Rethinking the concept of sepsis and septic shock.

Sepsis is a major global health problem and represents a challenge for physicians all over the world. The knowledge of sepsis and septic shock is a topic of interest among the scientific community and society in general. New guidelines for management of sepsis and septic shock were developed in 2016, providing an update on this area. In Sepsis-3 new definitions for sepsis and septic shock were published. The purpose of this narrative review is to discuss and compare the new criteria of 2016 with the old criteria, purposing at the same time an alternative approach for this topic. SOFA criteria (Sequential Organ Failure Assessment Score) are more complete, but too extensive and usually difficult to apply outside the intensive care units, therefore inducing potentially delay in the proper treatment. We purpose combined criteria for the selection of sepsis patients. Initially, we could apply qSOFA (quick Sepsis Related Organ Failure Assessment) criteria, due to its easy application, associated with the SIRS (systemic inflammatory response syndrome) criteria, allowing to select the patients who are infected and need faster treatment. In that way we would use the best of old and newest criteria, allowing the early selection of patients who are infected and require faster treatment, while the search for a better and faster tool continues.

Vasodilators in acute heart failure - evidence based on new studies.

Acute heart failure (AHF) contributes largely to the worldwide burden of heart failure (HF) and is associated with high mortality, poor prognosis and high rehospitalization rate. The pharmacologic therapy of AHF includes diuretics and vasodilators, which are a keystone when fluid overload and congestion are present. However, vasodilators are mainly focused on controlling symptoms, and drugs that also improve long-term mortality and morbidity seem to be in high demand. In this review, we summarize the existing evidence on mortality benefits of IV vasodilators in AHF. There is lack of evidence on the mortality benefits of IV vasodilators in AHF, as well as well-designed and large-scale trials for some of them. The existing trials on nitrates have conflicting results and are insufficient to establish definitive conclusions. Other vasodilators, such as enalaprilat, clevidipine, carperitide, and ularitide, have been evaluated only in a few trials assessing mortality. Levosimendan, nesititide and carperitide are approved by some regulatory agencies; however, data regarding mortality are also conflicting and large-scale post-marketing studies would be important. Serelaxin is a recent therapy with a novel mechanism of action and seemed to be promising; although serelaxin was safe and well tolerated in earlier trials, the results of a larger phase III trial failed to meet the primary endpoints of reduction in cardiovascular death at day 180 and reduction of worsening heart failure at day 5. The absence of definitive mortality benefits and high-quality and large-scale data not allow firm conclusions to be drawn about the role of IV vasodilators in AHF. Well-designed studies are needed to clarify the role of these drugs in the long-term outcome of AHF, as well as new therapies entering the clinical investigation.

[Rhythm and conduction disorders immediately after ventricular fulguration]. / Les troubles du rythme et de la conduction au décours immédiat de la fluguration ventriculaire.

UNLABELLED: Forty-four patients with ventricular tachycardias (VT) refractory to medical treatment underwent 73 sessions of endocavitary electrode catheter ablation. The clinical series included 16 cases of post-infarction VT, 14 cases of arrhythmogenic right ventricular dysplasia, 6 cases of dilated cardiomyopathy, 6 cases of idiopathic VT, 1 case of sequela of myocarditis and 1 case of VT consecutive to surgical repair of a congenital cardiopathy. Cardiomegaly was present in 30 patients, and 16 patients had an ejection fraction of less than 30 p. 100. None of the patients were receiving digitalis or class I antiarrhythmic drugs when ablation was performed. A total of 235 shocks of 100 to 320 J (mean 221 +/- 42 J) were delivered. 115 shocks (49 p. 100) were complicated by dysrhythmia and/or disorders of conduction; 29 shocks (12 p. 100) induced 13 ventricular fibrillations and 16 ventricular tachycardias. No relation was found between energy delivered, shock synchronization, haemodynamic status, heart cavity treated, underlying heart disease, CK MB levels and these arrhythmias. On the other hand, ablations performed while the patients were experiencing VT increased the risk of arrhythmia (p less than 0.02). 36 AV blocks, 21 left bundle branch blocks, 12 right bundle branch blocks and 11 sinus bradycardia were observed. With the exception of one right bundle branch block and one left posterior hemi-block, all blocks were transient. IN PRACTICE: (1) electrode catheter ablation may be complicated by disorders of cardiac rhythm or conduction in 50 p. 100 of the cases; (2) these disorders can easily be corrected by stimulation or defibrillation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anti-tachycardia radiofrequency pacemakers. Experience with 44 cases]. / Les pacemakers antitachycardiques à radio-fréquence. Expérience de 44 cas.

Programmed cardiac stimulation may be performed externally using implanted radiofrequency receiving capsules. Between 1979 and 1984, 44 patients underwent implantation of these devices, 12 with atrial leads for supraventricular tachycardias (8 orthodromic reciprocating tachycardias, 1 intranodal junctional tachycardia and 3 atrial tachycardias), and 32 with ventricular leads for ventricular tachycardias. In the first case the transmitter was given to the patients so that they could terminate the tachycardias themselves. In the second case, the transmitter was kept in the cardiology department. All patients were also prescribed prophylactic antiarrhythmic drugs. The radiofrequency method was effective in 11 out of 12 cases of supraventricular tachycardia with a follow-up period ranging from 24 to 65 months (average 45 +/- 11 months). In the ventricular tachycardia group, the device was used in 11 patients to terminate ventricular tachycardia and in all patients to evaluate the efficacy of the antiarrhythmic therapy by provocative programmed stimulation with a follow-up ranging from 2 to 81 month (average 24 +/- 20 months). This palliative therapeutic method has reduced the number of hospital admissions in these patients. The indications are relatively few because of the efficacy of currently available antiarrhythmic agents and the possibility of radical treatment of tachyarrhythmias by surgery or catheter ablation.