[Treatment of cardiogenic shock due to right ventricular involvement]. / Tratamiento del choque cardiogénico con compromiso ventricular derecho.

The right ventricle is susceptible to changes in preload, afterload, and contractility. The answer is its dilation with dysfunction/acute failure; filling is limited to the left ventricle and cardiac output. Systemic venous congestion is retrograde to the right heart, it is involved in the genesis of cardiogenic shock due to right ventricle involvement. This form of shock is less well known than that which occurs due to left ventricular failure, therefore, treatment may differ. Once the primary treatment has been carried out, since no response is obtained, supportive treatment aimed at ventricular pathophysiology will be the next option. It is suggested to evaluate the preload for the reasoned indication of liquids, diuretics or even ultrafiltration. Restore or maintain heart rate and sinus rhythm, treat symptomatic bradycardia, arrhythmias that make patients unstable, use of temporary pacing or cardioversion procedures. Improving contractility and vasomotility, using vasopressors and inotropes, alone or in combination, the objective will be to improve right coronary perfusion pressure. Balance the effect of drugs and maneuvers on preload and/or afterload, such as mechanical ventilation, atrial septostomy and pulmonary vasodilators. And the increasing utility of mechanical support of the circulation that has become a useful tool to preserve/restore right heart function.

El ventrículo derecho es susceptible a cambios en la precarga, poscarga y la contractilidad y la respuesta fisiopatológica es la dilatación con disfunción/falla aguda lo que limita el llenado del ventrículo izquierdo y el gasto cardiaco. La congestión venosa sistémica, está implicada en la génesis del choque cardiogénico con compromiso del ventrículo derecho. Esta forma de choque es menos conocida que la que sucede por falla ventricular izquierda, por ende, el tratamiento puede diferir. La primera línea de tratamiento son las medidas de soporte y en caso de no funcionar, el tratamiento dirigido a la fisiopatología ventricular será la siguiente opción. Se sugiere evaluar la precarga para la indicación razonada de líquidos, diuréticos o la ultrafiltración. Restaurar o mantener la frecuencia cardiaca y el ritmo sinusal, tratar la bradicardia sintomática, las arritmias que inestabilizan a los pacientes, el uso de marcapaso temporal o procedimientos de cardioversión. Mejorar la contractilidad y vasomotilidad a través del uso de vasopresores e inotrópicos, solos o combinados, el objetivo será mejorar la presión de perfusión coronaria derecha. Balancear el efecto de fármacos y maniobras en la precarga y/o poscarga, como la ventilación mecánica, septostomía atrial y vasodilatadores pulmonares. Y la creciente utilidad del soporte mecánico de la circulación que se ha convertido en una herramienta útil para preservar/restaurar la función cardiaca derecha.

Assessing the venous system: Correlation of mean systemic filling pressure with the venous excess ultrasound grading system in cardiac surgery.

BACKGROUND: Evaluation of the venous system has long been underestimated as an important component of the circulatory system. As systemic venous pressure increases, the perfusion pressure to the tissues is compromised. During initial resuscitation in cardiac surgery, excessive fluid administration is associated with increased morbidity and mortality. METHODS: We conducted a cross-sectional study of 60 consecutive adult patients who underwent cardiac surgery and in whom it was possible to obtain the venous excess ultrasound (VExUS) grading system and mean systemic filling pressure (Pmsf) in the postoperative period upon admission, at 24 and 48 h. We then determined the correlation between VExUS grading and Pmsf. RESULTS: On admission, patients with VExUS grading 0 predominated, with a progressive increase in venous congestion and an increase in Pmsf over the course of the first 48 h. There was a strong positive correlation between VExUS grading and the invasive measurement of Pmsf at 24 and 48 h after arrival. The presence of grade 2 or grade 3 venous congestion in the postoperative period poses an increased risk of developing acute kidney injury. CONCLUSION: The VExUS grading system indicates a high degree of systemic venous congestion in the first 48 h of the postoperative period after cardiac surgery and correlates with the Pmsf, which is the best surrogate of stressed circulatory volume.

[Anatomy-physiology considerations for cardiogenic shock with right ventricular involvement].

Since the discovery of right ventricular infarction, interest in the characteristics of the right ventricle has been increasing. Right ventricular function is now known to be a predictor of mortality in different settings. The right ventricle is a low-pressure, high-compliance, high-volume chamber. To carry out its normal function, it is coupled to the pulmonary circulation and the left ventricle. In the face of acute changes in pressure, volume overload and ischemia, it dilates to adapt to its new load. Its manifestation may be ventricular dysfunction and/or failure that will progress to cardiogenic shock due to right ventricular involvement. Various entities may be the cause of acute dysfunction: right ventricular infarction (alterations in contractility due to ischemia) and high-risk pulmonary thromboembolism (increased afterload). Both share a similar ventricular pathophysiology and high mortality without treatment. Understanding anatomy and physiology, dysfunction and acute ventricular failure are important to define a convenient diagnosis and treatment oriented towards pathophysiology. In this first part, the anatomy and physiology, acute right ventricular dysfunction/failure and cardiogenic shock are taken into consideration, from the perspective of these two entities. In another paper, treatment aimed at cardiogenic shock due to right ventricular involvement will be reviewed.

Desde el conocimiento del infarto del ventrículo derecho, el interés por las características del ventrículo derecho ha sido cada vez mayor. Ahora se sabe que la función ventricular derecha es un predictor de mortalidad en diferentes contextos. El ventrículo derecho es una cavidad de baja presión, alta compliancia y alto volumen. Para llevar a cabo su función normal se encuentra acoplado a la circulación pulmonar y al ventrículo izquierdo. Ante alteraciones agudas de sobrecarga de presión, volumen e isquemia, se dilata para adaptarse a su nueva carga. Su manifestación puede ser disfunción o falla ventricular que progresará a choque cardiogénico por involucro del ventrículo derecho. Diversas entidades pueden ser la causa de la disfunción aguda: el infarto del ventrículo derecho (alteraciones de la contractilidad por isquemia) y la tromboembolia pulmonar de alto riesgo (aumento de la poscarga). Ambas comparten una fisiopatología ventricular similar y alta mortalidad sin tratamiento. Entender la anatomía fisiológica, la disfunción y la falla ventricular aguda es importante para definir un diagnóstico oportuno y un tratamiento orientado a la fisiopatología. En esta primera parte se toma en consideración la anatomía fisiológica y la disfunción/falla aguda ventricular derecha y su desenlace en el choque cardiogénico, desde la perspectiva de estas dos entidades. En otro trabajo se revisará el tratamiento orientado al choque cardiogénico por involucro ventricular derecho.

Left atrial veno-arterial extracorporeal membrane oxygenation in post-myocardial infarction ventricular septal defect with cardiogenic shock: a case report.

Background: Ventricular septal defect (VSD) complicating acute myocardial infarction (MI) represents a life-threatening condition and has a mortality of >90% if left untreated. Case summary: A 53-year-old man with a prior medical history of diabetes and hypertension presented with cardiogenic shock secondary to VSD as a mechanical complication of non-reperfused inferior MI. Discussion: The choice of mechanical support can be difficult in this type of patient. Given the risk of an increased shunt because of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and the increase in left ventricle (LV) afterload, several measures were taken to plan the best ECMO configuration. Given the absence of any real improvement in the LV and an elevated residual ratio between pulmonary and systemic flow (Qp/Qs), the final decision was to switch to left atrial VA-ECMO (LAVA-ECMO). The use of LAVA-ECMO improved the patient's haemodynamics and allowed his condition to stabilize; LAVA-ECMO is feasible and may be effective as a mechanical circulatory support (MCS) strategy for patients in cardiogenic shock due to VSD as a mechanical complication of acute MI.

Severe Acute Thrombocytopenia After Treatment with Tirofiban: A Case Series Approach.

Glycoprotein IIb/IIIa inhibitors are an adjuvant therapy for the treatment of patients with acute coronary syndromes. The main adverse reactions are bleeding and thrombocytopenia in 1-2% of cases. A 66-year-old woman arrived at the emergency department with ST-elevation MI. The catheterisation lab was busy, so she received thrombolytic therapy. Coronary angiography revealed a 90% stenosis in the middle segment of the left anterior descending artery and Thrombolysis in MI 2 flow. Subsequent percutaneous coronary intervention showed abundant thrombus and a coronary dissection and it was necessary to insert five drug-eluting stents. Non-fractionated heparin and a tirofiban infusion were used. After the percutaneous coronary intervention, she developed severe thrombocytopenia, haematuria and gingivorrhagia, for which infusion of tirofiban was suspended. In follow-up, no major bleeding or subsequent haemorrhagic complications were identified. It is crucial to distinguish between heparin-induced thrombocytopenia and thrombocytopenia caused by other drugs. A high level of suspicion should be employed in these cases.

Left circumflex artery injury occurring during mitral valve surgery treated successfully with percutaneous intervention in a high surgical and bleeding risk patient.

Perioperative myocardial infarction is a complication of cardiac surgery, and the cause can be multifactorial. Injury of the left circumflex coronary artery has been described, particularly after mitral valve replacement. We present the case of a 72-year-old woman who underwent mitral valve replacement but developed a lesion in the proximal circumflex coronary artery related to partial mechanical kinking caused by a suture. The therapeutic options are surgical or percutaneous. In this patient, the percutaneous strategy was successful. Learning objective: • Percutaneous coronary intervention is an option in cases involving kinking of the left circumflex coronary artery after mitral valve replacement.• If unable to cross the lesion with a workhorse guide wire, one alternative is to use wires with good support properties and avoid very high tip loads to reduce the risk of perforation.In patients at high risk of bleeding, use of a drug-eluting stent and short-duration dual antiplatelet therapy is recommended.

Usefulness of the velocity-time integral of the left ventricular outflow tract variability index to predict fluid responsiveness in patients undergoing cardiac surgery.

BACKGROUND: Haemodynamic monitoring of patients after cardiac surgery using echocardiographic evaluation of fluid responsiveness is both challenging and increasingly popular. We evaluated fluid responsiveness in the first hours after surgery by determining the variability of the velocity-time integral of the left ventricular outflow tract (VTI-LVOT). METHODS: We conducted a cross-sectional study of 50 consecutive adult patients who underwent cardiac surgery and in whom it was possible to obtain VTI-LVOT measurements. We then determined the variability and correlations with our pulse pressure variation (PPV) measurements to predict fluid responsiveness. RESULTS: A strong positive correlation was seen between the VTI-LVOT variability index absolute values and PPV for predicting fluid responsiveness in the first hours after cardiac surgery. We also found that the VTI-LVOT variability index has high specificity and a high positive likelihood ratio compared with the gold standard using a cut-off point of ≥ 12%. CONCLUSIONS: The VTI-LVOT variability index is a valuable tool for determining fluid responsiveness during the first 6 postoperative hours in patients undergoing cardiac surgery.

Cardiogenic Shock Among Patients with and without Acute Myocardial Infarction in a Latin American Country: A Single-Institution Study.

Background: Latin America has limited information about the full spectrum cardiogenic shock (CS) and its hospital outcome. This study sought to examine the temporal trends, clinical features and outcomes of patients with CS in a coronary care unit of single Mexican institution. Methods: This was a retrospective study of consecutive patients hospitalized with CS in a Mexican teaching hospital between 2006-2019. Patients were classified according to the presence or absence of acute myocardial infarction (AMI). Results: Of 22,747 admissions, 833 (3.7%) exhibited CS. Among patients with AMI (n = 12,438), 5% had AMI-CS, and in patients without AMI (n = 10,309), 2.3% developed CS (non-AMI-CS). Their median age was 63 years and 70.5% were men. Cardiovascular risk factors were more frequent among the AMI-CS group, whereas a history of heart failure was greater in non-AMI-CS patients (70.1%). In AMI-CS patients, the median delay time was 17.2 hours from the onset of AMI symptoms to hospital admission. Overall, the median left ventricular ejection fraction (LVEF) was 30%. Patients with CS at admission showed end-organ dysfunction, evidenced by lactic acidosis, renal impairment, and elevated liver transaminases. Of the 620 AMI-CS patients, the main cause was left ventricular dysfunction in 71.3%, mechanical complications in 15.2% and right ventricular infarction in 13.5%. Among the 213 non-AMI-CS patients, valvular heart disease (49.3%) and cardiomyopathies (42.3%) were the most frequent etiologies. In-hospital all-cause mortality rates were 69.7% and 72.3% in the AMI-CS and non-AMI-CS groups, respectively. Among AMI-CS patients, renal dysfunction, diabetes, older age, depressed LVEF, absence of revascularization and the use of mechanical ventilation were independent predictors of in-hospital mortality. However, in the non-AMI-CS group, only low LVEF and high lactate levels proved significant. Conclusions: This study demonstrates differences in the epidemiology of CS compared to high-income countries; the high mortality reflects critically ill patients and the lack of contemporary effective therapies in the population studied.

Bilateral spontaneous pneumothorax in SARS-CoV-2 infection: A very rare, life-threatening complication.

In the coronavirus disease 2019 (COVID-19) era, the presence of acute respiratory failure is generally associated with acute respiratory distress syndrome; however, it is essential to consider other differential diagnoses that require different, and urgent, therapeutic approaches. Herein we describe a COVID-19 case complicated with bilateral spontaneous pneumothorax. A previously healthy 45-year-old man was admitted to our emergency department with sudden-onset chest pain and progressive shortness of breath 17 days after diagnosis with uncomplicated COVID-19 infection. He was tachypneic and presented severe hypoxemia (75% percutaneous oxygen saturation). Breath sounds were diminished bilaterally on auscultation. A chest X-ray revealed the presence of a large bilateral pneumothorax. A thoracic computed tomography (CT) scan confirmed the large bilateral pneumothorax, with findings consistent with severe COVID-19 infection. Chest tubes were inserted, with immediate clinical improvement. Follow-up chest CT scan revealed resolution of bilateral pneumothorax, reduction of parenchymal consolidation, and formation of large bilateral pneumatoceles. The patient remained under observation and was then discharged home. Bilateral spontaneous pneumothorax is a very rare, potentially life-threatening complication in patients with COVID-19. This case highlights the importance of recognizing this complication early to prevent potentially fatal consequences.

Critical care ultrasonography during COVID-19 pandemic: The ORACLE protocol.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is characterized by severe lung involvement and hemodynamic alterations. Critical care ultrasonography is vital because it provides real time information for diagnosis and treatment. Suggested protocols for image acquisition and measurements have not yet been evaluated. METHODS: This cross-sectional study was conducted at two centers from 1 April 2020 to 30 May 2020 in adult patients with confirmed COVID-19 infection admitted to the critical care unit. Cardiac and pulmonary evaluations were performed using the ORACLE protocol, specifically designed for this study, to ensure a structured process of image acquisition and limit staff exposure to the infection. RESULTS: Eighty-two consecutively admitted patients were evaluated. Most of the patients were males, with a median age of 56 years, and the most frequent comorbidities were hypertension and type 2 diabetes, and 25% of the patients had severe acute respiratory distress syndrome. The most frequent ultrasonographic findings were elevated pulmonary artery systolic pressure (69.5%), E/e' ratio > 14 (29.3%), and right ventricular dilatation (28%) and dysfunction (26.8%). A high rate of fluid responsiveness (82.9%) was observed. The median score (19 points) on pulmonary ultrasound did not reveal any variation between the groups. Elevated pulmonary artery systolic pressure was associated with higher in-hospital mortality. CONCLUSION: The ORACLE protocol was a feasible, rapid, and safe bedside tool for hemodynamic and respiratory evaluation of patients with COVID-19. Further studies should be performed on the alteration in pulmonary hemodynamics and right ventricular function and its relationship with outcomes.

Histological and Mechanical Behavior of INC 01 and 02 Bare Metal Stents Against a Commercial Stent: A Preclinical Study in a Porcine Model.

BACKGROUND: PCI is an expensive procedure in our population and it implies a huge cost for the institutions and National Health Service. AIM OF THE STUDY: The main objective was to evaluate the technical and biological success of two stents designed in Mexico. METHODS: Ten York pigs, 4-6 months of age, underwent implantation of the bare metal INC-01 (10 stents) and INC-02 (6 stents) coronary stent in addition to a conventional commercial stent (10 stents). Technical success was evaluated immediately with angiography and Intravascular Ultrasound IVUS, continued by a mean follow-up of 4 month and a final angiographic, IVUS and histological evaluation. RESULTS: Initial technical success, angiography and IVUS between the three stents were not significant. One stent presented restenosis in follow-up (commercial stent), but all other stents presented excellent clinical outcome, satisfactory angiographic and IVUS results. Inflammation, proliferation and endothelialization between the stents had no major differences in histological analysis in a mean of 4 months follow-up. CONCLUSIONS: In this pig model, the INC 01 and INC 02 stents showed the same delivering technical success, angiographic and IVUS features, biological and histological response compared to commercial last generation stents.

Normal function of a 43-year-old Braunwald Cutter heart valve.

We present the case of a 72-year-old woman diagnosed with rheumatic fever at the age of 6. In 1972, she was diagnosed with mitral valve insufficiency and mitral valve stenosis, then in 1974, a decision was made to perform mitral valve replacement surgery with a 32-mm Braunwald-Cutter ball cage prosthesis. An echocardiogram performed in 2014 revealed normal biventricular systolic function, mechanical prosthesis in mitral position with maximum speed of 1.9 m/s, maximum gradient of 15 mmHg, mean gradient of 6 mmHg, severe tricuspid valve insufficiency, inferior vena cava measuring 15 mm with more than 50% collapse and pulmonary artery systolic pressure of 40 mmHg. We report the use of the 32-mm Braunwald-Cutter ball cage prosthesis with the longest longevity that remains functional after more than 43 years of implantation.