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PURPOSE: The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE). METHODS: A retrospective review of 79 patients undergoing PE repair with either INC or TE from May 2009 to December 2019 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long-term opioid use after discharge, and postoperative complications. RESULTS: LOS decreased to 2.5 days in the INC group compared to 5 days in the TE group (p < 0.0001). Surgical time was increased in the INC group, but there was no difference in total OR time. The INC group experienced significantly lower hospital costs. Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long-term opioid use in the INC group. CONCLUSIONS: INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings. We recommend that INC be included in the current practice for postoperative pain control in PE patients undergoing Nuss procedure.
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Analgésicos Opioides/administração & dosagem , Criocirurgia/métodos , Tórax em Funil/cirurgia , Tempo de Internação/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Adolescente , Adulto , Criança , Feminino , Humanos , Nervos Intercostais/cirurgia , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos , Adulto JovemRESUMO
PURPOSE: Three-dimensional (3D) dark-blood MRI has shown great potential in coronary artery plaque evaluation. However, substantial variability in quantification could result from superficial calcification because of its low signal. To address this issue, a 3D coronary dark-blood interleaved with gray-blood (cDIG) technique was developed. METHODS: cDIG is based on a balanced steady-state free precession readout combined with a local re-inversion-based double-inversion-recovery (LocReInv-DIR) preparation. The LocReInv-DIR is applied every two RR intervals. Dark-blood and gray-blood contrasts are collected in the first and second RR interval, respectively. To improve the respiratory gating efficiency, two independent navigators were developed to separately gate the respiratory motion for the two interleaved acquisitions. In vivo experiments in eight healthy subjects and one patient were conducted to validate the technique. RESULTS: cDIG provided dual-contrasts without compromise in scan time. The dark-blood images with cDIG demonstrated excellent wall and lumen signal performances and morphological measurements. Advantageously, cDIG yielded a second contrast that was shown to help identify the superficial calcification in the coronary plaque of a patient. CONCLUSION: A novel technique was developed for obtaining 3D coronary vessel wall and gray lumen images. The additional contrast may aid in identifying calcified nodules and thus potentially improve the evaluation of coronary plaque burden.
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Imageamento Tridimensional/métodos , Imageamento por Ressonância Magnética/métodos , Adulto , Simulação por Computador , Vasos Coronários/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: The aim of the current study was to examine whether the use of highly active antiretroviral therapy (HAART) in patients with HIV is associated with changes in pericardial fat and myocardial lipid content measured by cardiovascular magnetic resonance (CMR). METHODS: In this prospective case-control study, we compared 27 HIV seropositive (+) male subjects receiving HAART to 22 control male subjects without HIV matched for age, ethnicity and body mass index. All participants underwent CMR imaging for determination of pericardial fat [as volume at the level of the origin of the left main coronary artery (LM) and at the right ventricular free wall] and magnetic resonance spectroscopy (MRS) for evaluation of intramyocardial lipid content (% of fat to water in a single voxel at the interventricular septum). All measurements were made by two experienced readers blinded to the clinical history of the study participants. Two-sample t-test, Spearman's correlation coefficient or Pearson's correlation coefficient and multivariable logistic regression were used for statistical analysis. RESULTS: Pericardial fat volume at the level of LM origin was higher in HIV (+) subjects (33.4 cm(3) vs. 27.4 cm(3), p = 0.03). On multivariable analysis adjusted for age, Framingham risk score (FRS) and waist/hip ratio, pericardial fat remained significantly associated to HIV-status (OR 1.09, p = 0.047). For both HIV (+) and HIV (-) subjects, pericardial fat volume showed strong correlation with intramyocardial lipid content (r = 0.58, p < 0.0001) and FRS (r = 0.53, p = 0.0002). Among HIV (+) subjects, pericardial fat was significantly higher in patients with lipo-accumulation (37 cm(3) vs. 27.1 cm(3), p = 0.03) and showed significant correlation with duration of both HIV infection (r = 0.5, p = 0.01) and HAART (r = 0.46, p = 0.02). CONCLUSIONS: Pericardial fat content is increased in HIV (+) subjects on chronic HAART (>5 years), who demonstrate HAART-related lipo-accumulation and prolonged HIV duration of infection. Further investigation is warranted to determine whether increased pericardial fat is associated with higher cardiovascular risk leading to premature cardiovascular events in this patient population.
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Tecido Adiposo/efeitos dos fármacos , Adiposidade/efeitos dos fármacos , Fármacos Anti-HIV/efeitos adversos , Infecções por HIV/tratamento farmacológico , Metabolismo dos Lipídeos/efeitos dos fármacos , Imageamento por Ressonância Magnética , Espectroscopia de Ressonância Magnética , Miocárdio/metabolismo , Pericárdio/efeitos dos fármacos , Tecido Adiposo/metabolismo , Tecido Adiposo/patologia , Adulto , Fármacos Anti-HIV/administração & dosagem , Terapia Antirretroviral de Alta Atividade/efeitos adversos , Estudos de Casos e Controles , Esquema de Medicação , Estudos de Viabilidade , Infecções por HIV/diagnóstico , Infecções por HIV/metabolismo , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Miocárdio/patologia , Razão de Chances , Pericárdio/metabolismo , Pericárdio/patologia , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: To examine whether controlled and tolerable levels of hypercapnia may be an alternative to adenosine, a routinely used coronary vasodilator, in healthy human subjects and animals. MATERIALS AND METHODS: Human studies were approved by the institutional review board and were HIPAA compliant. Eighteen subjects had end-tidal partial pressure of carbon dioxide (PetCO2) increased by 10 mm Hg, and myocardial perfusion was monitored with myocardial blood oxygen level-dependent (BOLD) magnetic resonance (MR) imaging. Animal studies were approved by the institutional animal care and use committee. Anesthetized canines with (n = 7) and without (n = 7) induced stenosis of the left anterior descending artery (LAD) underwent vasodilator challenges with hypercapnia and adenosine. LAD coronary blood flow velocity and free-breathing myocardial BOLD MR responses were measured at each intervention. Appropriate statistical tests were performed to evaluate measured quantitative changes in all parameters of interest in response to changes in partial pressure of carbon dioxide. RESULTS: Changes in myocardial BOLD MR signal were equivalent to reported changes with adenosine (11.2% ± 10.6 [hypercapnia, 10 mm Hg] vs 12% ± 12.3 [adenosine]; P = .75). In intact canines, there was a sigmoidal relationship between BOLD MR response and PetCO2 with most of the response occurring over a 10 mm Hg span. BOLD MR (17% ± 14 [hypercapnia] vs 14% ± 24 [adenosine]; P = .80) and coronary blood flow velocity (21% ± 16 [hypercapnia] vs 26% ± 27 [adenosine]; P > .99) responses were similar to that of adenosine infusion. BOLD MR signal changes in canines with LAD stenosis during hypercapnia and adenosine infusion were not different (1% ± 4 [hypercapnia] vs 6% ± 4 [adenosine]; P = .12). CONCLUSION: Free-breathing T2-prepared myocardial BOLD MR imaging showed that hypercapnia of 10 mm Hg may provide a cardiac hyperemic stimulus similar to adenosine.
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Circulação Coronária/fisiologia , Hipercapnia/fisiopatologia , Imageamento por Ressonância Magnética/métodos , Adenosina/farmacologia , Animais , Cães , Eletrocardiografia , Humanos , Aumento da Imagem/métodos , Oximetria , Reprodutibilidade dos Testes , Vasodilatadores/farmacologiaRESUMO
BACKGROUND: Multi-contrast weighted imaging is a commonly used cardiovascular magnetic resonance (CMR) protocol for characterization of carotid plaque composition. However, this approach is limited in several aspects including low slice resolution, long scan time, image mis-registration, and complex image interpretation. In this work, a 3D CMR technique, named Multi-contrast Atherosclerosis Characterization (MATCH), was developed to mitigate the above limitations. METHODS: MATCH employs a 3D spoiled segmented fast low angle shot readout to acquire data with three different contrast weightings in an interleaved fashion. The inherently co-registered image sets, hyper T1-weighting, gray blood, and T2-weighting, are used to detect intra-plaque hemorrhage (IPH), calcification (CA), lipid-rich necrotic core (LRNC), and loose-matrix (LM). The MATCH sequence was optimized by computer simulations and testing on four healthy volunteers and then evaluated in a pilot study of six patients with carotid plaque, using the conventional multi-contrast protocol as a reference. RESULTS: On MATCH images, the major plaque components were easy to identify. Spatial co-registration between the three image sets with MATCH was particularly helpful for the reviewer to discern co-existent components in an image and appreciate their spatial relation. Based on Cohen's kappa tests, moderate to excellent agreement in the image-based or artery-based component detection between the two protocols was obtained for LRNC, IPH, CA, and LM, respectively. Compared with the conventional multi-contrast protocol, the MATCH protocol yield significantly higher signal contrast ratio for IPH (3.1±1.3 vs. 0.4±0.3, p<0.001) and CA (1.6±1.5 vs. 0.7±0.6, p=0.012) with respect to the vessel wall. CONCLUSIONS: To the best of our knowledge, the proposed MATCH sequence is the first 3D CMR technique that acquires spatially co-registered multi-contrast image sets in a single scan for characterization of carotid plaque composition. Our pilot clinical study suggests that the MATCH-based protocol may outperform the conventional multi-contrast protocol in several respects. With further technical improvements and large-scale clinical validation, MATCH has the potential to become a CMR method for assessing the risk of plaque disruption in a clinical workup.
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Artérias Carótidas/patologia , Estenose das Carótidas/diagnóstico , Meios de Contraste , Interpretação de Imagem Assistida por Computador/métodos , Angiografia por Ressonância Magnética/métodos , Placa Aterosclerótica , Idoso , Algoritmos , Estenose das Carótidas/patologia , Simulação por Computador , Estudos de Viabilidade , Fibrose , Hemorragia/diagnóstico , Hemorragia/patologia , Humanos , Imageamento Tridimensional , Masculino , Pessoa de Meia-Idade , Modelos Cardiovasculares , Necrose , Projetos Piloto , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Razão Sinal-Ruído , Calcificação Vascular/diagnóstico , Calcificação Vascular/patologiaRESUMO
Perioperative care delivery is a patient-centered, multidisciplinary process. It relies heavily on synchronized teamwork from a well-coordinated team. Perioperative physicians-surgeons and anesthesiologists-face enormous challenges in surgical care delivery due to changing work environments, post-COVID consequences, shift work disorder, value conflict, escalating demands, regulatory complexity, and financial uncertainties. Physician burnout in this working environment has become increasingly prevalent. It is not only harmful to physicians' health and well-being, but it also affects the quality and safety of patient care. Additionally, the economic costs associated with physician burnout are untenable due to the high turnover rate, high recruitment expenses, and potential early permanent exit from medical practice. In this deteriorating environment of unbalanced physician supply/demand, recognizing, managing, and preventing physician burnout may help preserve the system's most valuable asset and contribute to higher quality and safety of patient care. Leaders in government agencies, health care systems, and organizations must work together to re-engineer the health care system for better physicians and patient care.
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Esgotamento Profissional , COVID-19 , Medicina Perioperatória , Médicos , Humanos , Esgotamento Profissional/prevenção & controle , Esgotamento Psicológico , Assistência ao Paciente , Qualidade da Assistência à SaúdeRESUMO
Microaggression is widespread in the health care industry and occurs in every health care delivery setting. It comes in many forms, from subtle to obvious, unconscious to conscious, and verbal to behavioral. Women and minority groups (eg, race/ethnicity, age, gender, sexual orientation) are often marginalized during medical training and subsequent clinical practice. These contribute to the development of psychologically unsafe working environments and widespread physician burnout. Physicians experiencing burnout who work in unsafe psychological environments impact the safety and quality of patient care. In turn, these conditions impose high costs on the health care system and organizations. Microaggressions and psychological unsafe work environments are intricately related and mutually enhanced. Therefore, addressing both simultaneously is a good business practice and a responsibility for any health care organization. Additionally, addressing them can reduce physician burnout, decrease physician turnover, and improve the quality of patient care. To counter microaggression and psychological unsafe, it takes conviction, initiative, and sustainable efforts from individuals, bystanders, organizations, and government agencies.
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Esgotamento Profissional , Médicos , Humanos , Masculino , Feminino , Microagressão , Esgotamento Profissional/psicologia , Esgotamento Psicológico , Atenção à Saúde , Médicos/psicologiaAssuntos
Estenose da Valva Aórtica/cirurgia , Angiografia por Tomografia Computadorizada/métodos , Meios de Contraste , Angiografia por Ressonância Magnética/métodos , Intensificação de Imagem Radiográfica/métodos , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Feminino , Artéria Femoral/diagnóstico por imagem , Humanos , Artéria Ilíaca/diagnóstico por imagem , MasculinoRESUMO
Administration of post-operative opioids following pediatric tonsillectomy can elicit respiratory events in this patient population that often arise as central and obstructive sleep apnea. The primary objective of this study was to determine whether a perioperative combination of dexmedetomidine and acetaminophen could eliminate post-operative (in recovery and at home) opioid requirements. Following IRB approval and a waiver for informed consent, the medical records of 681 patients who underwent tonsillectomy between 1 January 2013 and 31 December 2018 were evaluated. Between 1 January 2013 and 31 December 2015, all patients received a fentanyl-sevoflurane-based anesthetic, without acetaminophen or dexmedetomidine, and received opioids in recovery and for discharge home. On 1 January 2016, an institution-wide practice change replaced this protocol with a multimodal perioperative regimen of acetaminophen (intravenous or enteral) and dexmedetomidine and eliminated post-operative opioids. This is the first time that the effect of an acetaminophen and dexmedetomidine combination on the perioperative and home opioid requirement has been reported. Primarily, we compared the need for rescue opioids in the post-anesthesia care period and after discharge. The multi-modal protocol eliminated the need for post-tonsillectomy opioid administration. Dexmedetomidine in combination with acetaminophen eliminated the need for post-operative opioids in the recovery period.
RESUMO
PURPOSE: Intercostal Nerve Cryoablation (INC) has significantly improved pain control following the Nuss repair of pectus excavatum (PE). This study sought to evaluate patients undergoing the Nuss repair with INC compared to the Nuss repair with an ERAS protocol, INC, and intercostal nerve blocks (INB). METHODS: In June 2020, a new protocol was implemented involving surgery, anesthesia, nursing, physical therapy, and child life with the goal of safe same day discharge for patients undergoing the Nuss repair. They were compared to a control group who underwent the Nuss repair with INC alone in 2017-2019. The primary outcome measure was hospital length of stay (LOS) in hours, secondary outcomes were number of patients discharged on postoperative day (POD) 0, and returns to the emergency department (ED), urgent care (UC), and operating room (OR). RESULTS: The characteristics between the groups were the same (Table 1). The mean LOS was 11.8 h in the INB group versus 58.2 h in the INC group, p < 0.01. 10 of 15 patients in the INB group went home on POD 0 (average of 5.5 h postop), versus 0 patients in the INC only group, p < 0.01. Five patients in the INB stayed overnight. Two patients stayed owing to anxiety, one owing to urinary retention, one owing to nausea, and one owing to drowsiness. None stayed for pain control. Four patients in the INC group returned to the ED for pain control, versus 0 in the INB group, and 1 patient in the INB returned to UC for constipation. CONCLUSIONS: The majority of patients undergoing the Nuss repair of PE with a multidisciplinary regimen of pre and postoperative nursing education, precise intraoperative anesthesia care, performance of direct vision INB and INC, as well as careful surgery can go home on the day of surgery without adverse outcomes or unanticipated returns to the hospital. LEVEL-OF-EVIDENCE: Level II.
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Anestesia por Condução , Tórax em Funil , Criança , Tórax em Funil/cirurgia , Humanos , Dor Pós-Operatória/etiologia , Alta do Paciente , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: The use of intercostal nerve cryoablation (INC) has been an effective modality for treating pain in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate if PE patients undergoing Nuss procedures with INC and intercostal nerve block (INB) could safely be discharged the same day of surgery. METHODS: A prospective study with IRB approval of 15 consecutive patients undergoing PE Nuss repair with INC, INB, and an enhanced recovery after surgery (ERAS) protocol was conducted. The primary outcome measure was hospital length of stay (LOS) in hours. Secondary variables included same day discharge, postoperative complications, emergency department (ED) visits, urgent care (UC) visits, opioid use, and return to the operating room (OR). RESULTS: LOS averaged 11.9 h amongst 15 patients. Ten patients (66.7%) went home on postoperative day (POD) 0, and the rest went home on POD 1. No patients stayed in the hospital due to pain. Reasons for failure to discharge included urinary retention, drowsiness, vomiting, and anxiety, but not pain. No patients were readmitted to the ED. One patient visited UC for constipation. One patient had bar migration requiring return to the OR for revision. Ten (66.7%) patients did not use opioids after discharge. CONCLUSIONS: Same day discharge is feasible and safe in PE patients undergoing Nuss procedure with INC and INB. INC with INB can adequately control pain without significant complications. Same day discharge can be safely considered for PE patients undergoing Nuss procedure with INC with INB. TYPE OF STUDY: Prognosis study LEVEL-OF-EVIDENCE RATING: Level II.
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Tórax em Funil , Tórax em Funil/cirurgia , Humanos , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/terapia , Alta do Paciente , Estudos Prospectivos , Estudos RetrospectivosAssuntos
Seleção do Doador/ética , Seleção do Doador/legislação & jurisprudência , Transplante de Coração/ética , Transplante de Coração/legislação & jurisprudência , Doadores de Tecidos/ética , Doadores de Tecidos/legislação & jurisprudência , Fatores Etários , Transmissão de Doença Infecciosa/ética , Transmissão de Doença Infecciosa/legislação & jurisprudência , Infecções por HIV/transmissão , Nível de Saúde , Humanos , Fatores de RiscoAssuntos
Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Vasos Coronários/diagnóstico por imagem , Ecocardiografia Transesofagiana/métodos , Implante de Prótese de Valva Cardíaca/métodos , Stents , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Bioprótese , Fluoroscopia , Humanos , Masculino , Monitorização IntraoperatóriaAssuntos
Procedimentos Cirúrgicos Cardiovasculares , Infecções por HIV/epidemiologia , Infecções por HIV/cirurgia , HIV-1 , Complicações Pós-Operatórias/epidemiologia , Terapia Antirretroviral de Alta Atividade/métodos , Procedimentos Cirúrgicos Cardiovasculares/efeitos adversos , Infecções por HIV/diagnóstico , Humanos , Complicações Pós-Operatórias/prevenção & controle , Carga Viral/métodosAssuntos
Angioplastia Coronária com Balão/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Doença da Artéria Coronariana/cirurgia , Comunicação Interventricular/cirurgia , Infarto do Miocárdio/cirurgia , Anestesia por Inalação , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico por imagem , Ecocardiografia Transesofagiana , Comunicação Interventricular/complicações , Comunicação Interventricular/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico por imagem , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/terapia , EsternotomiaRESUMO
Few orthotopic heart transplantations have been performed in patients infected with the human immunodeficiency virus since the first such case was reported in 2001. Since that time, advances in highly active antiretroviral therapy have resulted in potent and durable suppression of the causative human immunodeficiency virus-accompanied by robust immune reconstitution, reversal of previous immunodeficiency, a marked decrease in opportunistic and other infections, and near-normal long-term survival. Although human immunodeficiency virus infection is not an absolute contraindication, few centers in the United States and Canada have performed heart transplantations in this patient population; these patients have been de facto excluded from this procedure in North America. Re-evaluation of the reasons for excluding these patients from cardiac transplantation is warranted in light of such significant advances in antiretroviral therapy. This case report documents successful orthotopic heart transplantation in 2 patients infected with human immunodeficiency virus, and we describe their antiretroviral therapy and immunosuppressive management challenges. Both patients were doing well without sequelae 43 and 38 months after transplantation.
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Rejeição de Enxerto/prevenção & controle , Anticorpos Anti-HIV/análise , Infecções por HIV/tratamento farmacológico , Soropositividade para HIV , HIV-2/imunologia , Transplante de Coração/métodos , Imunossupressores/uso terapêutico , Idoso , Rejeição de Enxerto/complicações , Infecções por HIV/complicações , Infecções por HIV/virologia , Humanos , MasculinoRESUMO
OBJECTIVES: The purpose of this study was to investigate whether native T1 maps at 3-T can reliably characterize chronic myocardial infarctions (MIs) in patients with prior ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND: Late gadolinium enhancement (LGE) cardiac magnetic resonance is the gold standard for characterizing chronic MIs, but it is contraindicated in patients with end-stage chronic kidney disease. METHODS: Native T1 and LGE images were acquired at 3-T in patients with prior STEMI (n = 13) and NSTEMI (n = 12) at a median of 13.6 years post-MI. Infarct location, size, and transmurality were measured using mean ± 5 SDs thresholding criterion from LGE images and T1 maps and compared against one another. Independent reviewers assessed visual conspicuity of MIs on LGE images and T1 maps. RESULTS: Native T1 maps and LGE images were not different for measuring infarct size (STEMI: p = 0.46; NSTEMI: p = 0.27) and transmurality (STEMI: p = 0.13; NSTEMI: p = 0.21) using thresholding criterion. Using thresholding criterion, good agreement was observed between LGE images and T1 maps for measuring infarct size (STEMI: bias = 0.6 ± 3.1%; R(2) = 0.93; NSTEMI: bias = -0.4 ± 4.4%; R(2) = 0.85) and transmurality (STEMI: bias = 2.0 ± 4.2%; R(2) = 0.89; NSTEMI: bias = -2.7 ± 7.9%; R(2) = 0.68). Sensitivity and specificity of T1 maps for detecting chronic MIs based on thresholding criterion were 89% and 98%, respectively (STEMI), and 87% and 95%, respectively (NSTEMI). Relative to LGE images, the mean visual conspicuity score for detecting chronic MIs was significantly lower for T1 maps (p < 0.001 for both cases). Median infarct-to-remote myocardium contrast-to-noise ratio was 2.5-fold higher for LGE images relative to T1 maps (p < 0.001). Sensitivity and specificity of T1 maps for visual detection were 60% and 86%, respectively (STEMI), and 64% and 91% (NSTEMI), respectively. CONCLUSIONS: Chronic MIs in STEMI and NSTEMI patients can be reliably characterized using threshold-based detection on native T1 maps at 3-T. Visual detection of chronic MIs on native T1 maps in both patient populations has high specificity, but modest sensitivity.
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Interpretação de Imagem Assistida por Computador/métodos , Imagem Cinética por Ressonância Magnética/métodos , Infarto do Miocárdio/diagnóstico , Miocárdio/patologia , Idoso , Doença Crônica , Meios de Contraste , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/patologia , Variações Dependentes do Observador , Compostos Organometálicos , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Fatores de TempoRESUMO
This case report describes a patient who sustained a post-myocardial infarction ventricular septal defect (VSD) with an associated left ventricular aneurysm who developed cardiogenic shock and required an intra-aortic balloon pump for hemodynamic stabilization. After deployment of a single Amplatzer occluder (AGA Medical), a residual VSD measuring 0.5 cm was noted. Therefore, a second Amplatzer occluder was deployed and a minimal residual VSD remained. The patient remained hemodynamically stable throughout the procedure and was subsequently extubated with removal of intra-aortic balloon pump. Post-discharge, the patient was readmitted with congestive heart failure. A third Amplatzer device was deployed to ameliorate the recurrent VSD shunt. At 9-week follow-up, transthoracic echocardiogram was performed and findings included: 1) left ventricular ejection fraction of 62%; 2) appearance of 3 Amplatzer devices along the interventrcular septum seated well with no motion and residual shunt; 3) moderate diastolic dysfunction with pseudonormal left ventricular filling pattern; and 4) no valvular abnormalities. The patient had increased exercise tolerance with no shortness of breath at rest or with exertion. This case demonstrates the utility and viability of multiple Amplatzer device deployment as a means of repairing a large post-myocardial infarction VSD and recurrent VSDs.