Asunto(s)
Hipertensión , Riñón , Humanos , Riñón/inervación , Hipertensión/cirugía , Hipertensión/fisiopatología , Desnervación , Simpatectomía/métodosRESUMEN
AIMS: To examine the shot-term outcomes with catheter-directed thrombolysis (CDT) vs. catheter-directed embolectomy (CDE) for high-risk pulmonary embolism (PE). METHODS AND RESULTS: The Nationwide Readmissions Database was utilized to identify hospitalizations with high-risk PE undergoing CDE or CDT from 2016 to 2019. The main outcome was all-cause in-hospital mortality. Propensity score matching was used to compare the outcomes in both groups. Among 3216 high-risk PE hospitalizations undergoing catheter-directed interventions, 868 (27%) received CDE, 1864 (58%) received CDT, and 484 (15%) received both procedures. In the unadjusted analysis, the rate of all-cause in-hospital mortality was not different between CDE and CDT (39.6% vs. 34.2%, P = 0.07). After propensity score matching, there was no difference in the incidence of in-hospital mortality [adjusted odds ratio (aOR): 1.28, 95% confidence interval (CI): 0.95, 1.72, P = 0.10], intracranial haemorrhage (ICH) (adjusted OR 1.57, 95% CI: 0.75, 3.29, P = 0.23), or non-ICH bleeding (aOR: 1.17, 95% CI: 0.85, 1.62, P = 0.33). There were no differences in the length of stay, cost, and 30-day unplanned readmissions between both groups. CONCLUSION: In this contemporary observational analysis of patients admitted with high-risk PE undergoing CDT or CDE, the rates of in-hospital mortality, ICH, and non-ICH bleeding events were not different.
Asunto(s)
Fibrinolíticos , Embolia Pulmonar , Humanos , Catéteres , Embolectomía , Fibrinolíticos/uso terapéutico , Hemorragia/inducido químicamente , Hemorragias Intracraneales/etiología , Embolia Pulmonar/cirugía , Embolia Pulmonar/tratamiento farmacológico , Estudios Retrospectivos , Terapia Trombolítica/métodos , Resultado del TratamientoRESUMEN
Spontaneous coronary artery dissection (SCAD) is not uncommon but remains arguably an under-diagnosed etiology for acute coronary syndrome (ACS). It occurs predominantly in young-to-middle aged women who have no or few traditional atherosclerotic cardiovascular disease risk factors. Post-infarction mechanical complications are a dreaded outcome of ACS. However, very few case reports describe these mechanical complications related to SCAD. Unsuccessful revascularization is a particular concern for patients presenting with SCAD-induced ACS, which can increase the risk for certain mechanical complications. We present a case of a middle-aged woman who presented with anterior ST-segment elevation myocardial infarction and was found to have SCAD of left anterior descending coronary artery. Two attempts at revascularization were unsuccessful. Thereafter, her clinical course was complicated by the development of heart failure as a result of a reduced ejection fraction and a left ventricular pseudoaneurysm. Importantly she also suffered a ventricular septal rupture necessitating surgical intervention. Fortunately, our patient had a favorable longer-term outcome. Current literature, including five published case reports on SCAD complicated by mechanical complications are reviewed. Clinicians must remain aware of post-infarction mechanical complications in patients with high-risk and non-revascularized SCAD.
Asunto(s)
Síndrome Coronario Agudo , Infarto del Miocardio con Elevación del ST , Rotura Septal Ventricular , Persona de Mediana Edad , Humanos , Femenino , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Rotura Septal Ventricular/cirugía , Rotura Septal Ventricular/complicaciones , Angiografía Coronaria/efectos adversos , Síndrome Coronario Agudo/complicaciones , Infarto del Miocardio con Elevación del ST/etiologíaRESUMEN
There is an increasing prevalence of patients who have both liver cirrhosis (LC) and severe valvular heart disease. This combination typically poses prohibitive risk for liver transplantation. LC related malnourishment, hypoalbuminemia and hyperdynamic circulation places patients with severe LC at higher rates for significant bleeding and/or thrombosis, as well as infectious and renal complications, after either surgical or transcatheter valvular interventions. Although there remains scarce comparative evidence, the preponderance of data suggest that percutaneous strategies are preferred over surgical ones. A multidisciplinary team is ideal for identifying those patients with LC who would benefit from transcatheter valvular heart interventions.
Asunto(s)
Estenosis de la Válvula Aórtica , Enfermedades de las Válvulas Cardíacas , Implantación de Prótesis de Válvulas Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Estenosis de la Válvula Aórtica/cirugía , Resultado del Tratamiento , Cirrosis Hepática/complicaciones , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/terapia , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/cirugía , Válvula Aórtica/cirugía , Factores de RiesgoRESUMEN
We describe a case of an orthotopic heart transplant recipient who presented with chest pain related to blunt chest trauma 3 weeks post-transplantation. Electrocardiogram showed anterior ST-segment elevation. Coronary angiography revealed a dissection of the mid-distal left anterior descending artery with preserved antegrade flow. Conservative management of the coronary artery dissection was pursued. While the patient had a favorable long-term clinical outcome, the coronary dissection persisted on 1- and 2-year follow-up coronary angiography.
Asunto(s)
Disección Aórtica , Aneurisma Coronario , Trasplante de Corazón , Traumatismos Torácicos , Heridas no Penetrantes , Humanos , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Vasos Coronarios/lesiones , Aneurisma Coronario/diagnóstico por imagen , Aneurisma Coronario/etiología , Aneurisma Coronario/cirugía , Angiografía Coronaria , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/etiología , Disección Aórtica/cirugía , Trasplante de Corazón/efectos adversosAsunto(s)
Endocarditis Bacteriana , Endocarditis , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral , Humanos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Procedimientos Quirúrgicos de Citorreducción , Endocarditis Bacteriana/cirugía , Endocarditis/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Resultado del TratamientoAsunto(s)
Enfermedades Cardiovasculares , Sistema Cardiovascular , Neoplasias Cutáneas , Presión Sanguínea , Femenino , Humanos , Masculino , PotasioRESUMEN
Liver cirrhosis (LC) is becoming increasingly common among patients presenting with acute coronary syndromes (ACS) and is associated with significant cardiovascular morbidity and mortality. Management of such patients is complicated by LC related complications. Literature is scarce on the safety of antithrombotic regimens and invasive strategies for ACS in patients with LC, especially those undergoing liver transplant evaluation. Recently there has been evidence that cirrhosis is an independent risk factor for adverse outcomes in ACS. As patients with LC are generally excluded from large randomized trials, definitive guidelines for the management of ACS in this particular cohort are lacking. Many antithrombotic drugs require either hepatic activation or clearance; hence, an accurate assessment of hepatic function is required prior to initiation and dose adjustment. Despite a demonstrated survival benefit of optimal medical therapy and invasive revascularization techniques in LC patients with ACS, both strategies are currently underutilized in this population. This review aims to present currently available data and provide a practical, clinically oriented approach for the management of ACS in LC. Randomized clinical trials in LC patients with ACS are the need of the hour to further refine their management for favorable outcomes.
Asunto(s)
Síndrome Coronario Agudo , Fibrinolíticos , Cirrosis Hepática , Síndrome Coronario Agudo/tratamiento farmacológico , Fibrinolíticos/efectos adversos , Fibrinolíticos/uso terapéutico , Humanos , Cirrosis Hepática/complicaciones , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de RiesgoRESUMEN
A 52-year-old woman with cystic fibrosis presented to the emergency department with expressive aphasia and right-sided hemiparesis. CT scan of the brain revealed a left middle cerebral artery territory infarct. A diagnosis of cerebral paradoxical embolisation associated with patent foramen ovale and a history of deep venous thrombosis was made. The patient underwent endovascular thrombectomy and percutaneous closure of patent foramen ovale. Current literature, including five published case reports, pertaining to the subject is discussed. The unique aspects of the case are highlighted, including the particular risk of cerebral paradoxical embolisation in patients with cystic fibrosis. The result of this case report, in context to previously reported literature, suggests that clinicians should be aware of paradoxical embolisation in patients with cystic fibrosis via an intracardiac shunt, particularly with implanted vascular access devices and a history of deep venous thrombosis.
Asunto(s)
Fibrosis Quística , Embolia Paradójica , Foramen Oval Permeable , Encéfalo , Fibrosis Quística/complicaciones , Embolia Paradójica/etiología , Femenino , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/diagnóstico por imagen , Humanos , Persona de Mediana Edad , TrombectomíaRESUMEN
Despite improvements in acute care and survival following acute coronary syndrome (ACS) hospitalization, readmission remains common. In response, individual institutions have begun to develop their own protocols to reduce variability of care and readmission rates. This review provides approaches for developing and implementing institutional discharge protocols for continuity of care for ACS patients and describes key components of the discharge protocol. Furthermore, specific objectives of the protocol, including medication adherence, patient education, enabling access to cardiac rehabilitation, and clinical follow-up, as well as consideration of patient-specific needs, are discussed with the aim of providing successful continuity of care. TABLE OF CONTENTS SUMMARY: This review discusses approaches for developing and implementing institutional discharge protocols for continuity of care for patients with acute coronary syndrome. The discussion revolves around key components and objectives of a discharge protocol for facilitating successful transition of care.
Asunto(s)
Síndrome Coronario Agudo , Hospitalización , Humanos , Cumplimiento de la Medicación , Alta del Paciente , Readmisión del Paciente , Transferencia de PacientesRESUMEN
The optimal dose and duration of tissue plasminogen activator (tPA) administered with ultrasound-facilitated catheter-directed thrombolysis (USCDT) to patients with acute PE remains to be determined. Our institution recently adopted a shorter duration (4 h) of USCDT and lower dosing strategy (tPA 1 mg/h) based on data from the OPTALYSE PE Trial. The purpose was to evaluate the implementation at our institution of shorter duration (4 h) of USCDT and lower dosing strategy (tPA 1 mg/h) as outlined by OPTALYSE PE Trial. This was a retrospective, single-center, observational study included patients from 01/01/2017 to 12/31/2018 in a large, academic medical center. Group 1 represented patients who underwent USCDT prior to 01/18/18. Group 2 represented patients who underwent USCDT after 01/18/18 and received 4 h of USCDT and tPA 1 mg/h/catheter. The primary outcome was intensive care unit (ICU) length of stay (LOS). Secondary outcomes were the proportion of patients experiencing a composite of major adverse events (death, recurrent PE, major bleeding, or stroke), change in right ventricle size/function and pulmonary artery pressures, need for mechanical respiratory or hemodynamic support, hospital LOS and drug cost. A total of 31 patients were included in the study: twenty patients in Group 1 and eleven patients in Group 2. Median ICU LOS was 3.5 days in Group 1 and 1 day in Group 2. Group 2 had reduced MACE, requirement for mechanical respiratory or hemodynamic support, hospital LOS, drug costs and adverse events. Implementation of a shorter duration of USCDT and lower dosing strategy for tPA in patients with acute PE may be one strategy to reduce the total ICU LOS and costs associated with care.