BACKGROUND: There is great variability among individual patients in platelet inhibition after aspirin intake. Aspirin resistance has been associated with a higher incidence of ischemic events after percutaneous coronary intervention (PCI). The optimal antiplatelet therapy in aspirin-resistant patients undergoing PCI is unknown. The objective of this study was to evaluate whether aggressive antiplatelet therapy would reduce ischemic events in aspirin-resistant patients after PCI. METHODS: A total of 330 patients undergoing PCI (with bivalirudin) were screened for aspirin responsiveness. The resulting 36 aspirin-resistant patients were randomized into two arms: 1) conventional strategy patients received 325 mg aspirin orally and a loading dose of 600 mg clopidogrel at the time of the procedure; and 2) aggressive strategy patients received similar amounts of aspirin and clopidogrel, with the addition of an intravenous glycoprotein IIb/IIIa inhibitor bolus intraprocedurally. The primary outcome was an elevation of cardiac enzymes within 24 hours post procedure. The secondary outcome was a composite of major adverse cardiac events including death, myocardial infarction, stent thrombosis and urgent revascularization, and bleeding up to 30 days. RESULTS: Primary outcome occurred in 22% of the conventional strategy group and 11% of the aggressive strategy group (p = 0.36). The secondary outcome was reached in 27.8% of the conventional group and 5.5% of the aggressive strategy group (p = 0.17), which is suggestive of a statistical trend toward more ischemic events with conventional therapy. Importantly, there were 2 cases of definite stent thrombosis in the conventional strategy group. CONCLUSION: In aspirin-resistant patients, aggressive antiplatelet therapy tended to show better outcomes after PCI, without an increase in bleeding. These findings need validation in a large, randomized study.
Assuntos
Angioplastia Coronária com Balão , Antitrombinas/uso terapêutico , Plaquetas/efeitos dos fármacos , Fragmentos de Peptídeos/uso terapêutico , Inibidores da Agregação Plaquetária/administração & dosagem , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Adulto , Antitrombinas/administração & dosagem , Aspirina/farmacologia , Clopidogrel , Resistência a Medicamentos , Quimioterapia Combinada , Feminino , Hirudinas/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Fragmentos de Peptídeos/administração & dosagem , Projetos Piloto , Agregação Plaquetária/efeitos dos fármacos , Inibidores da Agregação Plaquetária/farmacologia , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/uso terapêutico , Ticlopidina/administração & dosagem , Ticlopidina/análogos & derivadosRESUMO
OBJECTIVES: This study evaluated the outcomes of patients discharged the day of percutaneous coronary intervention (PCI) by analyzing the data from a single-center, large, multioperator registry of interventions. BACKGROUND: Although same-day discharge is likely safe after interventions on low-risk stable patients, there is limited data to guide selection of a broader population of patients. Due to numerous patient variables and physician preferences, standardization of the length of stay after PCI has been a challenge. Most of the reported studies on same-day discharge have strict inclusion criteria and hence do not truly reflect a real-world population. METHODS: We analyzed the outcomes of consecutive same-day discharge in 2,400 of 16,585 patients who underwent elective PCI without any procedural or hospital complication. Composite end point included 30-day major adverse cardiac cerebral events and bleeding/vascular complications. RESULTS: The mean age of the study population was 57.0 +/- 23.7 years with 12% aged over 65 years. Twenty-eight percent received glycoprotein IIb/IIIa inhibitor with closure devices in 90.5%. Clinical and angiographic success was noted in 97% of all PCIs. The average length-of-stay following PCI was 8.2 +/- 2.5 h. The composite end point was reached in 23 patients (0.96%). Major adverse cardiac cerebral events occurred in 8 patients (0.33%) and vascular/bleeding complications in the form of Thrombolysis In Myocardial Infarction minor bleeding in 14 patients (0.58%) and pseudoaneurysm in 1 patient (0.04%). CONCLUSIONS: When appropriately selected, with strict adherence to the set protocol, same-day discharge after uncomplicated elective PCI is safe despite using femoral access in a wide spectrum of patients.
Assuntos
Angioplastia Coronária com Balão , Doença da Artéria Coronariana/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde , Alta do Paciente , Adulto , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/instrumentação , Protocolos Clínicos , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Cidade de Nova Iorque , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Inibidores da Agregação Plaquetária/uso terapêutico , Sistema de Registros , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
Job's syndrome (hyperimmunoglobulin E syndrome) is a congenitally acquired primary immune deficiency. The primary host defense defect in Job's syndrome is impaired phagocytosis. Accordingly, patients with Job's syndrome have difficulties eradicating staphylococcal infections. A continuous, high-grade Staphylococcus aureus bacteremia with a cardiac valve vegetation is the hallmark of S. aureus acute bacterial endocarditis (ABE). ABE may be caused by methicillin-sensitive Staphylococcus aureus or methicillin-resistant Staphylococcus aureus (MRSA). We report a case of Job's syndrome MRSA mitral valve ABE. Presumably because of impaired phagocytic function, his MRSA ABE was complicated by extensive metastatic septic complications manifested as brain abscess, multiple epidural abscesses, and multifocal vertebral osteomyelitis. The patient did not respond to 5 days of appropriately dosed linezolid and daptomycin and remained bacteremic because abscess drainage was not an option in this case and the continuous, high-grade MRSA bacteremia continued despite appropriate therapy. High-dose daptomycin (12 mg/kg intravenously every 24 hours) was given, and his MRSA bacteremia was rapidly terminated. Because daptomycin does not cross the blood-brain barrier in therapeutic concentrations, linezolid was used to treat the brain abscess. The extensiveness of infection in this case is remarkable and is probably related to impaired phagocytic function from Job's syndrome. High-dose daptomycin therapy rapidly cleared the bacteremia and cured the endocarditis and epidural abscesses/vertebral osteomyelitis. The patient was treated with 8 weeks of high-dose daptomycin therapy with no adverse effects. If MRSA and methicillin-sensitive S. aureus bacteremias are unresponsive to usually effective antistaphylococcal agents, and surgical drainage of abscesses and removal of infected devices are not clinically possible, then a prolonged, high dose of daptomycin is a therapeutic alternative in such situations. To the best of our knowledge, this is the first case of MRSA mitral valve ABE complicated by extensive epidural abscesses and vertebral osteomyelitis in a patient with Job's syndrome.