RESUMO
Peripartum cardiomyopathy (PPCM) is defined by acute heart failure in the late stages of pregnancy to a few months postpartum. Cardiogenic shock in PPCM, though rare, can be life-threatening, often requiring support with mechanical circulatory support devices. We present a case of 37-year-old Caucasian female who developed cardiogenic shock within 24 hours of the delivery of her twins. The echocardiogram demonstrated severe biventricular failure which necessitated biventricular device placement and support with a CentriMag® centrifugal pump. This biventricular support was employed, using a single-circuit CentriMag® pump, using a 'Y' connection which made weaning from right-sided support and conversion to univentricular support easier and feasible. The patient recovered four weeks later and was explanted off the CentriMag® support and did well. This technology allows for the CentriMag® to be considered as an early option for biventricular support in the treatment and management of these patients as a bridge to recovery.
Assuntos
Cardiomiopatias , Circulação Extracorpórea , Insuficiência Cardíaca , Período Pós-Parto , Complicações Cardiovasculares na Gravidez , Choque Cardiogênico , Adulto , Cardiomiopatias/fisiopatologia , Cardiomiopatias/cirurgia , Eletrocardiografia , Circulação Extracorpórea/instrumentação , Circulação Extracorpórea/métodos , Feminino , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/cirurgia , Humanos , Gravidez , Complicações Cardiovasculares na Gravidez/fisiopatologia , Complicações Cardiovasculares na Gravidez/cirurgia , Choque Cardiogênico/fisiopatologia , Choque Cardiogênico/cirurgiaRESUMO
OBJECTIVE: In a prospective phase II Food and Drug Administration trial, robotic mitral valve repairs were performed in 112 patients at 10 centers by using the da Vinci surgical system. The safety of performing valve repairs with computerized telemanipulation was studied. METHODS: After institutional review board approval, informed consent was obtained. Patients had moderate to severe mitral regurgitation. Operative technique included peripheral cardiopulmonary bypass, a 4- to 5-cm right minithoracotomy, a transthoracic aortic crossclamp, and antegrade cardioplegia. The successful study end point was grade 0 or 1 mitral regurgitation by transthoracic echocardiography at 1 month after surgery. RESULTS: Valve repairs included quadrangular resections, sliding plasties, edge-to-edge approximations, and both chordal transfers and replacements. The average age was 56.4 +/- 0.09 years (mean +/- SEM). There were 77 (68.8%) men and 35 (31.2%) women. Valve pathology was myxomatous degeneration in 105 (91.1%), and 103 (92.0%) had type II leaflet prolapse. Leaflet repair times averaged 36.7 +/- 0.2 minutes, with annuloplasty times of 39.6 +/- 0.1 minutes. Total robot, aortic crossclamp, and cardiopulmonary bypass times were 77.9 +/- 0.3 minutes, 2.1 +/- 0.1 hours, and 2.8 +/- 0.1 hours, respectively. On 1-month transthoracic echocardiography, 9 (8.0%) had grade 2 mitral regurgitation, and 6 (5.4%) of these had reoperations (5 replacements and 1 repair). There were no deaths, strokes, or device-related complications. CONCLUSIONS: Multiple surgical teams performed robotic mitral valve repairs safely early in development of this procedure, with a reoperation rate of 5.4%. Advancements in robotic design and adjunctive technologies may help in the evolution of this minimally invasive technique by decreasing operative times.
Assuntos
Insuficiência da Valva Mitral/cirurgia , Robótica , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/instrumentação , Procedimentos Cirúrgicos Cardíacos/métodos , Ecocardiografia Transesofagiana , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico por imagem , Estudos Prospectivos , Estados UnidosRESUMO
BACKGROUND: Recent scientific and clinical data suggest that chronic mechanical ventricular unloading may lead to myocardial recovery. Evaluating and monitoring patients for myocardial recovery and the optimal methods of weaning the left ventricular assist device are not well defined. METHODS: Six patients with advanced heart failure and severe mitral regurgitation have undergone successful bridge to recovery using a Thoratec left ventricular assist device. Data that details their monitoring for myocardial recovery and weaning from the left ventricular assist device were prospectively collected. RESULTS: Clinical data collected during the recovery phase included chest roentgenogram, echocardiography, plasma norepinephrine, tumor necrosis factor-alpha, bioimpedance, and cardiopulmonary exercise testing (peak oxygen consumption). Normalization of these variables with a 10% increase in the peak oxygen consumption was obtained before weaning. The Thoratec device rate and percent systole were manipulated to allow gradual reloading of the ventricle. The weaning process occurred for more than 5 to 10 days to allow time for observation of the ventricle and its response to the increasing workload. CONCLUSIONS: Select patients with advanced congestive heart failure and severe mitral insufficiency can benefit from mechanical device support. We describe our technique of monitoring for myocardial recovery using clinical variables. Our technique of weaning allows for gradual reloading of the ventricle and a longer period of observation before device removal. Additional research is needed to determine which variables will accurately predict long-term myocardial recovery and the optimal weaning method.
Assuntos
Insuficiência Cardíaca/terapia , Coração Auxiliar , Insuficiência da Valva Mitral/terapia , Adulto , Idoso , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Hypoxemia during bronchoscopy occurs frequently. It can usually be managed by supplemental oxygen and bronchodilators or, in some cases, occasionally stopping the procedure. Benzocaine spray is commonly used as a topical anesthetic agent during bronchoscopy. However, it has been associated with the development of methemoglobinemia. The following is a case report of hypoxia during bronchoscopy from benzocaine-induced methemoglobinemia and its management.
Assuntos
Anestésicos Locais/efeitos adversos , Benzocaína/efeitos adversos , Hipóxia/etiologia , Metemoglobinemia/induzido quimicamente , Idoso , Broncoscopia , Inibidores Enzimáticos/uso terapêutico , Humanos , Masculino , Metemoglobinemia/tratamento farmacológico , Azul de Metileno/uso terapêutico , Atelectasia Pulmonar/terapiaRESUMO
A technique is described for minimally invasive harvesting of the greater saphenous vein. This technique requires no new or disposable equipment, thus adding no additional cost to the procedure. It is rapid and reliable, and it can be performed in the majority of patients requiring greater saphenous vein for coronary artery bypass grafting.
Assuntos
Veia Safena/transplante , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Transplante Autólogo/métodosRESUMO
We report an unusual case of an enterovesical fistula secondary to adenocarcinoma of the appendix.