RESUMEN
The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists, reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure.
RESUMEN
When TAVR is performed with transfemoral percutaneous approach, local anesthesia, no routine post-procedural intensive care admission, an early discharge (<3 days) can be adopted in most TAVR patients Avoiding peri-procedural complications and minimizing pace-maker implantation rate are key to allow early patient discharge When properly selected, patients discharged early have low discharge have low risk of adverse events and readmissions in the first 30 days.
Asunto(s)
Tiempo de Internación , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Humanos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
The Cardioband system is a transcatheter direct annuloplasty device that is implanted in patients with severe symptomatic functional mitral regurgitation (MR) due to annulus dilatation and high surgical risk. This device covers the posterior two-thirds of the annulus, from the anterolateral to the posteromedial commissure, implanted in close proximity of the left circumflex artery, atrioventricular (AV) conduction system, and coronary sinus. We present the case of an 80-year-old-gentleman with prohibitive surgical risk, treated with Cardioband implantation for functional MR with an evident P1-P2 cleft and P2-P3 indentation, a relative contraindication to MitraClip implantation. We achieved procedural success with significative mitral annulus reduction (30% anteroposterior reduction from 37 to 26 mm) and MR reduction (from grade 4 to grade 1-2). A late onset Mobitz 2 AV block developed after 26 hr and evolved to complete AV block in the following day, requiring definitive biventricular pacemaker (PM). Less than 200 Cardioband implantations have been performed but, to our knowledge, this is the first reported AV block, possibly facilitated by the pre-existing bifascicular block, suggesting the opportunity of prolonged ECG monitoring after Cardioband like any other mechanical transcatheter structural intervention possibly affecting the AV conduction system.
Asunto(s)
Bloqueo Atrioventricular/etiología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Anuloplastia de la Válvula Mitral/efectos adversos , Anuloplastia de la Válvula Mitral/instrumentación , Insuficiencia de la Válvula Mitral/cirugía , Anciano de 80 o más Años , Bloqueo Atrioventricular/diagnóstico , Bloqueo Atrioventricular/fisiopatología , Bloqueo Atrioventricular/terapia , Terapia de Resincronización Cardíaca , Humanos , Masculino , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Diseño de Prótesis , Resultado del TratamientoRESUMEN
Arterial blood gas (ABG) analysis is a simple and quick test that can provide multiple respiratory and metabolic parameters. The interpretation of ABG analysis and acid-base disorders represents one of the most complex chapters of clinical medicine. In this brief review, the authors propose a rational approach that sequentially analyzes the information offered by the ABG to allow a rapid classification of the respiratory, metabolic or mixed disorder. The patient's history and clinical-instrumental assessment are the framework in which to insert the information derived from the ABG analysis in order to characterize the critical heart patient.
Asunto(s)
Análisis de los Gases de la Sangre , Unidades de Cuidados Coronarios , Humanos , Análisis de los Gases de la Sangre/métodos , Cardiopatías/sangre , Cardiopatías/diagnóstico , Desequilibrio Ácido-Base/sangre , Desequilibrio Ácido-Base/diagnóstico , Desequilibrio Ácido-Base/terapiaAsunto(s)
Enfermedad Coronaria/cirugía , Intervención Coronaria Percutánea/métodos , Implantes Absorbibles , Síndrome Coronario Agudo/cirugía , Adenosina/análogos & derivados , Adenosina/uso terapéutico , Cuidados Posteriores , Anciano de 80 o más Años , Técnicas de Imagen Cardíaca/métodos , Angiografía Coronaria/métodos , Puente de Arteria Coronaria/métodos , Angiopatías Diabéticas/cirugía , Quimioterapia Combinada , Fibrinolíticos/uso terapéutico , Reserva del Flujo Fraccional Miocárdico/fisiología , Oclusión de Injerto Vascular/prevención & control , Humanos , Paro Cardíaco Extrahospitalario/cirugía , Inhibidores de Agregación Plaquetaria/uso terapéutico , Guías de Práctica Clínica como Asunto , Clorhidrato de Prasugrel/uso terapéutico , Diseño de Prótesis , Antagonistas del Receptor Purinérgico P2Y/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Infarto del Miocardio con Elevación del ST/cirugía , Stents , Trombectomía/métodos , Ticagrelor , Tiempo de Tratamiento , Andamios del TejidoRESUMEN
Circulatory shock is a clinical condition characterized by hypotension and organ hypoperfusion, potentially fatal if the underlying cause is not promptly identified and corrected. Circulatory shock outcome is certainly conditioned from early diagnosis and early and adequate therapy. The aim of this review is to provide a tool for a rapid differential diagnosis among the various phenotypes of circulatory shock, based on the clinical, hemodynamic and biochemical profile. We also prompt to emphasize the role of multiparametric monitoring from the early phases of the management and the need to implement the time-dependent network to improve the outcome of these critical patients.
Asunto(s)
Hipotensión , Choque , Enfermedades Vasculares , Humanos , Choque/diagnóstico , Choque/etiología , Choque/terapia , Hemodinámica , Diagnóstico Precoz , Enfermedades Vasculares/complicaciones , Choque Cardiogénico/terapiaRESUMEN
Acute respiratory failure is a frequent complication of patients admitted to the intensive cardiac care unit and it is associated with a poor short- and long-term outcome. Acute respiratory failure can be managed with traditional oxygen therapy, with high-flow nasal cannula, continuous positive airway pressure, non-invasive ventilation or invasive ventilation according to clinical and blood gas condition. The use of advanced respiratory therapies is associated with both respiratory and hemodynamic effects, therefore the intensivist cardiologist should know deeply these respiratory devices. The intensivist cardiologist should perform an early diagnosis of acute respiratory failure, an appropriate selection of the respiratory device, and accurate monitoring and management to obtain clinical improvement and to avoid mechanical invasive ventilation.
Asunto(s)
Cánula , Insuficiencia Respiratoria , Humanos , Hipoxia/etiología , Hipoxia/terapia , Oxígeno , Intubación Intratraqueal , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapiaRESUMEN
AIMS: The presence of anti-human leucocyte antigen (HLA) antibodies has been implicated in a higher incidence of complications as well as mortality rate in heart transplantation. The aim of the study was to identify through non-invasive parameters early signs of myocardial dysfunction in the presence of anti-HLA antibodies but without evidence of antibody-mediated rejection (AMR) and its possible prognostic impact. METHODS AND RESULTS: A total of 113 heart-transplanted patients without acute cellular rejection (ACR) and AMR or cardiac allograft vasculopathy (CAV) were prospectively enrolled and divided into two groups ['HLA+' (50 patients) and 'HLA-' (63 patients)], based on the presence of anti-HLA antibodies. Each patient was followed for 2 years after the enrolment, recording episodes of AMR, ACR, CAV, and mortality. Clinical characteristics were similar between the two groups. Among laboratory data, N-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin values were significantly higher in the presence of anti-HLA antibodies (P < 0.001 and P = 0.003, respectively). The echocardiographic parameters that showed a statistically significant difference between the two groups were deceleration time of E wave (DecT E, P < 0.001), left ventricular global longitudinal strain (P < 0.001), tricuspid annular plane systolic excursion (P = 0.011), tricuspid S' wave (P = 0.002), and free wall right ventricular longitudinal strain (fwRVLS, P = 0.027), whereas left atrial strain did not differ significantly (P = 0.408). Univariate analysis showed that anti-HLA antibodies were associated with the development of CAV at both 1 and 2 year follow-up [odds ratio (OR) 11.90, 95% confidence interval (CI) 1.43-90.79, P = 0.022 and OR 3.37, 95% CI 1.78-9.67, P = 0.024, respectively]. Bivariate analysis demonstrated that both fwRVLS and DecT E were predictors of CAV development independently from HLA status. CONCLUSIONS: The presence of circulating anti-HLA antibodies is correlated with a mild cardiac dysfunction, even in the absence of AMR, and CAV development. Interestingly, reduced values of DecT E and fwRVLS were predictors of future development of CAV, independently from anti-HLA antibody.
Asunto(s)
Trasplante de Corazón , Humanos , Trasplante de Corazón/efectos adversos , Trasplante de Corazón/métodos , Anticuerpos , Pronóstico , Rechazo de Injerto/diagnóstico , EcocardiografíaRESUMEN
The management of the patient with fever in the intensive cardiac care unit begins with a thorough evaluation of the patient, particularly symptoms, clinical history and physical examination, to provide information regarding the origin of the fever. The global evaluation of the patient should be integrated with blood and microbiological tests, in particular blood culture and swab. The laboratory, microbiologic or radiologic tests could be more or less detailed and targeted depending on the type of suspected infection and clinical conditions of the patient. When therapy is necessary, it is crucial to switch, as soon as possible, from broad spectrum antibiotic therapy to antibiotic therapy based on the results of the microbiological exams. Antibiotic therapy could be associated with antipyretic and specific organ support therapy when necessary.
Asunto(s)
Fiebre , Unidades de Cuidados Intensivos , Humanos , Fiebre/etiología , Fiebre/terapia , Antibacterianos/uso terapéuticoRESUMEN
Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure >20 mmHg at rest during right heart catheterization. PH prevalence is about 1% of the global population. The PH clinical classification includes five groups: pulmonary arterial hypertension, PH associated with left heart disease, PH associated with lung disease, PH associated with pulmonary artery obstructions, PH with unclear and/or multifactorial mechanisms. In case of clinical suspicion, echocardiography is the first-line tool to start the diagnostic process. Right heart catheterization is the gold standard for diagnosis of PH, requires great experience and should be performed in expert centers. The classification of the PH patient in a specific subgroup requires multidisciplinary clinical and instrumental skills that only a reference center can provide. This document proposes a clinical pathway for the management of PH patients in the Tuscany region in order to standardize access to specialized care.
Asunto(s)
Cardiopatías , Hipertensión Pulmonar , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/etiología , Hipertensión Pulmonar/terapia , Vías Clínicas , Cateterismo Cardíaco , EcocardiografíaRESUMEN
Arrhythmias are a common complication in the adult population with congenital heart disease (ACHD). Arrhythmias often lead to hemodynamic instability and, on the other hand, may be a marker of hemodynamic impairment in ACHD patients, both in natural history and after cardiac surgery. Treatment requires knowledge of basic anatomy and any previous cardiac surgery; the availability of patient's health records, if possible, is therefore crucial for therapeutic choices. In the emergency setting, the first target is represented by the patient's hemodynamic stabilization; mainly in moderate or high complexity ACHD, the connection with the referral center is recommended, to which patients should be entrusted for follow-up. A regional epidemiological observatory, aiming to assess the number, type and outcomes of emergency admissions of ACHD patients could be a useful tool for analyzing the effectiveness of the collaboration network between the different structures involved and for implementing organizational pathways.
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Procedimientos Quirúrgicos Cardíacos , Cardiopatías Congénitas , Adulto , Humanos , Cardiopatías Congénitas/complicaciones , Cardiopatías Congénitas/epidemiología , Vías Clínicas , Arritmias Cardíacas/terapia , Arritmias Cardíacas/complicaciones , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Servicio de Urgencia en HospitalRESUMEN
The number of elderly patients admitted to cardiac intensive care units (CICU) is significantly increasing. Nowadays, novel diagnostic and therapeutic tools allow to treat the vast majority of cardiac acute diseases, nonetheless care of elderly patients requires a careful clinical evaluation. A favorable proportion of cost-effectiveness is warranted, aimed at avoiding futile procedures or treatments. On the other hand, the availability of minimally invasive procedures carries forward old limits to treatments in elderly patients in CICU. It appears evident that age cannot per se represent a limit in the care of elderly people. The present review gives insights in the management of the most common cardiovascular disease settings in elderly patients in the CICUs, thus providing important tools in complex decision-making.
Asunto(s)
Enfermedades Cardiovasculares , Cardiopatías , Anciano , Enfermedades Cardiovasculares/terapia , Cardiopatías/terapia , Mortalidad Hospitalaria , Hospitalización , Humanos , Unidades de Cuidados Intensivos , Inutilidad Médica , Estudios RetrospectivosRESUMEN
Cardio-oncology is now part of the standard clinical approach for patients with cancer and cannot be overlooked anymore. While its scientific background is solid and its clinical relevance is well known, its application in daily practice varies greatly among hospitals. To provide the best cardio-oncology care to cancer patients and to make cardio-oncology's clinical use uniform, we developed a shared multidisciplinary proposal for a dedicated clinical pathway. Our proposition presents the minimum requirements needed to which this path caters for, identifies patient categories to be entered into the path, highlights the role of a specific inter-hospital clinical and imaging network and indicates follow-up strategies during and after oncological treatments. The proposed pathway is based on some key elements and is easily adaptable to different hospitals with minimal changes.
Asunto(s)
Cardiología , Neoplasias , Vías Clínicas , Humanos , Oncología Médica , Neoplasias/terapia , Pacientes AmbulatoriosRESUMEN
Cardiogenic shock is a clinical syndrome characterized by hypotension and hypoperfusion due to the inability of the heart to provide adequate cardiac output. It is an infrequent clinical condition still burdened by high mortality rates. In patients with cardiogenic shock rapid diagnosis, multiparameter monitoring and timely therapeutic strategies with pharmacological agents or mechanical circulatory support are necessary to provide adequate peripheral tissue perfusion and to improve outcome. Recent investigations reported lower mortality rates to be associated with clinical pathways based on a well-organized network, and on admission in high-volume specialized hospitals (Shock Center) with a dedicated multidisciplinary team (Shock Team). The aim of this clinical pathway for cardiogenic shock is to describe the best organization to ensure to Tuscan citizens an equal access to care independently of the site where they suffer from cardiogenic shock.
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Hipotensión , Choque Cardiogénico , Vías Clínicas , Humanos , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/terapiaRESUMEN
The diagnosis of cardiac amyloidosis (CA) is challenging because of its phenotypic heterogeneity, multi-organ involvement often requiring the interaction among experts in different specialties and subspecialties, the lack of a single non-invasive diagnostic tool, and limited awareness in the medical community. Recent studies have challenged the dogma of CA as a rare, incurable disease, and have redefined the epidemiology and therapeutic options for this condition. Missing or delaying the diagnosis may have a profound impact on patient outcome, as potentially life-saving treatments may be omitted or delayed, particularly chemotherapy in the case of amyloid light-chain amyloidosis. For a timely identification, clinical cardiologists should be able to recognize the "red flags" prompting a dedicated diagnostic work-up. Cardiologists could also face the challenge of making decisions about drug and device therapies for patients with known CA. The present consensus document aims to provide a practical guide and an organizational framework for professionals belonging to the Tuscan network of hospital cardiologists.
Asunto(s)
Amiloidosis , Cardiólogos , Cardiología , Amiloidosis/diagnóstico , Amiloidosis/terapia , Consenso , Hospitales , Humanos , ItaliaRESUMEN
The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists (ANMCO), reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure. Data deriving from a national survey in Italian hospitals about IABP use are also provided.
Asunto(s)
Insuficiencia Cardíaca , Infarto del Miocardio , Insuficiencia Cardíaca/terapia , Humanos , Contrapulsador Intraaórtico , Choque Cardiogénico/terapia , Resultado del TratamientoRESUMEN
Refractory cardiogenic shock (RCS) or refractory cardiac arrest (RCA) complicating acute coronary syndrome (ACS) is associated with extremely high mortality rate. Veno-arterial extracorporeal life support (VA-ECLS) represents a valuable therapeutic option to stabilize patients' condition before or at the time of emergency revascularization. We analyzed 29 consecutive patients with RCS or RCA complicating ACS, and implanted with VA-ECLS in two centers who have adopted a similar, structured approach to ECLS implantation. Data were collected from January 2010 to December 2015 and ECLS had to be percutaneously implanted either before (within 48 h) or at the time of attempted percutaneous coronary revascularization (PCI). We investigated in-hospital outcome and factors associated with survival. Twenty-one (72%) were implanted for RCA, whereas 8 (28%) were implanted on ECLS for RCS. All RCA were witnessed and no-flow time was shorter than 5 min in all cases but one. All patients underwent attempted emergency PCI, using radial access in ten cases (34.5%), whereas in three patients a subsequent CABG was performed. Overall, ten patients (34.5%) survived, nine of them with a good neurological outcome. Life threatening complications, including stroke (4 pts), leg ischemia (4 pts), intestinal ischemia (5 pts), and deep vein thrombosis 2 pts), occurred frequently, but were not associated with in-hospital death. Main cause of death was multi-organ failure. PCI variables did not predict survival. Survivors were younger, with shorter low-flow time, and with ECLS mainly implanted for RCS. At multivariate analysis, levels of lactate at ECLS implantation (OR 4.32, 95%CI 1.01-18.51, p = 0.049) emerged as the only variable that independently predicted survival. In patients with RCA or RCS complicating ACS who are percutaneously implanted with ECLS before or at the time of coronary revascularization, in hospital survival rate is higher than 30%. Level of lactate at ECLS implantation appears to be the most important factor to predict survival.
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Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/terapia , Oxigenación por Membrana Extracorpórea , Paro Cardíaco/mortalidad , Paro Cardíaco/terapia , Lactatos/sangre , Choque Cardiogénico/mortalidad , Choque Cardiogénico/terapia , Síndrome Coronario Agudo/complicaciones , Biomarcadores/sangre , Femenino , Paro Cardíaco/complicaciones , Mortalidad Hospitalaria , Humanos , Italia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Valor Predictivo de las Pruebas , Sistema de Registros , Factores de Riesgo , Choque Cardiogénico/complicaciones , Tasa de SupervivenciaRESUMEN
: The article reviews the rate of embolic risk in permanent and paroxysmal atrial fibrillation reported in the current literature. The data analyzed suggest that the embolic risk in the two forms of atrial fibrillation is different and therefore careful clinical judgment is needed to offer patients tailored anticoagulation treatments.
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Fibrilación Atrial/complicaciones , Accidente Cerebrovascular/etiología , Tromboembolia/etiología , Administración Oral , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/tratamiento farmacológico , Toma de Decisiones Clínicas , Hemorragia/inducido químicamente , Humanos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/prevención & control , Tromboembolia/diagnóstico , Tromboembolia/prevención & control , Resultado del TratamientoRESUMEN
BACKGROUND: Calcified coronary lesions still represent a challenge for coronary angioplasty, with sub-optimal acute PCI results causing more frequent late stent failure. PURPOSE: The study aimed at the evaluation of the immediate procedural outcome in a real-world consecutive population of a selective use of lithotripsy based on the intravascular imaging assessment with IVUS or OCT. METHODS AND RESULTS: Thirty-one calcified stenoses (28 patients) out of a total of 455 lesions (370 patients) treated between November 2018 and May 2019 received IVL under intravascular imaging guidance. The majority of the IVL lesions had angiographically severe calcifications and were selected after intravascular imaging. A smaller group was identified by poor expansion after high-pressure balloon dilatation, in one case despite preliminary small burr Rotablation. After IVL, when OCT was performed calcium fractures were observed in 71% of cases. After OCT/IVUS guided stent optimization a satisfactory lumen enlargement (minimal stent area 7.09⯱â¯2.77â¯mm2) was observed with good stent expansion (residual area stenosis<20% in 29 lesions, 93.5%) Peri-procedural complications were limited to one dissection at the distal edge requiring an additional stent and 3 peri-procedural myocardial infarctions. There were no periprocedural coronary perforations or pericardial effusions, and no in-hospital or 30â¯days stent thrombosis. When patients were divided into two subgroups according to a calcium arc ≤180° (Group A: 10 lesions, calcium arc 140⯱â¯24°; Group B: 21 lesions, calcium arc 289⯱â¯53°), at OCT Group B presented also a higher number of calcium fractures post IVL than group A (group A: 38% vs group B: 92%, pâ¯=â¯0.03). The in-stent minimum lumen diameter (MSD), the in stent minimal lumen area (MSA) and the acute gain, however, were similar between the two groups (acute gain group A: 1.22⯱â¯0.29â¯mm; group B: 1.31⯱â¯0.52â¯mm, pâ¯=â¯0.63). CONCLUSIONS: A standardized algorithm applying intravascular imaging guidance of IVL facilitated second generation DES expansion delivers excellent immediate lumen expansion and patient outcome, both in concentric and eccentric calcifications.
Asunto(s)
Litotricia , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/terapia , Humanos , Intervención Coronaria Percutánea , Stents , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
Percutaneous treatment of heavily calcified coronary lesions still represents a challenge for interventional cardiology, with higher risk of immediate complications, late failure due to stent underexpansion and malapposition, and consequently poor clinical outcome. Good characterisation of calcium distribution with multimodal imaging is important to improve the successful treatment of these lesions. The use of traditional or new dedicated devices for the treatment of calcified lesions allows better lesion preparation; therefore, it is important that we know the different mechanisms and technical features of these devices.