Avaliação ecocardiográfica do paciente com choque circulatório: uma abordagem contemporânea / Echocardiographic evaluation of a patient in circulatory shock: a contemporary approach

O choque circulatório é caracterizado por um estado de ineficiência da oferta de oxigênio tecidual e disfunção múltipla de órgãos. Necessita de diagnóstico e terapias rápidas e assertivas para redução de sua alta letalidade. O ecocardiograma já se estabeleceu como método fundamental no manejo do paciente com choque circulatório. Auxilia de forma crucial no diagnóstico etiológico, prognóstico, monitorização hemodinâmica e estimativa volêmica desses pacientes, tendo como potenciais vantagens a portabilidade, ausência de contraste ou radiação, baixo custo e avaliação em tempo real e de forma seriada. Em ambiente de UTI, demonstra alta correlação com formas invasivas (cateter de artéria pulmonar) e minimamente invasivas (termodiluição transpulmonar) de monitorização hemodinâmica. Atualmente, outras técnicas, como ultrassom pulmonar e VExUS score, têm se agregado à avaliação ecocardiográfica, tornando o método mais abrangente e acurado. Essas técnicas acrescentam dados relevantes na estimativa da volemia do paciente crítico, influenciando na decisão probabilística de fluidoresponsividade e agregando informações no raciocínio diagnóstico das causas do choque, otimizando o prognóstico desses pacientes. O point of care ultrasound (POCUS) tem como objetivo tornar mais acessível, ao médico não especialista em radiologia, habilidades para se obter informações a beira leito, por meio do ultrassom, que o ajudem na tomada de decisões. Esse artigo aborda as diversas aplicabilidades do ecocardiograma em pacientes com choque circulatório, incluindo avaliação prognóstica e diagnóstico etiológico por meio dos parâmetros encontrados nas principais causas de choque, além da monitorização hemodinâmica, avaliação de fluido-responsividade e utilização prática do ultrassom pulmonar.(AU)

Circulatory shock is characterized by a state of inefficient tissue oxygen supply and multiple organ dysfunction. Patients with circulatory shock require fast and assertive diagnosis and therapies to reduce its high lethality. Echocardiography has already been established as a fundamental method in managing patients with circulatory shock. It provides crucial assistance in etiological diagnosis, prognosis, hemodynamic monitoring, and volume estimation in these patients; its potential advantages include portability, absence of contrast or radiation, low cost, and real-time serial assessment. In the intensive care unit setting, it demonstrates a high correlation with invasive (pulmonary artery catheter) and minimally invasive (transpulmonary thermodilution) forms of hemodynamic monitoring. Currently, other techniques, such as pulmonary ultrasound and VExUS score, have been added to echocardiographic assessment, making the method more comprehensive and accurate. These techniques add relevant data to blood volume estimation in critical patients, influencing the probabilistic decision of fluid responsiveness and providing additional information in the diagnostic reasoning of the causes of shock, thus optimizing these patients' prognosis. Point of care ultrasound (POCUS) aims to make abilities to obtain information at the bedside more accessible to physicians who are not specialists in radiology, by means of ultrasound, which assists them in decision-making. This article addresses the diverse applications of echocardiography in patients with circulatory shock, including prognostic evaluation and etiological diagnosis by means of the parameters found in the main causes of shock, in addition to hemodynamic monitoring, evaluation of fluid responsiveness, and practical use of pulmonary ultrasound.(AU)

Impact of VA-ECMO combined with IABP and timing on outcome of patients with acute myocardial infarction complicated with cardiogenic shock / 中华心血管病杂志

Objective: To investigate the impact of combined use and timing of arterial-venous extracorporeal membrane oxygenation (VA-ECMO) with intra-aortic balloon pump (IABP) on the prognosis of patients with acute myocardial infarction complicated with cardiogenic shock (AMICS). Methods: This was a prospective cohort study, patients with acute myocardial infarction and cardiogenic shock who received VA-ECMO support from the Heart Center of Lanzhou University First Hospital from March 2019 to March 2022 in the registration database of the Chinese Society for Extracorporeal Life Support were enrolled. According to combination with IABP and time point, patients were divided into VA-ECMO alone group, VA-ECMO+IABP concurrent group and VA-ECMO+IABP non-concurrent group. Data from 3 groups of patients were collected, including the demographic characteristics, risk factors, ECG and echocardiographic examination results, critical illness characteristics, coronary intervention results, VA-ECMO related parameters and complications were compared among the three groups. The primary clinical endpoint was all-cause death, and the safety indicators of mechanical circulatory support included a decrease in hemoglobin greater than 50 g/L, gastrointestinal bleeding, bacteremia, lower extremity ischemia, lower extremity thrombosis, acute kidney injury, pulmonary edema and stroke. Kaplan-Meier survival curves were used to analyze the survival outcomes of patients within 30 days of follow-up. Using VA-ECMO+IABP concurrent group as reference, multivariate Cox regression model was used to evaluate the effect of the combination of VA-ECMO+IABP at different time points on the prognosis of AMICS patients within 30 days. Results: The study included 68 AMICS patients who were supported by VA-ECMO, average age was (59.8±10.8) years, there were 12 female patients (17.6%), 19 cases were in VA-ECMO alone group, 34 cases in VA-ECMO+IABP concurrent group and 15 cases in VA-ECMO+IABP non-concurrent group. The success rate of ECMO weaning in the VA-ECMO+IABP concurrent group was significantly higher than that in the VA-ECMO alone group and the VA-ECMO+IABP non-concurrent group (all P<0.05). Compared with the ECMO+IABP non-concurrent group, the other two groups had shorter ECMO support time, lower rates of acute kidney injury complications (all P<0.05), and lower rates of pulmonary edema complications in the ECMO alone group (P<0.05). In-hospital survival rate was significantly higher in the VA-ECMO+IABP concurrent group (28 patients (82.4%)) than in the VA-ECMO alone group (9 patients) and VA-ECMO+IABP non-concurrent group (7 patients) (all P<0.05). The survival rate up to 30 days of follow-up was also significantly higher surviving patients within were in the ECMO+IABP concurrent group (26 cases) than in VA-ECMO alone group (9 patients) and VA-ECMO+IABP non-concurrent group (4 patients) (all P<0.05). Multivariate Cox regression analysis showed that compared with the concurrent use of VA-ECMO+IABP, the use of VA-ECMO alone and non-concurrent use of VA-ECMO+IABP were associated with increased 30-day mortality in AMICS patients (HR=2.801, P=0.036; HR=2.985, P=0.033, respectively). Conclusions: When VA-ECMO is indicated for AMICS patients, combined use with IABP at the same time can improve the ECMO weaning rate, in-hospital survival and survival at 30 days post discharge, and which does not increase additional complications.

Impact of VA-ECMO combined with IABP and timing on outcome of patients with acute myocardial infarction complicated with cardiogenic shock / 中华心血管病杂志

Objective: To investigate the impact of combined use and timing of arterial-venous extracorporeal membrane oxygenation (VA-ECMO) with intra-aortic balloon pump (IABP) on the prognosis of patients with acute myocardial infarction complicated with cardiogenic shock (AMICS). Methods: This was a prospective cohort study, patients with acute myocardial infarction and cardiogenic shock who received VA-ECMO support from the Heart Center of Lanzhou University First Hospital from March 2019 to March 2022 in the registration database of the Chinese Society for Extracorporeal Life Support were enrolled. According to combination with IABP and time point, patients were divided into VA-ECMO alone group, VA-ECMO+IABP concurrent group and VA-ECMO+IABP non-concurrent group. Data from 3 groups of patients were collected, including the demographic characteristics, risk factors, ECG and echocardiographic examination results, critical illness characteristics, coronary intervention results, VA-ECMO related parameters and complications were compared among the three groups. The primary clinical endpoint was all-cause death, and the safety indicators of mechanical circulatory support included a decrease in hemoglobin greater than 50 g/L, gastrointestinal bleeding, bacteremia, lower extremity ischemia, lower extremity thrombosis, acute kidney injury, pulmonary edema and stroke. Kaplan-Meier survival curves were used to analyze the survival outcomes of patients within 30 days of follow-up. Using VA-ECMO+IABP concurrent group as reference, multivariate Cox regression model was used to evaluate the effect of the combination of VA-ECMO+IABP at different time points on the prognosis of AMICS patients within 30 days. Results: The study included 68 AMICS patients who were supported by VA-ECMO, average age was (59.8±10.8) years, there were 12 female patients (17.6%), 19 cases were in VA-ECMO alone group, 34 cases in VA-ECMO+IABP concurrent group and 15 cases in VA-ECMO+IABP non-concurrent group. The success rate of ECMO weaning in the VA-ECMO+IABP concurrent group was significantly higher than that in the VA-ECMO alone group and the VA-ECMO+IABP non-concurrent group (all P<0.05). Compared with the ECMO+IABP non-concurrent group, the other two groups had shorter ECMO support time, lower rates of acute kidney injury complications (all P<0.05), and lower rates of pulmonary edema complications in the ECMO alone group (P<0.05). In-hospital survival rate was significantly higher in the VA-ECMO+IABP concurrent group (28 patients (82.4%)) than in the VA-ECMO alone group (9 patients) and VA-ECMO+IABP non-concurrent group (7 patients) (all P<0.05). The survival rate up to 30 days of follow-up was also significantly higher surviving patients within were in the ECMO+IABP concurrent group (26 cases) than in VA-ECMO alone group (9 patients) and VA-ECMO+IABP non-concurrent group (4 patients) (all P<0.05). Multivariate Cox regression analysis showed that compared with the concurrent use of VA-ECMO+IABP, the use of VA-ECMO alone and non-concurrent use of VA-ECMO+IABP were associated with increased 30-day mortality in AMICS patients (HR=2.801, P=0.036; HR=2.985, P=0.033, respectively). Conclusions: When VA-ECMO is indicated for AMICS patients, combined use with IABP at the same time can improve the ECMO weaning rate, in-hospital survival and survival at 30 days post discharge, and which does not increase additional complications.

Dispositivos de asistencia ventricular en el shock cardiogénico posinfarto: importancia del soporte hemodinámico: reporte de caso / Ventricular assist devices in post-infarction cardiogenic shock: importance of hemodynamic support: case report / Dispositivos de assistência ventricular no choque cardiogênico pós-infarto: importância do suporte hemodinâmico: relato de caso

El shock cardiogénico posinfarto caracterizado por un estado de insuficiencia circulatoria sistémica requiere de un tratamiento precoz en vistas a restablecer la estabilidad hemodinámica y la función ventricular. Este consta de la reperfusión coronaria mediante revascularización miocárdica; en algunos casos es necesaria la utilización de dispositivos de asistencia ventricular. El ECMO venoarterial es un sistema de circulación extracorpórea que permite un soporte biventricular oxigenando la sangre y reintroduciéndola mediante un flujo continuo hacia la circulación arterial sistémica. El uso de dicho dispositivo en pacientes con shock cardiogénico ha mostrado una mejoría significativa de la sobrevida a 30 días en comparación con el uso del balón de contrapulsación intraaórtico. No obstante, sus potenciales complicaciones, como dificultad en el vaciamiento ventricular izquierdo, síndrome de Arlequín, sangrados e infecciones, hacen fundamental la formación y el trabajo en equipo del heart team. Un porcentaje no menor de estos pacientes presentarán una severa disfunción ventricular permanente, por lo que podrían ser candidatos a dispositivos de asistencia ventricular izquierda de larga duración tipo Heartmate III como puente al trasplante cardíaco, el cual ha mostrado resultados satisfactorios con una excelente sobrevida a mediano plazo.

Post-infarction cardiogenic shock characterized by a state of systemic circulatory failure requires early treatment in order to restore hemodynamic stability and ventricular function. This consists of coronary reperfusion through myocardial revascularization, requiring in some cases the use of ventricular assist devices. Veno-arterial ECMO is an extracorporeal circulation system that allows biventricular support by oxygenating the blood and reintroducing it through a continuous flow towards the systemic arterial circulation. The use of this device in patients with cardiogenic shock has shown a significant improvement in survival at 30 days compared to the use of intra-aortic balloon pump. However, its potential complications, such as difficulty in left ventricular emptying, Harlequin syndrome, bleeding and infections, make the training and teamwork of the heart team essential. A great percentage of these patients will present a severe permanent ventricular dysfunction, so they could be candidates for long-term mechanical circulatory support devices like Heartmate III as a bridge to transplant or myocardial recovery, or destination therapy, which has shown satisfactory results with excellent medium-term survival.

O choque cardiogênico pós-infarto caracterizado por um estado de insuficiência circulatória sistêmica requer tratamento precoce para restabelecer a estabilidade hemodinâmica e a função ventricular. Esta consiste na reperfusão coronariana por meio de revascularização miocárdica, necessitando, em alguns casos, do uso de dispositivos de assistência ventricular. A ECMO venoarterial é um sistema de circulação extracorpórea que permite o suporte biventricular oxigenando o sangue e reintroduzindo-o através de um fluxo contínuo para a circulação arterial sistêmica. O uso desse dispositivo em pacientes com choque cardiogênico mostrou melhora significativa na sobrevida em 30 dias em relação ao uso de contrapulsação com balão intra-aórtico. No entanto, suas potenciais complicações, como dificuldade de esvaziamento ventricular esquerdo, síndrome de Harlequin, sangramentos e infecções, tornam imprescindível o treinamento e o trabalho em equipe do time do coração. Não uma pequena porcentagem desses pacientes apresentará uma condição ventricular permanente grave, podendo ser candidatos a dispositivos de assistência ventricular esquerda de longa duração do tipo Heartmate III como ponte para o transplante cardíaco, que tem demonstrado resultados satisfatórios com excelente sobrevida em médio prazo.

Hepatitis hipóxica en paciente con endomiocardiofibrosis / Hypoxic hepatitis in a patient with endomyocardial fibrosis

La endomiocardiofibrosis es una causa de miocardiopatía restrictiva frecuente en la región de África subsahariana, aunque poco frecuente en nuestra población. Posee estrecha relación con la presencia de hipereosinofilia en sangre y tiene alta morbimortalidad. La hepatitis hipóxica es una afección clínica con un patrón enzimático característico, muy prevalente en unidades de cuidados intensivos y elevada mortalidad. Se reconocen múltiples mecanismos fisiopatológicos, como la isquemia, la congestión venosa y la alteración en la utilización de oxígeno del hepatocito. Describimos el caso de u na paciente de 35 años, consumidora de cocaína, con diagnóstico de endomiocardiofibrosis secundario a síndrome hipereosinofílico idiopático que presentó shock cardiogénico y hepatitis hipóxica asociada. Evolucionó favorablemente con el tratamiento de sostén adecuado.

Endomyocardial fibrosis is a restrictive cardiomyopathy with high morbidity and mortality rates, prevalent in the sub-Saharan Africa region but infrequent in our population. It has a close relation with blood hypereosinophilia. Hypoxic hepatitis is frequently observed in intensive care units and its diagnosis is clinical. It shows a typical enzyme pattern with high mortality too. There are multiple mechanisms responsible for this condition, such as ischemia, passive congestion and dysoxia. We described the case of a 35 year-old cocaine addict woman diagnosed with endomyocardial fibrosis and hypereosinophilic syndrome who developed cardiogenic shock with hypoxic hepatitis. The patient evolved favorably with the appropriate treatment.

Complicaciones intrahospitalarias del infarto del miocardio con elevación del segmento ST / In-hospital complications of ST-segment elevation myocardial infarction

Introducción: el infarto con elevación del segmento ST es uno de los diagnósticos más frecuentes de los ingresos en unidades de cuidados intensivos en cualquier institución de salud cubana. Objetivo: analizar los principales factores de riesgo relacionados con el infarto agudo del miocardio y sus complicaciones intrahospitalarias, así como los predictores de estas complicaciones. Métodos: estudio descriptivo, longitudinal y prospectivo desde 2013 hasta 2016 que incluyó a 272 pacientes consecutivos que ingresaron en la Unidad de Cuidados Coronarios Intensivos del Hospital Militar Central Dr. Carlos J. Finlay con el diagnóstico de infarto agudo de miocardio con elevación del segmento ST. Resultados: La edad media fue de 63,4 ± 11,7 años, predominó el sexo masculino (61,8 por ciento). Los principales factores de riesgo: hipertensión arterial y tabaquismo (66,5 por ciento en ambos casos). Del total de pacientes, 109 sufrieron complicaciones intrahospitalarias, la angina postinfarto fue la más frecuente (34,9 por ciento). El shock cardiogénico y las complicaciones mecánicas se asociaron significativamente con la mortalidad intrahospitalaria (p = 0,007 y p < 0,001, respectivamente). La edad ≥ 60 años, la clase funcional Killip-Kimball ≥ II y la no realización de intervención coronaria percutánea constituyeron factores pronósticos de eventos adversos durante el ingreso. Conclusiones: las complicaciones intrahospitalarias del infarto agudo de miocardio con elevación del segmento ST no son frecuentes. Existen factores pronóstico de complicaciones como la edad avanzada, clase funcional Killip-Kimball ≥ II y la no realización del intervención coronaria percutánea(AU)

Introduction: ST-segment elevation acute myocardial infarction is one of the most frequent diagnoses of admission in intensive care units at any health institution in our country. Objective: Analyze the principal risk factors related with the acute myocardial infarction and its complications in the admission, as well as these complications predictors. Method: A descriptive, prospective study was conducted in 272 consecutive patients who were admitted in Coronary Intensive Care Unit of Dr. Carlos J. Finlay Central Military Hospital. ST-segment elevation myocardial infarction was their diagnosis. They period studied was from September 2013 to August 2016. Results: The patients` median age was 63.4 ± 11.7 years, and 168 (61.8 percent were male. The main risk factors were hypertension and smoking (66.5 percent in both cases). One hundred nine (109) patients suffered complications in hospital; the post-infarct angina was the most frequent (34.9 percent). The association among cardiogenic shock and mechanical complications with mortality was significant (p< 0.007 and p< 0.001, respectively). Independent associations were found between age ? 60 years, the Killip-Kimball functional classification ? II, non-performing percutaneous coronary intervention were prognostic factors for adverse events during admission. Conclusions: The complications of ST-segment elevation myocardial infarction during hospital admittance are not frequent. There are prognosis factors of complications like advanced age, functional Killip-Kimball classification ? II and non-performing percutaneous coronary intervention(AU)

Análise crítica do tratamento cirúrgico nas síndromes coronarianas agudas e suas complicaçõe / Critical analysis of surgical treatment in acute coronary syndromes and its complications

Apesar dos grandes avanços no tratamento médico, suporte farmacológico, técnicas de reperfusão e o suporte mecânico, as síndromes coronarianas ainda representam uma das principais causas de morbidade e mortalidade. Abordagens agressivas de revascularização miocárdica parecem estar associadas à redução da mortalidade em pacientes com síndromes coronarianas agudas (SCA). O melhor momento da intervenção não deve apenas reduzir a mortalidade em curto prazo, mas também oferecer resultados satisfatórios em longo prazo. Dependendo do tipo de evento, a síndrome coronariana aguda tem uma adequada modalidade terapêutica. Iremos abordar estratégias relacionadas ao infarto sem e com supra desnivelamento do segmento ST, infarto miocárdico com choque cardiogênico e as complicações mecânicas do infarto. De forma geral, a abordagem invasiva tem melhores resultados. Pacientes com infarto na fase aguda são abordados preferencialmente por técnicas percutâneas, pois a estratégia cirúrgica demanda tempo para a efetiva revascularização. Os resultados de seguimento em longo prazo variam de acordo com a extensão do infarto, a fração de ejeção e a anatomia coronariana. Aqueles pacientes que evoluem com choque cardiogênico têm alta mortalidade independente da estratégia utilizada. Pacientes que evoluem com complicações mecânicas, são necessariamente cirúrgicos, sendo que o melhor momento para a intervenção varia de acordo com a condição clínica e hemodinâmica...

Despite the great advances in medical treatment, pharmacological support, reperfusion techniques, and mechanical support, coronary syndromes are still among the main causes of morbidity and mortality. Aggressive myocardial revascularization approaches appear to be associated with reduced mortality in patients with ACS. The optimum moment of intervention should not only reduce mortality in the short term, but should also offer satisfactory results in the long term. Depending on the type of event, acute coronary syndrome has an adequate therapeutic modality. We address strategies related to infarction with and without ST segment elevation, myocardial infarction with cardiogenic shock, and mechanical complications of infarction. Ingeneral, the invasive approach has shown best results. Patients with infarction in the acute phase are preferably treated by percutaneous techniques, as the surgical approach requires time for effective revascularization. The long-term results vary, depending on the extent of the infarction, the ejection fraction, and the coronary anatomy. Patients who evolve with cardiogenic shock have high mortality, regardless of the strategy used. Patients who evolve with mechanical complications must undergo surgery, with the best moment for the intervention depending on the clinical and hemodynamic condition...

Indicações de dispositivos mecânicos de suporte na insuficiência cardíaca refratár / Indications of mechanical support devices in refractory heart failur

A insuficiência cardíaca refratária e o choque cardiogênico estão relacionados aelevadas taxas de mortalidade e a baixa qualidade de vida. As estratégias de tratamento para esses pacientes foram limitadas, nos últimos anos, às terapias farmacológicas que pouco modificaram a evolução da doença. Entretanto, com o desenvolvimento tecnológico em dispositivos mecânicos de suporte circulatório, diversas modalidades terapêuticas utilizando diferentes tipos de tecnologia proporcionam melhor suporte hemodinâmico, diminuição e reversão de disfunções orgânicas causadas pela insuficiência cardíaca.Esses dispositivos quando indicados corretamente melhoram os desfechos clínicos de pacientes que aguardam transplante cardíaco e dos que não são candidatos a transplante. Atualmente, observam-se indicações cada vez mais precoces de dispositivos de suporte circulatório, tornando-os uma terapia essencial no manejo de pacientes cominsuficiência cardíaca refratária ou choque cardiogênico. Esta revisão abordará os principais tipos de dispositivos disponíveis em nosso país e suas indicações...

The refractory heart failure and cardiogenic shock are related to high rates of mortality and poor quality of life. Treatment strategies for these patients have been limited in the last yearsto pharmacological therapies that change only slightly the evolution of the disease. However, with technological advances in mechanical devices for circulatory assistance, various therapeutic modalities using different types of technology provide better hemodynamic support, reduction and reversal of organic dysfunction caused by heart failure. When properly indicated,these devices can provide better clinical outcomes of patients on heart transplantation waiting list and those who are not candidates for transplantation. Contemporarily, indications for mechanical support devices are occurring increasingly earlier, making them an essential therapy in the management of patients with refractory heart failure or cardiogenic shock.This review covers the different types of devices available in our country and its indications...

Atualização no manejo clínico do choque cardiogênico / Update on clinical management of cardiogenic shock

O choque cardiogênico é uma síndrome clínica caracterizada por hipoperfusão tecidual secundária à disfunção cardíaca, na ausência de hipovolemia. A etiologia principal é o infarto agudo do miocárdio com falência de ventrículo esquerdo, embora existam outras causas relevantes, como complicações mecânicas do infarto, miocardites, evolução de cardiomiopatias, valvopatias agudas não isquêmicas e cardiomiopatia induzida pelo estresse, por exemplo. Apesar dos avanços terapêuticos, persiste como uma afecção de elevada mortalidade e sua incidência não se modificou significativamente nas últimas décadas. A instalação do choque em pacientes com síndromes coronarianasagudas ocorre mais frequentemente após a internação hospitalar, ressaltandoa importância da identificação de preditores e da monitorização de sinais precoces de hipoperfusão tecidual para pronta intervenção. O diagnóstico é essencialmente clínico e alguns exames subsidiários, como eletrocardiograma, marcadores de necrose miocárdica,ecocardiograma e cineangiocoronariografia, que são importantes para a definição da etiologia, estratificação da gravidade e do prognóstico. O manejo adequado dos pacientes requer avaliação dos parâmetros de macro e micro-hemodinâmica. Os principais objetivos terapêuticos incluem a restauração precoce da perfusão tecidual sistêmica ea recuperação da função ventricular. O tratamento inclui medidas gerais para pacientes com choque como ajuste de volemia e adequação da perfusão tecidual com uso de inotrópicos, vasopressores e dispositivos de assistência ventricular, além de medidasespecíficas, direcionadas para a etiologia do choque, como a revascularização precoce nas síndromes coronarianas agudas...

Cardiogenic shock is a clinical syndrome characterized by tissue hypoperfusionsecondary to cardiac dysfunction, in the absence of hypovolemia. Left ventricular failure complicating acute myocardial infarction is the main cause, although other relevant causes include mechanical complications of infarction, myocarditis, progression of cardiomyopathies, acute non-ischemic valvular heart disease, and stress-induced cardiomyopathies, for example. Despite therapeutic advances, it persists as a condition of high mortality, and its incidence has not changed significantly in the last decades.The onset of cardiogenic shock in patients with acute coronary syndromes frequently occurs after hospital admission, reinforcing the importance of identifying predictors and monitoring early signs of tissue hypoperfusion for prompt intervention. The diagnosisis essentially clinical plus some additional tests such as electrocardiogram, myocardial necrosis markers, echocardiogram, and coronary angiography, which are important fordefining the etiology, stratification of severity and prognosis. Proper management of patients requires assessment of macro- and micro-hemodynamic parameters. The maintherapeutic goals include early restoration of tissue perfusion and recovery of ventricular function. Treatment includes general medical care for patients with shock as optimizingvolemia and adjusting of tissue perfusion with inotropic agents, vasopressors and ventricular assist devices, as well as specific interventions focused on the shock etiology, like early revascularization in acute coronary syndromes...

Clinical Outcomes of Patients with Acute Myocardial Infarction Complicated by Severe Refractory Cardiogenic Shock Assisted with Percutaneous Cardiopulmonary Support

PURPOSE: Limited data are available on the role of percutaneous cardiopulmonary support (PCPS) for the treatment of acute myocardial infarction (AMI) patients with cardiogenic shock. We investigated the clinical outcomes and predictors of in-hospital mortality after PCPS in patients with AMI complicated by severe refractory cardiogenic shock. MATERIALS AND METHODS: From January 2004 to December 2011, we analyzed data from 96 consecutive AMI patients with cardiogenic shock assisted by a PCPS system. The primary outcome was in-hospital mortality. The predictors of in-hospital mortality were determined by a Cox proportional-hazards model. RESULTS: In-hospital mortality occurred in 51 (53.1%) patients and 58 (60.4%) patients were able to be weaned from PCPS. Cardiopulmonary resuscitation (CPR) was performed in 61 (63.5%) patients before PCPS initiation. On multivariate analysis, age > or =67 years [adjusted hazard ratio (HR), 4.74; 95% confidence interval (CI), 2.27-9.93; p<0.001], CPR (adjusted HR, 2.32; 95% CI, 1.11-4.85; p=0.03), lactate clearance for 48 hours <70% (adjusted HR, 2.50; 95% CI, 1.04-6.05; p=0.041), and unsuccessful revascularization (adjusted HR, 3.57; 95% CI, 1.85-6.90; p=0.002) were independent predictors of in-hospital mortality after PCPS in patients with AMI complicated by cardiogenic shock. CONCLUSION: In spite of PCPS management, AMI patients complicated by severe refractory cardiogenic shock demonstrated high mortality. Older age, CPR, lower lactate clearance for 48 hours, and unsuccessful revascularization were independent predictors of in-hospital mortality.

Características clínicas, predictores de mortalidad y resultados inmediatos y a largo plazo en el tratamiento con angioplastía primaria del infarto agudo al miocardio con supradesnivel del ST complicado con shock cardiogénico / Clinical characteristics and predictors of early and global mortality in patients with ST segment elevation myocardial infarction and cardiogenic shock undergoing primary angioplasty

Introducción: El shock cardiogénico (SC) es la complicación más grave del infarto agudo al miocardio (IAM). La mortalidad del SC varía entre un 40-60%. Con el acceso a la angioplastía primaria, el pronóstico del SC ha mejorado en los últimos años, aunque la mortalidad permanece elevada. Nuestro objetivo fue analizar las características clínicas, predictores de mortalidad intrahospitalaria y a largo plazo de los pacientes con IAM complicados con SC en 3 centros hospitalarios con disponibilidad de hemodinamia de urgencia las 24 horas del día.Métodos y Resultados. Estudio analítico observacional. Se incluyeron pacientes entre Enero 2009 y Agosto 2013. La mortalidad se confirmó por certificado de defunción emitido por el registro civil. En el período estudiado se encontraron 101 pacientes con IAM con SC, con una mortalidad intrahospitalaria de 40.8% y global de 53.5% con un seguimiento medio de 1.6 años. No hubo deiferencias significativas entre vivos y fallecidos, respecto de la edad de presentación, antecedentes CV, enfermedad renal, PCR al momento de presentación, tiempo transcurrido desde la presentación del SC, trombo-aspiración, uso de balón de contrapulsación intraórtico (BCIAo), ni resultado angiográfico final. El grupo de mortalidad presentaba mayor número de vasos enfermos (83.3% vs 63.2%; p:0.012), peor fracción de eyección (Fe<30% 66.7% vs 22.5%; p<0,001). Los predictores ajustados de mortalidad intrahospitalaria fueron la presencia de 2 o más vasos enfermos OR 2.9 (IC 95% 1.19-7,1; p= 0.012), y la FE < 30% (OR 6.8, IC 95% 2.23 - 21.27; p=0.001)...

Background. Cardiogenic shock in acute myocardial infarction (AMI) is associated with a high mortality rate (40-60%). An improvement in this prognosis has followed the introduction of primary angioplasty. The aim of this study was to analyze the clinical and angiographic characteristics as well as to determine the early and late mortality in patients with St elevation AMI and cardiogenic shock undergoing primary angioplasty in 3 hospital centers where this procedure was available on a 24hr basis.Methods and Results. We analyzed the clinical an angiographic data of patients treated with primary PTCA for AMI and cardiogenic shock from January 2009 to August 2013. Mortality was confirmed by the data from a National Statistics Office. 101 patients were included and followed for an average of 1.6 years after primary PTCA. Early and total mortality rates were 40.8% and 53.5%, respectively. No differences were found between survivors and non survivors regarding age, risk factors, previous cardiovascular disease, renal failure, CRP and time to PTCA. Intracoronary thrombus aspiration, use of intra-aortic balloon pumping or final angiographic findings were also similar between groups. Compared to survivors, deceased patients had more vessels involved (>= 2 vessels in 83.3% vs 63.2%, respectively, p=0.012) and lower EF (under 30% in 66.7% vs 22.5%, respectively, p<0.001). Predictors of hospital mortality were the presence of >= 2 vessel disease (OR 2.9, 95% C.I. 1.19 - 7.1, p=0.012) and EF under 30% (OR 6.8, C.I. 2.23 - 21.27, p= 0.001)...

Uso de betabloqueador no choque cardiogênico da cardiomiopatia de Takotsubo / Use of beta-blockers in cardiogenic shock due to Takotsubo cardiomyopathy

A cardiomiopatia de Takotsubo se caracteriza por alterações reversíveis na função sistólica e segmentar do ventrículo esquerdo associada à coronariografia normal. O choque associado a essa cardiomiopatia é causado por disfunção sistólica e/ou obstrução dinâmica do trato de saída do ventrículo esquerdo. A identificação da etiologia do choque tem implicações terapêuticas. Relata-se o caso de paciente feminina, 76 anos, com cardiomiopatia de Takotsubo cuja apresentação mimetizou infarto agudo do miocárdio complicado com choque cardiogênico. O choque foi revertido após administração endovenosa de propranolol.

Takotsubo cardiomyopathy is characterized by reversible changes in the systolic and segmental left ventricular function associated with normal coronariography. The shock associated with this cardiomyopathy is caused by left ventricular systolic dysfunction and/or dynamic left ventricular outflow tract obstruction. Identification of the etiology of the shock has implications for treatment. This case study reports on a 76-year-old women diagnosed with Takotsubo cardiomyopathy whose presentation mimicked an acute myocardial infarction complicated by cardiogenic shock. The shock was reversed after intravenous administration of propanolol.

Valvuloplastia aórtica percutânea como medida salvadora na estenose aórtica crítica com instabilidade hemodinâmica / Emergency percutaneous balloon aortic valvuloplasty in critical aortic stenosis with hemodynamic instability

Relatamos o caso de uma paciente de 81 anos, com estenose aórtica (EA) grave sintomática, que, durante cateterismo cardíaco diagnóstico, evoluiu com instabilidade hemodinâmica refratária e posterior parada respiratória. Foi submetida à valvuloplastia aórtica percutânea por balão como medida salvadora, com subsequente melhora hemodinâmica e compensação clínica. A possibilidade de tratamento cirúrgico da EA foi descartada pelo alto risco cirúrgico. O acompanhamento clínico de até 7 meses após o procedimento demonstrou melhora significativa da classe funcional e boa tolerância aos esforços.

We report the case of an 81-year-old patient with symptomatic severe aortic stenosis (AS) who developed refractory hemodynamic instability and respiratory arrest during a diagnostic cardiac catheterization. The patient was submitted to a percutaneous balloon aortic valvuloplasty as a life saving procedure with subsequent hemodynamic improvement and clinical stabilization. The possibility of surgical treatment for AS was excluded due to the high surgical risk. Clinical follow-up of up to 7 months after the procedure demonstrated significant improvement in functional class and good exercise tolerance.

Choque cardiogênico: avaliação clínico-laboratorial e estratégia medicamentosa / Cardiogenic shock: clinical-laboratorial and therapeutic evaluation

O choque cardiogênico é uma síndrome clínica caracterizada por hiperfluxo tecidual secundária à disfunção cardíaca, na ausência de hipovolemia. A etiologia principal é o infarto agudo do miocárdio com falência de ventrículo esquerdo, embora existam outras causas relevantes, como complicações mecânicas do infarto, miocardites, evolução de cardiomiopatias, valvopatias agudas não isquêmicas e cardiomiopatia induzida pelo estresse, por exemplo. Apesar dos avanços terapêuticos, persiste como uma condição de elevada mortalidade e sua incidência não se modificou significativamente nas últimas décadas. A instalação do choque em pacientes com síndromes coronárias agudas ocorre mais frequentemente após a admissão hospitalar, ressaltando a importância da identificação de preditores e da monitorização de sinais precoces de hipoperfusão incidual para pronta intervenção. O diagnóstico é essencialmente clínico e alguns exames subsidiários, como eletrocardiograma, marcadores de necrose miocárdica, ecocardiograma e cineangiocoronariografia, são importantes para a definição da etiologia, estratificação da gravidade e do prognóstico. O manejo adequado dos pacientes requer avaliação dos parâmetros de macro e micro-hemodinâmica. Os principais objetivos terapêuticos incluem a restauração precoce da perfusão tecidual sistêmica e a recuperação da função ventricular. O tratamento inclui medidas gerais para pacientes com choque como ajuste de volemia e adequação da perfusão tecidual com uso de inotrópicos, vasodilatadores e dispositivos de assistência ventricular, além de medidas específicas, direcionadas para etiologia do choque, como a resvascularização precoce nas síndromes coronárias agudas.

Cardiogenic shock is a clinical syndrome characterized by systemic hypoperfusion secondary to cardiac dysfunction, in the absence of hypovolemia. Left ventricular failure complicating massive acute myocardial infarction persists as the most common etiology, although other relevant causes include mechanical complications of acute myocardial infarction, acute myocarditis, non-ischemic valvular heart disease, cardiomyopathies progression and stress induced cardiomyopathies. Despite therapeutic advances the incidence of cardiogenic shock persists almost the same as in the last decades and mortality rate remains very high. the onset of cardiogenic shock, in patients presenting with acute coronary syndromes, frequently accurs after hospital admission, reinforcing the importance of identifying predictors and monitoring early stages of systemic hypoperfusion for early intervention. The diagnosis is established by findings. Diagnostic tests like electrocardiogram, cardiac biomakers, echocardiogram, and coronary angiography, in specific scenarios, can be helpful to confirm the diagnosis, define the etiology, stratify the risk, and provide prognostic information.

Tempestade elétrica e choque cardiogênico após infarto agudo do miocárdio / Electrical Storm and Cardiogenic Shock after Acute Myocardial Infarction

O infarto agudo do miocárdio (IAM) é a principal causa de choque cardiogênico, que ocorre pela disfunção cardíaca e consequente inadequada perfusão tecidual,com grave expressão clínica. Tempestade elétrica (TE)representa outra importante complicação do IAM. Relata-se a ocorrência simultânea dessas complicações num paciente com IAM. Suporte hemodinâmico farmacológico e mecânico associado à angioplastia percutânea primária, cardioversões, associação de antiarrítmicos e implante de cardiodesfibrilador implantável biventricular (CDIBIV)contribuíram para a evolução satisfatória do quadro.

Acute myocardial infarction (AMI) is the main cause of cardiogenic shock, due to cardiac dysfunction and the resulting inadequate tissue perfusion, with severe clinical consequences. Electrical storms are another possible complication for AMI. The simultaneous occurrence ofthese complications is reported in a patient with AMI. Mechanical, pharmacological and hemodynamic support associated with primary percutaneous angioplastyseveral cardioversions, combined anti-arrythmics and a biventricular cardio-defibrillator implant all contributedto a satisfactory outcome.

Desfechos intra-hospitalares e preditores de mortalidade no infarto agudo do miocárdio com choque cardiogênico tratados por angioplastia primária: dados do Registro InCor / In-hospital outcomes and predictors of mortality in acute myocardial infarction with cardiogenic shock treated by primary angioplasty: data from the InCor Registry

Introdução: O choque cardiogênico é a maior causa de morte em pacientes com infarto agudo do miocárdio comsupradesnivelamento do segmento de ST (IAMCSST). O presente estudo avaliou pacientes com IAMCSST e choque cardiogênico submetidosa intervenção coronária percutânea primária com o objetivo de estabelecer seu perfil e os preditores de mortalidadehospitalar. Métodos: Registro unicêntrico, incluindo 100 pacientes avaliados no período de 2001 a 2009 quanto a características clínicas, angiográficas e do procedimento, ea desfechos intra-hospitalares. Por análise multivariada foramdeterminados preditores independentes da mortalidade hospitalar. Resultados: Com relação às características clínicas, foi observada alta prevalência de fatores de risco, sendo a taxa de sucesso angiográfico de 92%, apesar da complexidade das lesões (83,1% do tipo B2/C). A artéria mais acometida foi a descendente anterior (45%), tendo o padrão multiarterial ocorrido em 73% dos casos. A taxa de mortalidade foi de 45%, sendo seus preditores independentes o padrão multiarterial[odds ratio (OR) 2,62; intervalo de confiança de 95% (IC 95%) 1,16-5,90] e o fluxo coronário TIMI < 3 ao final doprocedimento (OR 2,11, IC 95% 1,48-3,02). Conclusões: Os pacientes com IAMCSST complicado por choque cardiogênico apresentaram características clínicas e angiográficas de alto risco e, apesar do alto sucesso angiográfico do procedimento, altas taxas de mortalidade. Foram preditores independentes de mortalidade o padrão multiarterial e fluxo TIMI < 3 ao finaldo procedimento.

Evolução hospitalar de pacientes submetidos a assistência circulatória com balão intra-aórtico durante intervenção coronária percutânea de alto risco: registro InCor / In-hospital outcomes of patients submitted to circulatory support with intra-aortic balloon pump during high risk percutaneous coronary intervention: InCor registry

Introdução: O balão intra-aórtico (BIA) é utilizado há décadas como dispositivo de assistência circulatória, sendo recomendado na maioria das diretrizes, apesar da fraca evidência em relação à redução da mortalidade. O objetivo deste estudo foi avaliar o uso do BIA como ferramenta adjunta na intervenção coronária percutânea (ICP). Métodos: Registro unicêntrico que analisou a evolução hospitalar de 134 pacientes consecutivos que utilizaram BIA durante ICP de alto risco ou na vigência de choque cardiogênico. Resultados: A média de idade foi de 64,7 ± 12,5 anos e 67,9 eram do sexo masculino. A população apresentou características de alto risco, com 33,5 de diabéticos, 73,1 tratados na vigência de infarto do miocárdio, 68,6 com padrão triarterial, e fração de ejeção do ventrículo esquerdo de 38,6 ± 16,1. Fluxo TIMI 2/3 foi obtido em 86,4 dos casos, sendo tratada 1,6 ± 0,6 lesão/paciente. Ocorreram 18 (13,4) reinfartos, dos quais 9 (6,7) por trombose do stent, sendo 2 (1,4) pacientes encaminhados para cirurgia de revascularização miocárdica e 16 (11,9), para nova ICP. A mortalidade hospitalar foi de 61,2 e a taxa de eventos cardíacos adversos maiores (ECAM) foi de 67,2. Por análise multivariada, foram preditores de mortalidade: idade > 65 anos, ICP prévia, necessidade de diálise e padrão triarterial. Os preditores de sobrevida foram: função ventricular normal, fluxo TIMI 2/3 ao final do procedimento e permanência do BIA > 72 horas. Conclusões: Os pacientes que utilizaram BIA durante ICP apresentaram perfil clínico de risco muito alto, que se refletiu em elevada taxa de óbito. Fatores clínicos, angiográficos e do procedimento podem identificar variáveis que interferem independentemente na mortalidade.

The intra-aortic balloon pump (IABP) has been used for decades as a circulatory support device, being recommended in most guidelines, despite poor evidence of mortality reduction. The purpose of this study was to evaluate the use of IABP as an adjunct therapy in percutaneous coronary intervention (PCI). METHODS: Single center registry analyzing in-hospital outcomes of 134 consecutive patients submitted to IABP during high risk PCI or in the presence of cardiogenic shock. RESULTS: Mean age was 64.7 + 12.5 years and 67.9% were males. The population presented high-risk features, with 33.5% of diabetic patients, 73.1% treated in the presence of myocardial infarction, 68.6% with three-vessel disease and left ventricular ejection fraction of 38.6 + 16.1%. TIMI 2/3 flow was obtained in 86.4% of the cases and 1.6 + 0.6 lesion/patient was treated. There were 18 (13.4%) reinfarctions, of which 9 (6.7%) were due to stent thrombosis, 2 (1.4%) patients were referred for CABG and 16 (11.9%) for a new PCI. Hospital mortality was 61.2% and the major adverse cardiac events (MACE) rate was 67.2%. By multivariate analysis, predictors of mortality were: age > 65 years, prior PCI, need of dialysis and three-vessel disease. Predictors of survival were: normal ventricular function, TIMI 2/3 flow at the end of the procedure and IABP utilization > 72 hours. CONCLUSIONS: Patients undergoing PCI with IABP support have a very high risk clinical profile, which led to high mortality rates. Clinical, angiographic and procedure-related factors can identify independent variables for mortality.