ABSTRACT
BACKGROUND: Despite prognostic improvements in ST-elevation myocardial infarction (STEMI), patients presenting with cardiogenic shock (CS) have still high mortality. Which are the relevant early prognostic factors despite revascularization in this high-risk population is poorly investigated. METHODS: We analyzed STEMI patients treated with primary percutaneous coronary intervention (PCI) and enrolled at the University Hospital of Trieste between 2012 and 2018. A decision tree based on data available at first medical contact (FMC) was built to stratify patients for 30-day mortality. Multivariate analysis was used to explore independent factors associated with 30-day mortality. RESULTS: Among 1222 STEMI patients consecutively enrolled, 7.5% presented with CS. CS compared with no-CS patients had worse 30-day mortality (33% vs 3%, Pâ<â0.01). Considering data available at FMC, CS patients with a combination of age ≥76âyears, anterior STEMI and an expected ischemia time > 3âh and 21âmin were at the highest mortality risk, with a 30-day mortality of 85.7%. In CS, age (OR 1.246; 95% CI 1.045-1,141; Pâ=â0.003), final TIMI flow 2-3 (OR 0.058; 95% CI 0.004-0.785; Pâ=â0.032) and Ischemia Time (ORâ=â1.269; 95% CI 1.001-1.609; Pâ=â0.049) were independently associated with 30-day mortality. CONCLUSIONS: In a contemporary real-world population presenting with CS due to STEMI, age is a relevant negative factor whereas an early and successful PCI is positively correlated with survival. However, a subgroup of elderly patients had severe prognosis despite revascularization. Whether pPCI may have an impact on survival in a very limited number of irreversibly critically ill patients remains uncertain and the identification of irreversibly shocked patients remains nowadays challenging.
Subject(s)
Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction , Aged , Humans , Percutaneous Coronary Intervention/adverse effects , Prognosis , Risk Factors , ST Elevation Myocardial Infarction/diagnostic imaging , ST Elevation Myocardial Infarction/therapy , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/etiology , Shock, Cardiogenic/therapy , Time Factors , Treatment OutcomeABSTRACT
AIMS: To evaluate the prevalence and predictors of persistent sinus rhythm in a recent cohort of unselected patients undergoing electrical cardioversion for atrial fibrillation. METHODS: We enrolled all consecutive patients undergoing elective electrical cardioversion for atrial fibrillation between January 2017 and December 2018. We analysed baseline clinical and echocardiographic data as well as pharmacological antiarrhythmic therapy. Primary endpoint was the maintenance of sinus rhythm at 12 months after electrical cardioversion. RESULTS: Of the 300 patients enrolled, 270 (90%) had successful electrical cardioversion and among them, 201 patients have 12-month follow-up data (mean age 70â±â10âyears; 74% men). At 12âmonths, only 45.7% were in sinus rhythm. Patients without sinus rhythm compared with persistent sinus rhythm at 12âmonths had a lower baseline left ventricle ejection fraction (LVEF) (49.1â±â16 vs. 59.7â±â9%, Pâ=â0.02) and had more frequently a history of atrial fibrillation more than 12âmonths (55 vs. 34% Pâ=â0.003). At the multivariate analysis, only the duration of the disease beyond 12âmonths (OR 0.26, 95% CI: 0.08-0.88, Pâ=â0.032), LVEF (OR 1.06, 95% CI: 1.01-1.12, Pâ=â0.012) and the presence of sinus rhythm at 1-month follow-up (OR 18.28, 95% CI: 3.3-100, Pâ=â0.001) were associated with the probability of maintaining sinus rhythm at 12âmonths. CONCLUSION: In unselected patients with atrial fibrillation undergoing elective electrical cardioversion, only 45.7% were in sinus rhythm at 12 months. The presence of sinus rhythm at 1-month follow-up emerged as an independent predictor of maintenance of sinus rhythm. This highlights that early re-evaluation of these patients appears useful for assessing longer term outcomes also from the perspective of a possible selective approach to ablation strategies.
Subject(s)
Aftercare , Atrial Fibrillation/therapy , Electric Countershock , Heart Rate , Aftercare/methods , Aftercare/statistics & numerical data , Aged , Atrial Fibrillation/diagnosis , Electric Countershock/adverse effects , Electric Countershock/methods , Electric Countershock/statistics & numerical data , Female , Humans , Male , Prognosis , Recurrence , Stroke Volume , Time , Time Factors , Treatment Outcome , Ventricular Function, LeftABSTRACT
In a 23-year-old man having myocarditis in the context of eosinophilic granulomatosis with polyangiitis, a mobile left ventricular apical thrombus was found with transthoracic echocardiography. Its surgical removal was established because there were no signs of resizing after effective intravascular anticoagulation therapy. Surgery was carried out via a median sternotomy with cardiopulmonary bypass. The site of endocardial implantation of the thrombus was identified with epicardial ultrasonography scan. The trans-aortic approach was adopted to avoid complications such as ventricular dysfunction and arrhythmias secondary to ventricular incision. Real-time imaging of the complete removal was obtained with optical instruments.
Subject(s)
Cardiac Surgical Procedures/methods , Churg-Strauss Syndrome/complications , Heart Diseases/surgery , Heart Ventricles/surgery , Thrombosis/surgery , Aorta/surgery , Cardiopulmonary Bypass , Echocardiography , Heart Diseases/diagnostic imaging , Heart Diseases/etiology , Humans , Male , Myocarditis/etiology , Sternotomy , Thrombosis/diagnostic imaging , Thrombosis/etiology , Ultrasonography , Young AdultSubject(s)
Antibodies, Monoclonal, Murine-Derived/adverse effects , Antirheumatic Agents/adverse effects , Arthritis, Rheumatoid/drug therapy , Immunocompromised Host , Immunosuppressive Agents/adverse effects , Methotrexate/adverse effects , Pericarditis/chemically induced , Staphylococcal Infections/chemically induced , Aged , Anti-Bacterial Agents/therapeutic use , Arthritis, Rheumatoid/diagnosis , Arthritis, Rheumatoid/immunology , Cardiac Tamponade/chemically induced , Cardiac Tamponade/microbiology , Electrocardiography , Humans , Male , Pericardial Effusion/chemically induced , Pericardial Effusion/microbiology , Pericarditis/diagnosis , Pericarditis/drug therapy , Pericarditis/immunology , Pericarditis/microbiology , Rituximab , Staphylococcal Infections/diagnosis , Staphylococcal Infections/drug therapy , Staphylococcal Infections/immunology , Staphylococcal Infections/microbiology , Treatment OutcomeABSTRACT
A 74-year-old man was referred to hospital for sustained dyspnea. The patient was normotensive (110/70âmmHg) with clinical evidence of congestive heart failure. ECG showed atrial flutter (145âbpm). Transthoracic echocardiography demonstrated a mildly dilated left ventricle with severe systolic dysfunction and a big irregular mobile mass, a mildly dilated right ventricle with moderate systolic dysfunction and a large mass protruding into the cavity. The patient was treated surgically for high embolic and sudden death risk after coronarography, which showed a single stenosis (70%) of the left anterior descending coronary. Myocardial biopsy demonstrated interstitial and endocardial fibrosis, no inflammatory pattern. After 6 months of follow-up echocardiography was normal.
Subject(s)
Atrial Flutter/complications , Cardiomyopathy, Dilated/etiology , Cardiomyopathy, Dilated/surgery , Thrombosis/etiology , Aged , Atrial Flutter/diagnosis , Biopsy , Cardiac Surgical Procedures , Cardiomyopathy, Dilated/diagnosis , Coronary Stenosis/diagnosis , Coronary Stenosis/etiology , Echocardiography, Three-Dimensional , Heart Failure/diagnosis , Heart Failure/etiology , Humans , Male , Predictive Value of Tests , Risk Factors , Thrombectomy , Thrombosis/diagnosis , Thrombosis/surgery , Treatment Outcome , Ventricular Dysfunction, Left/diagnosis , Ventricular Dysfunction, Left/etiologyABSTRACT
Physiological adaptation to pregnancy exposes mother's cardiovascular system to relevant hemodynamic overload. These changes and other specific conditions of pregnancy, such as amniotic embolism, can point out unrecognized preexisting heart disease or, in the presence of some cofactors, be burdensome even for healthy hearts. Thus, tragic cases of heart failure or cardiac arrest may occur, whose management requires several considerations with respect of trying to save two lives at the same time, the need for drugs potentially harmful to the fetus, and assessment of emergent cesarean section.
Subject(s)
Heart Arrest , Heart Failure , Obstetric Labor Complications , Pregnancy Complications, Cardiovascular , Cesarean Section , Delivery, Obstetric , Female , Heart Arrest/etiology , Heart Arrest/physiopathology , Heart Failure/etiology , Heart Failure/physiopathology , Humans , Obstetric Labor Complications/physiopathology , Pregnancy , Pregnancy Complications, Cardiovascular/physiopathology , Risk Factors , Severity of Illness IndexABSTRACT
A 59-year-old male patient affected by pleural mesothelioma presented with chest pain and localized ST elevation in the electrocardiogram. Urgent coronary angiography excluded an acute coronary occlusion, whereas high-resolution computed tomography of the chest revealed tumor infiltration and associated acute inflammation of the pericardial sac. This case illustrates how initial clinical evaluation during emergency conditions could be misled by the time-effectiveness imperative in the primary percutaneous coronary intervention era. In conclusion, early valorization of clinical signs and noninvasive diagnostic elements may add accuracy in directing the postadmission patient course.