Systemic thrombolysis and anticoagulation improved biomarker measurements in massive-like pulmonary embolism and severe COVID-19 pneumonia: a case report.

BACKGROUND: From asymptomatic patients to severe acute respiratory distress syndrome, COVID-19 has a wide range of clinical presentations, and venous thromboembolism has emerged as a critical and frequent complication. CASE SUMMARY: We present a case of a 69-year-old man with a clinical presentation of massive-like pulmonary embolism (PE) overlapping with severe COVID-19 pneumonia. The diagnosis was made based on hypotension, severe oxygen desaturation (33%), and right ventricular dysfunction (RVD). We used alteplase and low-molecular-weight heparin, obtaining immediate clinical improvement. Also, we identified an extremely elevated D-dimer (31.2 mcg/mL), and computed tomography pulmonary angiography (CTPA) revealed an unexpected low thrombus burden and a crazy-paving pattern. Considering this, we decided to discontinue the alteplase. Therefore, the mechanisms of pulmonary hypertension and RVD could be multifactorial. Despite the patient's respiratory status worsening and ongoing mechanical ventilation, biomarkers kept lowering to normal ranges. It appears a favourable outcome was related to early PE diagnosis and a multimodal therapeutic approach. DISCUSSION: Physicians in the ER should be warned about extremely high D-dimer measurements and severe oxygen desaturation as possible markers of severe COVID-19 pneumonia in patients with high-clinical suspicion of PE. Although ESC guidelines recommend immediate reperfusion in cardiogenic shock secondary to PE, we suggest initial CTPA in patients with high-clinical suspicion of severe COVID-19.

[Heart transplant in Monterrey, Nuevo León]. / Trasplante cardiaco en Monterrey, Nuevo León.

Heart failure constantly increases its incidence and prevalence in our society, it was imperative to start a heart transplant program to improve the survival rates of patients with end stages of the disease. Legal issues made impossible to transplant patients out of Mexico City until recent years. Even with an acute hemodynamic and clinic improvement after the transplant, these patients frequently develop complications such as graft rejection or opportunistic infections due to the immunosuppressive schemes increasing the morbidity and mortality of the procedure. In the present article we report the experience acquired with 65 heart transplant patients from 4 transplant programs in Monterrey, Nuevo Leon, one of them from the socialized system and the other three from private hospitals. Our program not only has successfully transplanted patients with advanced age but, for the first time in Latin America we have transplanted patients assisted with the ambulatory Thoratec TLC II system. Even that we have faced obstacles like a newly started donation culture in our population and limited resources, our patient's survival rate push us to continue working with these very ill population.

[Heart transplant in "Nuevo Leon": the first 33 cases]. / Estado actual del trasplante cardíaco en Nuevo León: primeros 33 casos.

Heart failure is one of the most important causes of death worldwide. Heart transplant is the last effective alternative when the medical and surgical treatments have failed in patients with end stage heart failure, giving them an 80% one year survival rate. Unfortunately, during the outcome, the heart transplant patients can develop complications such as graft rejection and opportunistic infections because of the use of immunosuppressive therapy. In the present article we report the experience with 33 heart transplant patients. Our program not only has successfully transplanted patients with advanced age but, for the first time in Latin America we have transplanted patients assisted with the ambulatory Thoratec TLC II system. Even with limited resources, we have managed the same complications than other heart transplant programs, our 82% one year survival rate is similar than reports in medical literature.

Estado actual del trasplante cardíaco en Nuevo León: primeros 33 casos / Heart transplant in Nuevo Leon: the first 33 cases

Heart failure is one of the most important causes of death worldwide. Heart transplant is the last effective alternative when the medical and surgical treatments have failed in patients with end stage heart failure, giving them an 80% one year survival rate. Unfortunately, during the outcome, the heart transplant patients can develop complications such as graft rejection and opportunistic infections because of the use of immunosuppressive therapy. In the present article we report the experience with 33 heart transplant patients. Our program not only has successfully transplanted patients with advanced age but, for the first time in Latin America we have transplanted patients assisted with the ambulatory Thoratec TLC II system. Even with limited resources, we have managed the same complications than other heart transplant programs, our 82% one year survival rate is similar than reports in medical literature.

[Importance of tumor necrosis factor-alpha in the pathogenesis of heart failure]. / Importancia del factor de necrosis tumoral alfa en la patogenia de la insuficiencia cardíaca.

Clinical and experimental evidence demonstrating the effects of tumor necrosis factor-alpha (TNF-alpha) in patients with heart failure continues to accumulate. It is well established that high concentrations of TNF-alpha appear in the circulation of patients with heart failure and that these levels have a directly proportional correlation with the patient's functional class. TNF-alpha levels also show a linear relation with prognosis. These circulating levels are responsible for the decreased expression of myocardial TNF-alpha receptors observed in heart failure. As a result of extrapolation of findings from experimental animals, we assume that TNF-alpha is deleterious to myocardial function in humans because it induces a negative inotropic state in patients who have not undergone heart transplant. Supporting this assumption is the fact that the resolution or improvement of pressure overload (obstructive hypertrophic myocardiopathy, by ethanol ablation) and volume overload (terminal dilated myocardiopathy, by ventricular assistance) states is accompanied by a decrease in myocardial TNF-alpha expression. The use of specific antagonists of circulating TNF-alpha in patients with symptomatic heart failure has been demonstrated to be safe and possibly effective. At present, multicenter studies are under way to assess the efficacy of this antagonism in a larger number of patients. If the results of these studies are favorable, we will have new therapeutic elements for managing patients with advanced hear failure. The transplanted heart behaves differently from the native heart. From the early stages of HTx, myocardial TNF-alpha expression is greatly increased (much more than in patients with heart failure) and not associated with contractile dysfunction, in contrast with what occurs in the native heart. However, we know that the transplanted heart soon develops ventricular hypertrophy, fibrosis, diastolic dysfunction, and late graft failure, even in the presence of normal epicardial coronary arteries. Clinical evidence suggests that TNF-alpha may be involved in these processes.

Importancia del factor de necrosis tumoral alfa en la patogenia de la insuficiencia cardíaca / Importance of Tumor Necrosis Factor-Alpha in the Pathogenesis of Heart Failure

La evidencia clínica y experimental que demuestra los efectos del factor de necrosis tumoral alfa (TNF- ) en pacientes con insuficiencia cardíaca continúa acumulándose. Está bien establecido que las concentraciones elevadas de TNF- aparecen en la circulación de pacientes con insuficiencia cardíaca y que dichas concentraciones tienen una correlación directamente proporcional con la clase funcional en la que éstos se encuentran; asímismo, existe una relación lineal como factor pronóstico. Dichas concentraciones circulantes son las responsables de la disminución en la expresión de receptores miocárdicos de TNF- observada en la insuficiencia cardíaca. Por lo demostrado en animales de experimentación, suponemos que el TNF- es deletéreo para la función miocárdica en seres humanos, al inducir un estado inotrópico negativo en pacientes no trasplantados de corazón. Para sustentar esta suposición está el hecho de que sabemos que la resolución o mejoría de estados de sobrecarga de presión (cardiomiopatía hipertrófica obstructiva, con ablación con etanol) y de volumen (cardiomiopatía dilatada terminal, con asistencia ventricular) va acompañada de disminución de la expresión miocárdica de TNF- .El uso de antagonistas específicos del TNF- circulante en pacientes con insuficiencia cardíaca sintomática ha demostrado ser segura, en primer lugar, y posiblemente eficaz en segundo. En el momento actual se están llevando a cabo estudios multicéntricos que valoran la eficacia de este antagonismo en un número mayor de pacientes. De ser positivos dichos estudios, dispondremos de nuevos elementos terapéuticos para manejar a pacientes con insuficiencia cardíaca avanzada. El corazón trasplantado presenta un comportamiento diferente que el corazón nativo. Desde etapas tempranas del trasplante cardíaco se observa una expresión aumentada (muy superior a los valores encontrados en pacientes con insuficiencia cardíaca) de TNF- miocárdico, y dicha expresión, a diferencia de los corazones nativos, no se asocia a disfunción contráctil. Sin embargo, sabemos que un corazón trasplantado desarrolla hipertrofia ventricular temprana, fibrosis, disfunción diastólica y fallo tardío del injerto aun en presencia de arterias coronarias epicárdicas normales, pudiendo implicarse en estos procesos el TNF- , de acuerdo con la evidencia clínica comunicada (AU)

Comisurotomía mitral percutánea con técnica de Inoue y embarazo: experiencia inicial en México / Percutaneous mitral commissurotomy in pregnancy

Desde marzo de 1986 hasta enero de 1993, se ha realizado comisurotomía mitral percutánea (CMP) en 91 pacientes con el diagóstico de estenosis mitral de etiología reumática. De éstos 2 cursaban con ambarazo de 30 (paciente 1) y 27 semanas (paciente 2) y estenosis mitral severa. Se realizó CMP con la técnica de Inoue, obteniendo incremento en el área valvular (0.8 a 1.6 y 0.7 a 1.9 cm²) y caída del gradiente transvalvular (19 a 4 y 12 a 0 mm Hg) inmediatamente después de la dilatación. En ambos casos, no se obtuvó comunicación interauricular (CIA) o insuficiencia mitral residual ni otras complicaciones. El tiempo de exposición a la radiación fue en promedio de 6.4 minutos de fluoroscopía y 6 segundos de angiografía. Con el fin de limitar la exposición a la radiación, se utilizó ecocardiografía Doppler color y se realizó protección radiológica del feto durante el procedimiento en ambos casos. En la paciente 1 se interrumpió el embarazo mediante cesárea a las 34 semanas por indicación obstétrica, y la paciente No. 2 tuvo parto por vía vaginal a las 37 semanas de embarazo sin complicaciones ni para la madre ni para el producto en ambos casos. Durante el seguimiento, el área valvular es de 1.7 y 2.1 cm², 15 y 4 meses después de la dilatación, respectivamente. Pensamos que la CMP con la técnica de Inoue es una excelente alternativa de tratamiento en pacientes embarazadas con estenosis mitral, lo que ofrece mejoría clínica inmediata sin los riesgos del tratamiento quirúrgico