Acute Treatment of Isolated Posterior Cerebral Artery Occlusion: Single Center Experience.

BACKGROUND AND OBJECTIVES: Randomized trials for mechanical thrombectomy (MT) excluded patients with ischemic strokes due to isolated posterior cerebral artery occlusion (IPCAO), and there is no evidence for best acute treatment strategy in these patients. We aimed to assess the effectiveness and safety of MT in acute IPCAO. METHODS: We retrospectively analyzed consecutive patients with acute stroke due to IPCAO submitted to MT and/or intravenous thrombolysis (IVT), between 2015-2019. Effectiveness outcomes (recanalization rate, first-pass effect, NIHSS 24h improvement and 3-month Modified Ranking Scale - mRS) and safety outcomes (complications, symptomatic intracranial hemorrhage (SICH) and 3-month mortality) were described and compared between groups. RESULTS: A total of 38 patients were included, 25 underwent MT and 13 had IVT alone. Successful and complete recanalization were achieved in 68% and 52% of MT patients, respectively. NIHSS improvement at 24h was found in 56% of MT patients versus 30.8% of patients submitted to IVT alone (OR [95% CI]=2.86 [0.69-11.82]) and excellent functional outcome at 3 months (mRS≤1) was achieved in 54.2% of MT patients versus 38.5% in the IVT group (OR [95% CI]=1.60 [0.41-6.32]). Complications occurred in 3 (12%) procedures and there were no SICH. Mortality at 3 months was 20% in the MT group and 15.4% in patients submitted to IVT alone. CONCLUSIONS: Our results reflect a real-world scenario in a single center and seem to support the recently growing literature showing that MT is a feasible and safe treatment in IPCAO, with favorable effectiveness.

Hypersensitivity to antibiotics in drug reaction with eosinophilia and systemic symptoms (DRESS) from other culprits.

BACKGROUND: Antibiotics have been implicated in the reactivation of exanthema and systemic involvement in drug reaction with eosinophilia and systemic symptoms (DRESS); however, it is not clear whether these patients become sensitized to the antibiotic. OBJECTIVE: To evaluate if, after DRESS, patients become sensitized to antibiotics. METHODS: We retrospectively reviewed the patch test (PT) data and clinical files of DRESS patients who were administered antibiotics during DRESS from other culprits. RESULTS: Nine patients out of 17 (53%) were positive to antibiotics in PT: six to the penicillin group and three to cephalosporins (including one patient with additional positivity to vancomycin). Considering the eight patients who were negative to antibiotics in PT, seven were exposed to a fluoroquinolone. Four cases were patch tested again and three remained positive to antibiotics 2 to 5 years thereafter. Two patients with positive PT results had an accidental re-exposure to antibiotics and developed a maculopapular exanthema without systemic symptoms. CONCLUSION: Exposure to antibiotics during DRESS or its prodromal phase could enhance sensitization to antibiotics, as confirmed by a positive PT. Reproducibility of positive PTs to antibiotics after several years and reactivation after re-exposure support that T-cell-mediated hypersensitivity to antibiotics in the setting of DRESS is a specific reaction.

Mechanical thrombectomy in stroke in nonagenarians: useful or futile?

BACKGROUND: Mechanical thrombectomy is the standard treatment in acute ischemic stroke due to large vessel occlusion, but there is limited evidence about its efficacy in very old patients. We sought to analyse safety and effectiveness of mechanical thrombectomy in nonagenarian versus octagenarian patients. METHODS: We included consecutive patients with acute ischemic stroke due to large vessel occlusion subjected to mechanical thrombectomy, during 29 months in a tertiary center. Patients were divided into two sub-groups, according to age: 80-89 and >90 years old. Recanalization, complications, functional outcome and mortality at discharge and at 3 months were compared. Multivariable analysis was performed to identify independent predictors of functional outcome at 3 months of follow-up, assessed by the modified Rankin Scale. RESULTS: A total of 128 octogenarians (88.9%) and 16 nonagenarians (11.1%) met the inclusion criteria. Successful revascularization was achieved in 87.5% of octagenarians and in 81.3% of nonagenarians (p = 0.486). Symptomatic hemorrhage occurred in 3.1% and 6.3% of younger and older patients, respectively (p = 0.520). Cerebral edema occured in 35.2% of octagenarians versus 25.0% of nonagenarians (p = 0.419). Functional independence (mRS ≤ 2) at 3 months was achieved in 28 (22.6%) and 5 (31.3%) of octagenarians and nonagenarians, respectively (p = 0.445). Mortality at 3 months was not significantly higher in nonagenarians (37.5%) versus octagenarians (33.9%, p = 0.773). CONCLUSIONS: No significant diferences were found in functional outcome, mortality, recanalization and complication rates between octagenarians and nonagenarians submitted to mechanical thrombectomy, underlining that patients should not be excluded from mechanical thrombectomy based on age alone.

Dosimetric assessment of the exposure of radiotherapy patients due to cone-beam CT procedures.

Cone-beam computed tomography (CBCT) is widely used for pre-treatment verification and patient setup in image-guided radiation therapy (IGRT). CBCT imaging is employed daily and several times per patient, resulting in potentially high cumulative imaging doses to healthy tissues that surround exposed target organs. Computed tomography dose index (CTDI) is the parameter used by CBCT equipment as indication of the radiation output to patients. This study aimed to increase the knowledge on the relation between CBCT organ doses and weighted CTDI (CTDIW) for a thorax scanning protocol. A CBCT system was modelled using the Monte Carlo (MC) radiation transport program MCNPX2.7.0. Simulation results were validated against half-value layer (HVL), axial beam profile, patient skin dose (PSD) and CTDI measurements. For organ dose calculations, a male voxel phantom ("Golem") was implemented with the CBCT scanner computational model. After a successful MC model validation with measurements, a systematic comparison was performed between organ doses (and their distribution) and CTDI dosimetry concepts [CTDIW and cumulative dose quantities f100(150) and [Formula: see text]]. The results obtained show that CBCT organ doses vary between 1.2 ± 0.1 mGy and 3.3 ± 0.2 mGy for organs located within the primary beam. It was also verified that CTDIW allows prediction of absorbed doses to tissues at distances of about 5 cm from the isocentre of the CBCT system, whereas f100(150) allows prediction of organ doses at distances of about 10 cm from the isocentre, independently from its location. This study demonstrates that these dosimetric concepts are suitable methods that easily allow a good approximation of the additional CBCT imaging doses during a typical lung cancer IGRT treatment.

Intracranial Internal Carotid Artery Wall Calcification in Ischemic Strokes Treated with Thrombolysis.

BACKGROUND: Calcifications are an important element of atherosclerotic plaques and have been used as a marker of atherosclerosis and clinical outcome predictor in different vascular territories. CT-scan, performed in the acute ischemic stroke setting, can reliably detect intracranial arterial calcifications. OBJECTIVES: To investigate the association between intracranial internal carotid artery calcification and functional outcome, symptomatic intracerebral hemorrhage (sICH), recanalization, and death. METHODS: We included 396 consecutive ischemic stroke patients submitted to recombinant tissue plasminogen activator treatment between January 2011 and September 2014. Admission CT-scans were reviewed to calculate the Total Carotid Syphon Calcification score. Patients were followed for up to at least 6 months post-stroke or until death. Outcome measures included evaluation of recanalization on the first 24 h (transcranial color coded Doppler or angio-CT), sICH, and assessment of functional outcome at 3 months after stroke (using modified Rankin scale). RESULTS: Carotid artery wall calcification did not predict sICH, recanalization or any good outcome. However, it was a statistically significant predictor of death (OR 1.102, 95% CI [1.004-1.211], p = 0.042). DISCUSSION: Intracranial carotid artery calcification does not increase the risk of thrombolysis-induced sICH. Patients with higher grade of carotid artery wall calcification may have a higher mortality rate.

Supporting Nature-Based Solutions via Nature-Based Thinking across European and Latin American cities.

Nature-Based Solutions concepts and practices are being used worldwide as part of attempts to address societal challenges but have also been criticised for not dealing with deeper transformations needed to face urgent issues including biodiversity loss, climate change and inclusion. In this paper, we explore how an inclusive, integrated and long-sighted approach, emphasising a more radical integration of nature within cities, might support the transformations needed to endure major contemporary challenges. Addressing important emerging critiques of Nature-Based Solutions, we consider the potential of a more incisive form of Nature-Based Thinking (NBT) in cities, based on more holistic perspectives. The paper draws on a reflective and iterative research process that engaged both the research and practice communities through a symposium and a series of futures workshops that together explored the potential of NBT to develop future nature-cities relations in Europe and Latin America. The results of the reflective process suggest that notions of nature with people-not for people- new organisational structures, and the intention and capacity to apply long-term perspectives, are needed when planning for NBS interventions aimed at sustainable urban development. This includes developing a cultural-structural change based on new and inclusive understandings of human-nature relations, and novel governance paradigms that allow cross-sectoral coordination and engagement of local stakeholders beyond formal organisational structures.

Endovascular Treatment of Brain Arteriovenous Malformations in Pediatric Patients: A Single Center Experience and Review of the Literature.

BACKGROUND: Brain arteriovenous malformations (bAVMs) are abnormal vascular connections with direct arteriovenous shunts, generally symptomatic in the adult life. However, a small number of bAVMs may manifest in pediatric patients, with higher bleeding risk and mortality rates when compared to adults. The purpose of this study is to review our experience with endovascular treatment of bAVMs in pediatric patients. METHODS: This is a retrospective analysis of all bAVMs in pediatric patients (0-18 years) who underwent diagnostic digital subtraction angiography (DSA) at our institution from January 2010 to June 2021. RESULTS: Twenty-six patients met the inclusion criteria, of which 12 underwent endovascular treatment. Treated patients had a mean age of 10.25 years and 58% were females. Complete angiographic exclusion was achieved in five (42%) patients with endovascular treatment. Five patients with residual bAVM after embolization needed adjuvant therapy with surgery (n = 3) or stereotactic radiosurgery (SRS; n = 2). Two patients are still undergoing embolization sessions. Procedure-related complications occurred in two patients (17%) and included small vessel perforation and an occipital ischemic stroke. Two patients showed bAVM recurrence on follow-up (17%) and subsequently underwent SRS (n = 1) or surgery (n = 1), both resulting in complete bAVM exclusion. All patients had a modified Rankin scale (mRS) score of 0 to 2 on follow-up. CONCLUSION: Our experience supports the effectiveness and safety of endovascular treatment of bAVM in selected pediatric patients. A multidisciplinary approach combining surgery and SRS is warranted to achieve higher complete bAVM obliteration rates. Long-term follow-up is important as these lesions may show recurrence over time, especially in the pediatric population.

Acute intracranial stenting in acute ischemic stroke with underlying atherosclerosis: A two-center retrospective study.

OBJECTIVE: In patients with large vessel occlusion, successful reperfusion is a predictor of favorable outcome. However, patients with underlying intracranial atherosclerotic disease (ICAD) show higher rates of immediate reocclusion, frequently requiring rescue stenting. We aimed to investigate the safety, efficacy, and outcome of acute stenting in acute stroke patients with underlying ICAD. METHODS: Prospective databases from two centers between 2012 and 2021 were reviewed. Adult patients who underwent ICAD-related acute intracranial stenting, after mechanical thrombectomy (MT) were included. Clinical and procedural data, technical success measured by Modified Thrombolysis in Cerebral Infarction score, periprocedural complications, stent restenosis, and follow up mRS at three months were evaluated. RESULTS: During a 10-year period, a total of 96 patients with acute stroke and intracranial atherosclerotic steno-occlusive lesions underwent stenting after MT. Mean age was 63 (SD 14) and 54 patients were male (56.3%). Successful reperfusion (TICI ≥ 2b) was achieved in 86 patients (89.6%) following rescue stenting; favorable clinical outcome (mRS < 3) was observed in 32 patients (37.6%). Symptomatic intracranial hemorrhage and mortality were observed in 9.5% and 22.4% of patients, respectively. Multivariate regression yielded older age (OR: 0.477, 95% CI: 0.933-0.999, p=0.046) as an independent negative predictor of favorable functional outcome after acute intracranial stenting. CONCLUSION: Our results suggest that acute intracranial stenting is safe and effective as a rescue treatment after MT in acute stroke patients with underlying ICAD. Younger age was found as an independent predictor of good outcome. Nevertheless, ICAD still carries a high mortality and poor functional clinical outcome.

Effects of CPAP on Metabolic Syndrome in Patients With OSA: A Randomized Trial.

BACKGROUND: OSA is associated with metabolic syndrome (MS), but it is unclear whether OSA treatment with CPAP can revert MS. RESEARCH QUESTION: Does OSA treatment with CPAP per se have effects on the MS reversibility and the associated metabolic, adiposity and vascular parameters? STUDY DESIGN AND METHODS: The TREATOSA-MS trial is a randomized placebo-controlled trial that enrolled adult patients with a recent diagnosis of MS and moderate or severe OSA (apnea-hypopnea index [AHI], ≥ 15 events/h) to undergo therapeutic CPAP or nasal dilator strips (placebo group) for 6 months. Before and after each intervention, we measured anthropometric variables, BP, glucose, and lipid profile. To control potential-related mechanisms and consequences, we also measured adiposity biomarkers (leptin and adiponectin), body composition, food intake, physical activity, subcutaneous and abdominal fat (visceral and hepatic fat), and endothelial function. RESULTS: One hundred patients (79% men; mean age, 48 ± 9 years; BMI, 33 ± 4 kg/m2; AHI, 58 ± 29 events/h) completed the study (n = 50 per group). The mean CPAP adherence was 5.5 ± 1.5 h/night. After 6 months, most patients with OSA randomized to CPAP retained the MS diagnosis, but the rate of MS reversibility was higher than observed in the placebo group (18% vs 4%; OR, 5.27; 95% CI, 1.27-35.86; P = .04). In the secondary analysis, CPAP did not promote significant reductions in the individual components of MS, weight, hepatic steatosis, lipid profile, adiponectin, and leptin, but did promote a very modest reduction in visceral fat and improved endothelial function (all analyses were adjusted for baseline values). INTERPRETATION: Despite the higher rate of MS reversibility after CPAP therapy as compared with placebo, most patients retained this diagnosis. The lack of significant or relevant effects on adiposity biomarkers and depots supports the modest role of OSA in modulating MS. TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT02295202; URL: www. CLINICALTRIALS: gov.

Endovascular treatment of pediatric ischemic stroke: A single center experience and review of the literature.

INTRODUCTION: Mechanical thrombectomy is standard treatment for large vessel occlusion (LVO) in adults. There are no randomized controlled trials for the pediatric population. We report our single-center experience with thrombectomy of LVO in a series of pediatric patients, and perform a review of the literature. METHODS: Retrospective review of consecutive pediatric thrombectomy cases between 2011 and 2018. Demographic variables, imaging data, technical aspects and clinical outcome were recorded. RESULTS: In a period of 7 years, 7 children were treated for LVO at our center. Median age was 13 (2-17), and median Ped-NIHSS was 15 (3-24), and the median ASPECTS was 8 (2-10). Five patients had cardiac disease, and 2 of them were under external cardiac assistance. Median time from onset of symptoms to beginning of treatment was 7h06m (2h58m-21h38m). Five patients had middle cerebral artery occlusions. Thrombectomy was performed using a stentriever in 3 patients, aspiration in 3 patients, and combined technique in 1 patient. Six patients had good recanalization (TICI 2 b/3). There were no immediate periprocedural complications. At 3 months, 4 patients (57%) were independent (mRS score <3). Two patients died, one after haemorrhagic transformation of an extensive MCA infarct, and one due to extensive brainstem ischemia in the setting of varicella vasculitis. DISCUSSION: Selected pediatric patients with LVO may be treated with mechanical thrombectomy safely. In patients under external cardiac assistance and under anticoagulation, thrombectomy is the only alternative for treatment of LVO. A multidisciplinary approach in specialized pediatric stroke centers with trained neurointerventionalists are essential for good results.

Assessment of out-of-field doses in radiotherapy treatments of paediatric patients using Monte Carlo methods and measurements.

PURPOSE: To assess out-of-field doses in radiotherapy treatments of paediatric patients, using Monte Carlo methods to implement a new model of the linear accelerator validated against measurements and developing a voxelized anthropomorphic paediatric phantom. METHODS: CT images of a physical anthropomorphic paediatric phantom were acquired and a dosimetric planning using a TPS was obtained. The CT images were used to perform the voxelization of the physical phantom using the ImageJ software and later implemented in MCNP. In order to validate the Monte Carlo model, dose measurements of the 6 MV beam and Linac with 120 MLC were made in a clinical setting, using ionization chambers and a water phantom. Afterwards TLD measurements in the physical anthropomorphic phantom were performed in order to assess the out-of-field doses in the eyes, thyroid, c-spine, heart and lungs. RESULTS: The Monte Carlo model was validated for in-field and out-of-field doses with average relative differences below 3%. The average relative differences between TLD measurements and Monte Carlo is 14,3% whilst the average relative differences between TLD and TPS is 55,8%. Moreover, organs up to 22.5 cm from PTV center show TLD and MCNP6 relative differences and TLD and TPS relative differences up to 21.2% and 92.0%, respectively. CONCLUSIONS: Our study provides a novel model that could be used in clinical research, namely in dose evaluation outside the treatment fields. This is particularly relevant, especially in pediatric patients, for studying new radiotherapy treatment techniques, since it can be used to estimate the development of secondary tumours.

Collateral pial circulation relates to the degree of brain edema on CT 24 hours after ischemic stroke.

Background Cerebral edema is frequent in patients with acute ischemic stroke (AIS) who undergo reperfusion therapy and is associated with high mortality. The impact of collateral pial circulation (CPC) status on the development of edema has not yet been determined. Methods We studied consecutive patients with AIS and documented M1-middle cerebral artery (MCA) and/or distal internal carotid artery (ICA) occlusion who underwent reperfusion treatment. Edema was graded on the 24-hour non-contrast computed tomography (NCCT) scan. CPC was evaluated at the acute phase (≤6 hours) by transcranial color-coded Doppler, angiography and/or CT angiography. We performed an ordinal regression model for the effect of CPC on cerebral edema, adjusting for age, baseline National Institutes of Health Stroke Scale, Alberta Stroke Program Early Computed Tomography Score (ASPECTS) on admission, NCCT, parenchymal hemorrhagic transformation at 24 hours and complete recanalization at six hours. Results Among the 108 patients included, 49.1% were male and mean age was 74.2 ± 11.6 years. Multivariable analysis showed a significant association between cerebral edema and CPC status (OR 0.22, 95% CI 0.08-0.59, p = 0.003), initial ASPECTS (OR 0.72, 95% CI 0.57-0.92, p = 0.007) and parenchymal hemorrhagic transformation (OR 23.67, 95% CI 4.56-122.8, p < 0.001). Conclusions Poor CPC is independently associated with greater cerebral edema 24 hours after AIS in patients who undergo reperfusion treatment.

Aortic Counterpulsation Therapy in Patients with Advanced Heart Failure: Analysis of the TBRIDGE Registry.

BACKGROUND: The use of aortic counterpulsation therapy in advanced heart failure is controversial. OBJECTIVES: To evaluate the hemodynamic and metabolic effects of intra-aortic balloon pump (IABP) and its impact on 30-day mortality in patients with heart failure. METHODS: Historical prospective, unicentric study to evaluate all patients treated with IABP between August/2008 and July/2013, included in an institutional registry named TBRIDGE (The Brazilian Registry of Intra-aortic balloon pump in Decompensated heart failure - Global Evaluation). We analyzed changes in oxygen central venous saturation (ScvO2), arterial lactate, and use of vasoactive drugs at 48 hours after IABP insertion. The 30-day mortality was estimated by the Kaplan-Meier method and differences in subgroups were evaluated by the Log-rank test. RESULTS: A total of 223 patients (mean age 49 ± 14 years) were included. Mean left ventricle ejection fraction was 24 ± 10%, and 30% of patients had Chagas disease. Compared with pre-IABP insertion, we observed an increase in ScvO2 (50.5% vs. 65.5%, p < 0.001) and use of nitroprusside (33.6% vs. 47.5%, p < 0.001), and a decrease in lactate levels (31.4 vs. 16.7 mg/dL, p < 0.001) and use of vasopressors (36.3% vs. 25.6%, p = 0.003) after IABP insertion. Thirty-day survival was 69%, with lower mortality in Chagas disease patients compared without the disease (p = 0.008). CONCLUSION: After 48 hours of use, IABP promoted changes in the use of vasoactive drugs, improved tissue perfusion. Chagas etiology was associated with lower 30-day mortality. Aortic counterpulsation therapy is an effective method of circulatory support for patients waiting for heart transplantation.

Dosimetric characterization and organ dose assessment in digital breast tomosynthesis: Measurements and Monte Carlo simulations using voxel phantoms.

PURPOSE: Due to its capability to more accurately detect deep lesions inside the breast by removing the effect of overlying anatomy, digital breast tomosynthesis (DBT) has the potential to replace the standard mammography technique in clinical screening exams. However, the European Guidelines for DBT dosimetry are still a work in progress and there are little data available on organ doses other than to the breast. It is, therefore, of great importance to assess the dosimetric performance of DBT with respect to the one obtained with standard digital mammography (DM) systems. The aim of this work is twofold: (i) to study the dosimetric properties of a combined DBT/DM system (MAMMOMAT Inspiration Siemens(®)) for a tungsten/rhodium (W/Rh) anode/filter combination and (ii) to evaluate organs doses during a DBT examination. METHODS: For the first task, measurements were performed in manual and automatic exposure control (AEC) modes, using two homogeneous breast phantoms: a PMMA slab phantom and a 4 cm thick breast-shaped rigid phantom, with 50% of glandular tissue in its composition. Monte Carlo (MC) simulations were performed using Monte Carlo N-Particle eXtended v.2.7.0. A MC model was implemented to mimic DM and DBT acquisitions for a wide range of x-ray spectra (24 -34 kV). This was used to calculate mean glandular dose (MGD) and to compute series of backscatter factors (BSFs) that could be inserted into the DBT dosimetric formalism proposed by Dance et al. Regarding the second aim of the study, the implemented MC model of the clinical equipment, together with a female voxel phantom ("Laura"), was used to calculate organ doses considering a typical DBT acquisition. Results were compared with a standard two-view mammography craniocaudal (CC) acquisition. RESULTS: Considering the AEC mode, the acquisition of a single CC view results in a MGD ranging from 0.53 ± 0.07 mGy to 2.41 ± 0.31 mGy in DM mode and from 0.77 ± 0.11 mGy to 2.28 ± 0.32 mGy in DBT mode. Regarding the BSF, the results achieved may lead to a MGD correction of about 6%, contributing to the improvement of the current guidelines used in these applications. Finally, considering the MC results obtained for the organ dose study, the radiation doses found for the tissues of the body other than the breast were in the range of tens of µSv, and are in part comparable to the ones obtained in standard DM. Nevertheless, in a single DBT examination, some organs (such as lung and thyroid) receive higher doses (of about 9% and 21%, respectively) with respect to the CC DM acquisition. CONCLUSIONS: Taking into account an average breast with a thickness of 4.5 cm, the MGDs for DM and DBT acquisitions were below the achievable value (2.0 mGy) defined by the European protocol. Additionally, in the case of a fusion imaging study (DM + DBT), the MGD for a 4.5 cm thick breast is of the order of 1.88 ± 0.36 mGy. Finally, organ dose evaluations underline the need to improve awareness concerning dose estimation of DBT exams for some organs, especially when radiation risk is assessed by using the effective dose.

Cat-scratch disease presenting as multiple hepatic lesions: case report and literature review.

Although infectious diseases are the most prevalent cause of fevers of unknown origin (FUO), this diagnosis remains challenging in some pediatric patients. Imaging exams, such as computed tomography (CT) are frequently required during the diagnostic processes. The presence of multiple hypoattenuating scattered images throughout the liver associated with the history of cohabitation with cats should raise the suspicion of the diagnosis of cat-scratch disease (CSD), although the main etiologic agent of liver abscesses in childhood is Staphylococcus aureus. Differential diagnosis by clinical and epidemiological data with Bartonella henselae is often advisable. The authors report the case of a boy aged 2 years and 9 months with 16-day history of daily fever accompanied by intermittent abdominal pain. Physical examination was unremarkable. Abdominal ultrasound performed in the initial work up was unrevealing, but an abdominal CT that was performed afterwards disclosed multiple hypoattenuating hepatic images compatible with the diagnosis of micro abscesses. Initial antibiotic regimen included cefotaxime, metronidazole, and oxacillin. Due to the epidemiology of close contact with kittens, diagnosis of CSD was considered and confirmed by serologic tests. Therefore, the initial antibiotics were replaced by clarithromycin orally for 14 days followed by fever defervescence and clinical improvement. The authors call attention to this uncommon diagnosis in a child presenting with FUO and multiple hepatic images suggestive of micro abscesses.

Aortic Counterpulsation Therapy in Patients with Advanced Heart Failure: Analysis of the TBRIDGE Registry / Terapia de Contrapulsação Aórtica em Pacientes com Insuficiência Cardíaca Avançada: Análise do Registro TBRIDGE

Abstract Background: The use of aortic counterpulsation therapy in advanced heart failure is controversial. Objectives: To evaluate the hemodynamic and metabolic effects of intra-aortic balloon pump (IABP) and its impact on 30-day mortality in patients with heart failure. Methods: Historical prospective, unicentric study to evaluate all patients treated with IABP betwen August/2008 and July/2013, included in an institutional registry named TBRIDGE (The Brazilian Registry of Intra-aortic balloon pump in Decompensated heart failure - Global Evaluation). We analyzed changes in oxygen central venous saturation (ScvO2), arterial lactate, and use of vasoactive drugs at 48 hours after IABP insertion. The 30-day mortality was estimated by the Kaplan-Meier method and diferences in subgroups were evaluated by the Log-rank test. Results: A total of 223 patients (mean age 49 ± 14 years) were included. Mean left ventricle ejection fraction was 24 ± 10%, and 30% of patients had Chagas disease. Compared with pre-IABP insertion, we observed an increase in ScvO2 (50.5% vs. 65.5%, p < 0.001) and use of nitroprusside (33.6% vs. 47.5%, p < 0.001), and a decrease in lactate levels (31.4 vs. 16.7 mg/dL, p < 0.001) and use of vasopressors (36.3% vs. 25.6%, p = 0.003) after IABP insertion. Thirty-day survival was 69%, with lower mortality in Chagas disease patients compared without the disease (p = 0.008). Conclusion: After 48 hours of use, IABP promoted changes in the use of vasoactive drugs, improved tissue perfusion. Chagas etiology was associated with lower 30-day mortality. Aortic counterpulsation therapy is an effective method of circulatory support for patients waiting for heart transplantation.

Resumo Fundamento: A utilização da terapia de contrapulsação aórtica na insuficiência cardíaca avançada é controversa. Objetivos: Avaliar o efeito hemodinâmico e metabólico do balão intra-aórtico (BIA) e seu impacto sobre a mortalidade em 30 dias em pacientes com insuficiência cardíaca. Métodos: Estudo prospectivo histórico, unicêntrico, avaliando todos os pacientes tratados com BIA entre agosto/2008 e julho/2013, incluídos em registro institucional denominado TBRIDGE (The Brazilian Registry of Intra-aortic balloon pump in Decompensated heart failure - Global Evaluation). Analisaram-se variações na saturação venosa central de oxigênio (SVO2), lactato arterial e uso de fármacos vasoativos 48 horas após instalação do dispositivo. A mortalidade em 30 dias foi estimada pelo método de Kaplan-Meier e diferenças entre subgrupos foram avaliadas pelo teste de Log-rank. Resultados: Foram incluídos 223 pacientes com idade média de 49 ± 14 anos, fração de ejeção do ventrículo esquerdo média de 24 ± 10%, sendo 30% acometidos por Doença de Chagas. Em comparação à pré-instalação do BIA, após a instalação, houve aumento da SVO2 (51% vs. 66%, p < 0,001) e no uso de nitroprussiato (34% vs. 48%, p < 0,001), além de redução do lactato (31 vs. 17 mg/dL, p < 0,001) e no uso de vasopressores (36% vs. 26%, p = 0,003). A sobrevida em 30 dias foi de 69%, com menor mortalidade nos pacientes chagásicos comparativamente aos não chagásicos (p = 0,008). Conclusão: Nas primeiras 48 horas de utilização, o BIA promoveu mudança no uso de fármacos vasoativos e melhora da perfusão tecidual. A etiologia chagásica associou-se a menor mortalidade em 30 dias. A terapia de contrapulsação aórtica mostrou-se opção eficaz de suporte circulatório em pacientes candidatos a transplante cardíaco.