Diagnóstico y manejo de la congestión en insuficiencia cardíaca aguda / Diagnosis and management of congestion in acute heart failure / Diagnóstico e tratamento da congestão na insuficiência cardíaca aguda

La congestión en pacientes con insuficiencia cardíaca representa una manifestación de diversos procesos estructurales y funcionales cardiovasculares, asociada a alta morbimortalidad y reducción de calidad de vida, se considera la principal causa de ingreso a hospitalización y reingreso por insuficiencia cardíaca. Durante las últimas décadas, se ha logrado un mejor entendimiento de los diversos eventos fisiopatológicos desencadenantes, lo cual ha mejorado su pronóstico, diagnóstico y tratamiento. Por estos constantes avances, es necesaria su frecuente revisión y análisis. La atención del paciente con insuficiencia cardíaca y episodios de congestión es compleja y crucial. Su abordaje inicia con el reconocimiento temprano de las manifestaciones clínicas, uso de métodos no invasivos diagnósticos, delimitación del perfil de congestión; consecuentemente, es necesario brindar un manejo oportuno, intensivo y eficaz que contemple el empleo temprano de diuréticos intravenosos, la evaluación de metas de descongestión y, en casos específicos, terapia diurética combinada e incluso medicamentos vasoactivos o ultrafiltración continua.

Congestion in patients with heart failure represents a manifestation of various cardiovascular structural and functional processes, associated with high morbidity and mortality and reduced quality of life, being considered the main cause of hospitalization and readmission due to heart failure. During the last decades, a better understanding of the various triggering pathophysiological events has been achieved, modifying their prognosis, diagnosis, and treatment. Due to these constant advances, its frequent review and analysis is necessary. The care of patients with heart failure and episodes of congestion is complex and crucial. Its approach begins with early recognition of clinical manifestations, use of non-invasive diagnostic methods, delimitation of the congestion profile; followed by timely, intensive, and effective management that contemplates the early use of intravenous diuretics, evaluation of decongestion goals and, in specific cases, combined diuretic therapy, and even vasoactive medications or continuous ultrafiltration.

A congestão em pacientes com insuficiência cardíaca representa manifestação de diversos processos cardiovasculares estruturais e funcionais, associada a elevada morbidade e mortalidade e redução da qualidade de vida, é considerada a principal causa de internação e reinternação por insuficiência cardíaca. Durante as últimas décadas, conseguiu-se uma melhor compreensão dos vários eventos fisiopatológicos desencadeantes, o que melhorou o seu prognóstico, diagnóstico e tratamento. Devido a esses constantes avanços, sua revisão e análise frequente se fazem necessárias. O cuidado de pacientes com insuficiência cardíaca e episódios de congestão é complexo e crucial. Sua abordagem inicia-se com reconhecimento precoce das manifestações clínicas, utilização de métodos diagnósticos não invasivos, delimitação do perfil de congestão. Consequentemente, é necessário proporcionar manejo oportuno, intensivo e eficaz que inclua o uso precoce de diuréticos intravenosos, a avaliação das metas de descongestão e, em casos específicos, terapia diurética combinada e até mesmo medicações vasoativas ou ultrafiltração contínua.

Exercise training attenuates the pressor response evoked by peripheral chemoreflex in rats with heart failure.

The effects of exercise training (ExT) on the pressor response elicited by potassium cyanide (KCN) in the rat model of ischemia-induced heart failure (HF) are unknown. We evaluated the effects of ExT on chemoreflex sensitivity and its interaction with baroreflex in rats with HF. Wistar rats were divided into four groups: trained HF (Tr-HF), sedentary HF (Sed-HF), trained sham (Tr-Sham), and sedentary sham (Sed-Sham). Trained animals underwent to a treadmill running protocol for 8 weeks (60 m/day, 5 days/week, 16 m/min). After ExT, arterial pressure (AP), baroreflex sensitivity (BRS), peripheral chemoreflex (KCN: 100 µg/kg body mass), and cardiac function were evaluated. The results demonstrate that ExT induces an improvement in BRS and attenuates the pressor response to KCN relative to the Sed-HF group (P < 0.05). The improvement in BRS was associated with a reduction in the pressor response following ExT in HF rats (P < 0.05). Moreover, ExT induced a reduction in left ventricular end-diastolic pressure and pulmonary congestion compared with the Sed-HF group (P < 0.05). The pressor response to KCN in the hypotensive state is decreased in sedentary HF rats. These results suggest that ExT improves cardiac function and BRS and attenuates the pressor response evoked by KCN in HF rats.

Medicinal leeches for surgically uncorrectable venous congestion after free flap breast reconstruction.

BACKGROUND: Free tissue transfer is an accepted method for breast reconstruction. Surgically uncorrectable venous congestion is a rare but real occurrence after these procedures. Here, we report our experience with the management of surgically uncorrectable venous congestion after free flap breast reconstruction using medicinal leech therapy. METHODS: We queried our prospectively maintained institutional database for all patients with venous congestion after free flap breast reconstruction since 2005. Chart review was performed for all patients having post-operative venous congestion. We compared patients with surgically correctable venous congestion and surgically uncorrectable venous congestion requiring medicinal leech therapy. RESULTS: Twenty-three patients had post-operative venous congestion, and four of these patients were surgically uncorrectable requiring medicinal leech therapy. Patients who required leech therapy had lower hemoglobin nadirs, received more blood transfusions, and received a higher number of total units of red blood cells than patients who did not require leech therapy. Among four patients who required leech therapy, one flap was partially salvaged and three flaps were completely lost. Leech therapy was associated with higher total flap loss rates (75.0% vs. 42.1%) and longer length of stay (8.0 ± 3.6 days vs. 6.5 ± 2.1 days) when compared to non-leeched flaps. These differences were not statistically significant (P = 0.32 and P = 0.43, respectively). CONCLUSIONS: In patients with surgically uncorrectable venous congestion after free flap breast reconstruction, total flap loss is common despite leech therapy. When venous congestion cannot be corrected, total flap removal may be a better option than attempted salvage with leech therapy.