Venous thromboembolism in critically ill patients affected by ARDS related to COVID-19 in Northern-West Italy.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is an emerging infectious disease that was first reported in Wuhan, China, and has subsequently spread worldwide. An association between increased venous thromboembolism in patients with pneumonia-related to COVID-19 has not yet been well described. PATIENTS AND METHODS: We aimed to illustrate cases of pulmonary thromboembolism in patients with acute respiratory distress syndrome related to COVID-19 treated in our intensive care unit. The medical records of patients affected by COVID-19 with acute respiratory distress syndrome in our institute from 1/3/2020 to 31/3/2020 were retrospectively reviewed. RESULTS: Our center registered a high prevalence of thromboembolic events among 62 patients affected by acute respiratory distress syndrome related to COVID-19 despite a regular antithrombotic prophylaxis. Out of these, 32 patients were transferred to other hospitals, and 30 were treated in our center. Venous thromboembolism was registered in 12 (19.3%) cases. In particular, 11 diagnoses of pulmonary embolism and 1 diagnosis of deep vein thrombosis were formulated. We described a case series of venous thromboembolism in nine patients treated in our Intensive Care Unit (ICU). Main pulmonary arteries were always involved in these patients. None of them died. CONCLUSIONS: In conclusion, critically ill patients with ARDS related to COVID-19 may have an increased risk of VTE that could be a leading cause of mortality. These patients require a high index of clinical suspicion and an accurate diagnostic approach, in order to immediately start an appropriate anticoagulant treatment.

Oxidative stress in critical care and vitamins supplement therapy: "a beneficial care enhancing".

OBJECTIVE: Critical illnesses are a significant public health issue because of their high rate of mortality, the increasing use of the Intensive Care Units and the resulting healthcare cost that is about 80 billion of dollars per year. Their mortality is about 12% whereas sepsis mortality reaches 30-40%. The only instruments currently used against sepsis are early diagnosis and antibiotic therapies, but the mortality rate can also be decreased through an improvement of the patient's nutrition. The aim of this paper is to summarize the effects of vitamins A, B, C and E on the balance between pro-oxidants and anti-oxidants in the critical care setting to confirm "a beneficial care enhancing". MATERIALS AND METHODS: The peer-reviewed articles analyzed were selected from PubMed databases using the keywords "critical care", "intensive care", "critical illness", "sepsis", "nutritional deficiency", "vitamins", "oxidative stress", "infection", and "surgery". Among the 654 papers identified, 160 articles were selected after title and abstract examination, removal of duplicates and of the studies on pediatric population. Finally, only the 92 articles relating to vitamins A, C, E and the B complex were analyzed. RESULTS: The use of vitamins decreased morbidity and mortality in perioperative period and critically ill patients, especially in ICU. Among the most encouraging results, we found that the use of vitamins, both as monotherapy and in vitamins combinations, play a crucial role in the redox balance. Vitamins, especially vitamins A, C, E and the B complex, could help prevent oxidative damage through the breakdown of the oxidizing chemical chain reaction. CONCLUSIONS: Even if the results of the studies are sometimes discordant or inconclusive, the current opinion is that the supplementation of one or more of these vitamins in critically ill patients may improve their clinical outcome, positively affecting the morbidity and the mortality. Further, randomized studies are required to deeply understand the potentiality of a vitamin supplementation therapy and develop homogeneous and standardized protocols to be adopted in every critical care scenario.

Non-infarctual ST elevation and acute cardiopulmonary failure in carbon monoxide poisoning: a case report.

OBJECTIVE: Carbon monoxide is produced by the incomplete combustion of organic fuel. In the United States, it is responsible for about 500 deaths annually. Increased carboxyhemoglobin concentration and hypoxia disrupt cardiac myocyte integrity and cause dysrhythmias, acute cardiac failure and coronary artery disease. We described a case of a patient with CO-poisoning and ST elevation at ECG precordial leads who developed severe transient heart failure. CASE PRESENTATION: A 57-year-old man was admitted to the emergency department for acute carbon monoxide poisoning that led to respiratory and cardiac failure. The electrocardiogram showed ST elevation in precordial leads, but the coronary angiography was normal. The patient was successfully treated and discharged. Three days later he was readmitted for similar symptoms and subsequently died. We hypothesize that the ECG findings were related to transient coronary vasospasm due to CO poisoning and that acute respiratory and cardiac failure related to carbon monoxide toxicity caused death. CONCLUSIONS: The management of patients poisoned by carbon monoxide requires early identification and intensive treatment and a careful evaluation of the home environment prior to discharge. ST elevation in such patients may be related to coronary vasospasm.

Atherosclerotic aneurysm of the left main coronary artery. Case report and review of the literature.

Coronary artery aneurysms involve the right coronary artery, the left anterior descending and the left circumflex coronary arteries in descending order of frequency; aneurysms involving the main left coronary artery are extremely rare. Atherosclerosis is the most common cause. Only eleven patients surgically treated with atherosclerotic left main coronary artery aneurysms are reported. We observed the twelfth case of atherosclerotic aneurysm of the left main coronary artery, successfully treated. In a 65-year-old man we found a large aneurysm originating at the distal segment of the left main coronary artery. A thromboendarterectomy was per-formed and was extended back into the left main and down the left anterior descending artery. An aneurysmorrhaphy and a three-vessel coronary artery bypass grafting were also performed. Three years later the patient was asymptomatic. Management of these cases is still controversial and based on anedoctal experience rather than controlled trials. Although surgery has been recommended to prevent complications, there are no available data comparing medical and surgical management. We feel that coronary bypasses should be performed in coronary artery aneurysm patients only when indicated by the severity of stenosis or progressive angina despite medical therapy. It is our opinion that anurysmorraphy should preserve native flow as much as possible.

Thrombosis of mechanical valve prosthesis: thrombolysis vs surgical treatment. Report of two cases, personal experience and review of the literature.

We report the cases of two patients, previously operated for mitral mechanical valve replacement who developed thrombosis of the prosthesis. The two patients were successfully treated with pharmacological thrombolysis with no recurrence. One patient developed late peripheral embolization most probably due to late mobilisation of a thrombotic fragment. Our experience with surgical management is reported (39 mitral and 5 aortic prosthetic thrombosis from 1982 to 1999 among 89 patients with prosthetic malfunction). Average time interval between surgery and thrombus formation is 26 months (max 204, min 1 month). Rate of mitral thrombosis is 3.9% and aortic 0.25%. Clinical presentation spreads from almost asymptomatic patients to critically ill patients with pulmonary oedema or frank cardiogenic shock. Temporary suspension of anticoagulant therapy (83% in our study group) to rule out minor surgery, appears to be the most frequent cause of thrombosis. Transthoracic or better transoesophageal echo-cardiography and Doppler are by far the most accurate diagnostic tools that can entirely replace angiographic assessment. Operative mortality was 64% in the prosthetic mitral thrombosis and 20% in the aortic one. Thrombolytic treatment may be affected by minor to relevant complications such as peripheral or central embolization but in our experience and according to the literature it seems much less hazardous than re-do surgery. Thrombolytic treatment is advocated for critical patients unless emergency institution of cardio pulmonary bypass is required and/or indicated. Re-do surgery remains indicated for all other cases of prosthetic malfunction.

Elective coronary and valve surgery without blood transfusion in patients treated with recombinant human erythropoietin (epoetin-alpha).

BACKGROUND: This study evaluates the real effectiveness of epoetin-alpha associated with ferrous sulphate, in reducing blood transfusion in patients undergoing elective open heart surgery not treated with autologous donation. METHODS: Sixty patients had been divided into 2 groups: group A (30 patients) treated with 525 mg ferrous sulphate three time a day per os for 3 weeks; group B (30 patients) treated with epoetin-alpha 10,000 UI twice a week and 525 mg ferrous sulphate 3 times a day. Grouping of patients has been randomized. In both groups hemoglobin, hematocrit, reticulocytes, iron values, ferritine, transferrine, and serological values, have been evaluated sequentially before treatment, before surgery, day of operation, 1st, 2nd, 3rd, 7th postoperative days and at discharge. RESULTS: In group A 86% patients needed blood transfusion (26 out of 30); in group B only 3% of patients needed blood transfusion (1 patient). One year follow up didn't show side effects related to epoetin-alpha. CONCLUSIONS: This study confirms the real effectiveness of epoetin-alpha in reducing the postoperative need for homologous blood transfusion. No side effects due to epoetin-alpha treatment have been proved. The conclusion is drawn that epoetin-alpha can be used as an alternative to blood transfusion or in association with predeposit and in the treatment of basal anemia.

Posttraumatic left ventricular pseudoaneurysm due to intramyocardial dissecting hematoma.

A left ventricular aneurysm can develop in patients sustaining blunt chest injury. This condition has been attributed to myocardial contusion or to a direct vascular lesion leading to myocardial necrosis. We report the case of a pseudoaneurysm resulting from myocardial dissection beginning from a small tear in the endocardial wall. Successful surgical exclusion of the pseudoaneurysm by endoaneurysmal patch closure of the communications between the aneurysm and the left ventricular cavity is described.