Ductular cholestasis, an unusual form of intrahepatic cholestasis, associated with cardiogenic shock and ventricular assist device.

Ventricular assist devices have been shown to be effective in advanced heart failure selected patients. They often have borderline end-organ function, what facilitates organ dysfunction. Liver failure is difficult to manage and leads to increased morbidity and mortality. We report a case of ductular cholestasis, an unusual cholestatic hepatic failure with untractable coagulopathy, developed during the use of a magnetic levitation centrifugal pump, implanted as a bridge to heart transplantation, in a patient with cardiogenic shock (as an end-stage disease of idiopathic dilated cardiomyopathy). We discussed the pathophysiology of this entity and the possible related factors, including the assist device. Preemptive interventions have been advocated as the primary way of treatment. Preoperative optimization of heart function and avoidance of visceral hypoperfusion and sepsis may play a major role.

[Neurologic complications in the immediate postoperative period after cardiac surgery. Role of brain magnetic resonance imaging]. / Complicaciones neurológicas en el postoperatorio inmediato de la cirugía cardíaca. Aportación de la resonancia magnética cerebral.

INTRODUCTION AND OBJECTIVES: Neurologic complications still cause significant morbidity and mortality in the immediate postoperative period following cardiac surgery. Our understanding of the pathogenesis, prevention, and management of these lesions is constantly developing. MATERIAL AND METHOD: We describe neurologic complications and their course in a cardiac surgery cohort and analyze the value of brain magnetic resonance imaging (MRI), using T1-weighted, T2-weighted, and FLAIR sequences, in patients with postoperative stroke or encephalopathy in whom CT scanning revealed no abnormalities explaining their clinical condition. RESULTS: In 688 patients studied postoperatively, we observed 57 neurologic complications (8.3%): 25 strokes, 24 encephalopathies, 5 seizure disorders, 2 brain deaths, and 1 intracranial hemorrhage. Initial CT scanning failed to show significant findings in 70%. 18 patients underwent brain MRI. In all but 1 of the 11 with stroke, MRI showed areas of acute or subacute infarction (i.e., hyperintensity in FLAIR or T2-weighted sequences) in different locations, mainly in a watershed distribution. In 3 of the 4 patients with mild-to-moderate encephalopathy, MRI showed lesions similar to those previously described for stroke. In the remaining 3 patients, who had severe encephalopathy, MRI showed diffuse cortical necrosis. CONCLUSIONS: The incidence of neurologic complications in the postoperative period following cardiac surgery is significant. In a high percentage of patients, brain CT scanning may not show pathologic findings. In selected patients, MRI could help identify areas of infarction not detected by CT. These images could improve clinicians' understanding of the pathogenic, pathophysiologic, clinical, and prognostic characteristics of such neurologic complications.

[Levosimendan for postoperative ventricular dysfunction following heart transplantation]. / Utilidad de levosimendán en la disfunción ventricular postoperatoria del injerto en el trasplante cardiaco.

The development of postoperative ventricular dysfunction immediately after heart transplantation is a serious complication that leads to low-output syndrome and which necessitates circulatory support. It is one of the most common causes of early morbidity and mortality. We present our experience with 6 heart transplant patients who were treated with intravenous levosimendan, a calcium sensitizer with inodilator properties, after regular hemodynamic therapy with sympathomimetic amines failed to result in a satisfactory hemodynamic status. Use of this drug was well tolerated and brought about hemodynamic improvements that were sufficient to enable patients to be weaned from inotropic support with amines and which led to clinical recovery, with 5 of the 6 patients being discharged from the intensive care unit.

Utilidad de levosimendán en la disfunción ventricular postoperatoria del injerto en el trasplante cardiaco / Levosimendan for postoperative ventricular dysfunction following heart transplantation

La disfunción ventricular del injerto en el postoperatorio inmediato del paciente trasplantado cardiaco es una complicación grave, que cursa con un síndrome de bajo gasto cardiaco y necesidad de soporte circulatorio, y es una de las causas más frecuentes de morbimortalidad inicial. Presentamos la experiencia clínica con 6 pacientes trasplantados en los que, tras un manejo hemodinámico habitual con aminas simpaticomiméticas, no se consiguió una adecuada situación hemodinámica y se utilizó levosimendán intravenoso, un fármaco sensibilizador al calcio con propiedades inodilatadoras. El uso de este fármaco fue bien tolerado y favoreció una mejoría hemodinámica que facilitó la retirada del soporte inotrópico con aminas y la recuperación clínica (con alta de UCI de 5 de los 6 pacientes) (AU)

The development of postoperative ventricular dysfunction immediately after heart transplantation is a serious complication that leads to low-output syndrome and which necessitates circulatory support. It is one of the most common causes of early morbidity and mortality. We present our experience with 6 heart transplant patients who were treated with intravenous levosimendan, a calcium sensitizer with inodilator properties, after regular hemodynamic therapy with sympathomimetic amines failed to result in a satisfactory hemodynamic status. Use of this drug was well tolerated and brought about hemodynamic improvements that were sufficient to enable patients to be weaned from inotropic support with amines and which led to clinical recovery, with 5 of the 6 patients being discharged from the intensive care unit (AU)

Complicaciones neurológicas en el postoperatorio inmediato de la cirugía cardíaca. Aportación de la resonancia magnética cerebral / Neurologic complications in the immediate postoperative period after cardiac surgery. Role of brain magnetic resonance imaging

Introducción y objetivos. Las complicaciones neurológicas (CN) causan una importante morbimortalidad en el postoperatorio inmediato de la cirugía cardíaca. La comprensión de la etiopatogenia, la prevención y el tratamiento de éstas están en constante evolución. Material y método. Se describen las CN y su evolución en una serie quirúrgica, y se analizan las aportaciones de la resonancia magnética cerebral (RMC) con secuencias T1, T2 y la supresión de líquido cefalorraquídeo, en los pacientes que presentan ictus o encefalopatía poscirugía y tomografía computarizada (TC) craneal sin hallazgos que justifiquen la situación clínica. Resultados. Se estudió a 688 postoperados; se observaron 57 CN (8,3%): 25 ictus, 24 encefalopatías, 5 pacientes con crisis convulsivas, 2 muertes cerebrales y una hemorragia intracerebral. La TC craneal inicial no mostró hallazgos relevantes en el 70% de las ocasiones. Se realizó RMC en 18 pacientes, 11 de ellos con ictus: excepto en un estudio, en la RMC encontramos áreas de infarto agudo o subagudo (hiperintensas en la secuencia T2 y FLAIR) en diferentes localizaciones. También se realizó en 4 pacientes con encefalopatía leve-moderada y mostró en 3 de ellos lesiones similares a las descritas en los ictus. En los restantes 3 casos con encefalopatía severa, la RMC mostró áreas con múltiples infartos corticales. Conclusiones. Las CN tras cirugía cardíaca se presentan con una incidencia no despreciable. La TC craneal puede no presentar hallazgos patológicos en un alto porcentaje. En pacientes seleccionados, la RMC puede presentar lesiones, y demostrar áreas isquémicas no detectadas en la TC que ayudan a comprender a los clínicos la etiopatogenia, la fisiopatología, la clínica y la evolución de estas complicaciones (AU)

Introduction and objectives. Neurologic complications still cause significant morbidity and mortality in the immediate postoperative period following cardiac surgery. Our understanding of the pathogenesis, prevention, and management of these lesions is constantly developing. Matherial and method. We describe neurologic complications and their course in a cardiac surgery cohort and analyze the value of brain magnetic resonance imaging (MRI), using T1-weighted, T2-weighted, and FLAIR sequences, in patients with postoperative stroke or encephalopathy in whom CT scanning revealed no abnormalities explaining their clinical condition. Results. In 688 patients studied postoperatively, we observed 57 neurologic complications (8.3%): 25 strokes, 24 encephalopathies, 5 seizure disorders, 2 brain deaths, and 1 intracranial hemorrhage. Initial CT scanning failed to show significant findings in 70%. 18 patients underwent brain MRI. In all but 1 of the 11 with stroke, MRI showed areas of acute or subacute infarction (i.e., hyperintensity in FLAIR or T2-weighted sequences) in different locations, mainly in a watershed distribution. In 3 of the 4 patients with mild-to-moderate encephalopathy, MRI showed lesions similar to those previously described for stroke. In the remaining 3 patients, who had severe encephalopathy, MRI showed diffuse cortical necrosis. Conclusions. The incidence of neurologic complications in the postoperative period following cardiac surgery is significant. In a high percentage of patients, brain CT scanning may not show pathologic findings. In selected patients, MRI could help identify areas of infarction not detected by CT. These images could improve clinicians' understanding of the pathogenic, pathophysiologic, clinical, and prognostic characteristics of such neurologic complications (AU)