[Circulatory support with venovenous ECMO in a patient with reperfusion pulmonary edema after pulmonary artery thromboendarterectomy]. / Soporte circulatorio con ECMO venovenoso en paciente con síndrome de reperfusión pulmonar secundario a tromboendarterectomía arterial pulmonar.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a subtype of pulmonary hypertension characterized by the obstruction of pulmonary arteries secondary to chronic thromboembolism. Pulmonary thromboendarterectomy surgery (PTE) is the main treatment for patients with CTEPH, as it removes the chronic thrombi from the pulmonary arteries. Pulmonary reperfusion syndrome is a common complication of the surgery, which involves the development of pulmonary edema in the area where blood perfusion improves after the surgery. The incidence of this syndrome varies from 8 to 91% depending on the criteria used for diagnosis, and it is one of the most serious complications of pulmonary thromboendarterectomy. In such cases, circulatory support with extracorporeal membrane oxygenation (ECMO) has become a valuable therapeutic modality. We present the case of a 60-year-old woman with a history of acute pulmonary embolism due to deep vein thrombosis of the right pelvic limb who was diagnosed later with CTEPH who was admitted for scheduled surgical treatment involving bilateral PTE. However, during the immediate postoperative period, she developed cardiogenic shock and refractory hypoxemia secondary to pulmonary reperfusion syndrome following the surgical procedure. As a result, she required veno-venous ECMO circulatory support for 6 days, leading to resolution of the pulmonary condition and clinical improvement.

La hipertensión pulmonar tromboembólica crónica (HPTEC) es un subtipo de hipertensión pulmonar caracterizada por la obstrucción de las arterias pulmonares secundaria a tromboembolias crónicas. La cirugía de tromboendarterectomía pulmonar (TEAP) es el tratamiento principal para los pacientes con HPTEC, elimina los trombos crónicos de las arterias pulmonares. El síndrome de reperfusión pulmonar es una complicación común de la cirugía, se trata del desarrollo de edema pulmonar en el área en la que la perfusión sanguínea mejora después de la cirugía. La incidencia del síndrome varía del 8 al 91% según los criterios utilizados para diagnosticarlo y es una de las complicaciones más graves de la tromboendarterectomía pulmonar. En tales casos, el soporte circulatorio con oxigenación por membrana extracorpórea (ECMO) se ha convertido en una valiosa modalidad terapéutica. Presentamos el caso de una paciente de 60 años de edad con antecedente de tromboembolia pulmonar aguda secundaria a trombosis venosa profunda de miembro pélvico derecho a quien durante el seguimiento se realizó el diagnóstico de HPTEC e ingresó de manera programada para tratamiento quirúrgico con realización de TEAP bilateral, sin embargo durante el posquirúrgico inmediato presentó choque cardiogénico e hipoxemia refractaria secundarios a síndrome de reperfusión pulmonar, por lo cual requirió soporte circulatorio con ECMO venovenosa durante seis días, con resolución del cuadro pulmonar y mejoría clínica.

ELANE rs17223045C/T and rs3761007G/A variants: Protective factors against COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for causing coronavirus disease 2019 (COVID-19). The development and severity of this infectious disease is influenced by a combination of environmental and genetic factors. Angiotensin-converting enzyme 2 (ACE2) facilitates SARS-CoV-2 entry into human cells, with transmembrane serine protease 2 (TMPRSS2) playing a crucial role in S protein priming. Other proteases, such as cathepsin L and elastase, neutrophil-expressed (ELANE), have the capability to prime the S protein and contribute to SARS-CoV-2 infection. ELANE variants have not been previously examined in COVID-19 patients. We aimed to assess the association of single nucleotide variants (SNVs) within ELANE with COVID-19 and biochemical markers. The study included 319 SARS-CoV-2-infected patients and 288 controls. Genotyping of ELANE rs17216663C/T (Pro257Leu), rs17223045C/T (As1n30Asn), and rs3761007G/A was conducted using a 5'-nuclease allelic discrimination assay (TaqMan assay). Our findings indicate that ELANE rs17223045C/T (C vs T: odds ratio [OR] 0.08, P = 0.005, and CC vs CT: OR 0.08, P = 0.005) and rs3761007G/A (G vs A: OR 0.38, P = 0.009, and GG vs GA: OR 0.40, P = 0.008) confer protection against COVID-19. However, these variants were not associated with biochemical markers. In conclusion, our data suggests that ELANE rs17223045C/T and rs3761007G/A SNVs may play a protective role against COVID-19.

[North-south syndrome, a complication of circulatory assistance with Veno-Arterial ECMO. A case report.] / El síndrome de norte-sur, una complicación de la asistencia circulatoria con ECMO Venoarterial. Reporte de caso.

We present the case of a 34-year-old male patient with a history of Marfan syndrome who was admitted to the emergency room for acute aortic regurgitation secondary to aneurysmal dilation of the ascending thoracic aorta. In the postoperative period, post-cardiotomy cardiogenic shock was documented, so circulatory support was initiated with peripheral Veno-Arterial ECMO, which developed hypoxemia due to bacterial pneumonia and data compatible with North-South syndrome. We present a review, non-conventional cannulation strategies and a diagnostic alternative for this entity.

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.

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.

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.

Endarterectomía carotídea en paciente con estenosis aórtica crítica. Importancia de la anestesia regional y del neuromonitoreo / Carotid endarterectomy in a patient with critical aortic stenosis. Importance of regional anesthesia and transoperative neurological monitoring

Resumen: La estenosis carotídea (EC) ocurre en 13% de los pacientes con estenosis valvular aórtica (EVA). El riesgo de evento vascular cerebral (EVC), en los pacientes con EC significativa sometidos a cirugía valvular cardíaca, puede aumentar hasta 11%. Someter a un paciente con EVA crítica y fracción de eyección del ventrículo izquierdo (FEVI) disminuida a endarterectomía carotídea es todo un reto anestésico, cuyo principal objetivo es evitar la hipotensión y el bajo gasto cardíaco. La anestesia regional es una opción para estos pacientes. Presentamos el caso de un hombre de 70 años con diagnóstico de EC significativa y EVA crítica con disfunción ventricular izquierda, al que se realizó endarterectomía carotídea con bloqueo del plexo cervical superficial por alto riesgo de colapso circulatorio. Dicha estrategia anestésica permitió mantener al paciente despierto durante la cirugía, al valorar continuamente su estado neurológico. Asimismo, se documentaron los cambios transoperatorios en el NIRS (Near-infrared spectroscopy) cerebral y Doppler transcraneal (DTC), los cuales se correlacionaron con el estado clínico del paciente. En un segundo tiempo se hizo cambio valvular aórtico sin complicaciones. En este caso destaca la importancia de la anestesia regional y el monitoreo neurológico con Doppler transcraneal, en pacientes sometidos a endarterectomía carotídea con alto riesgo quirúrgico por EVA crítica.

Abstract: Carotid stenosis occurs in 13% of patients with aortic valve stenosis. The risk of stroke in patients with significant carotid stenosis undergoing heart valve surgery may increase to 11%. Proposing a patient with critical aortic valve stenosis and left ventricular dysfunction to carotid endarterectomy is an anesthetic challenge, where the objective is to avoid hypotension and low cardiac output. Regional anesthesia is an option for these patients. Due to the high incidence of intraoperative stroke during carotid endarterectomy, continuous neurological monitoring is of relevance. We present the case of a 70-year-old man diagnosed with significant carotid stenosis and critical aortic valve stenosis and left ventricular dysfunction who underwent carotid endarterectomy with superficial cervical plexus block due to a high risk of circulatory collapse. In addition, this anesthetic strategy made it possible to keep the patient awake during surgery, and to continuously assess their neurological status. Likewise, transoperative changes in brain NIRS and transcranial Doppler were documented, which correlated with the patient's clinical status. In a second time, aortic valve replacement was performed without complications. This case highlights the importance of regional anesthesia and neurological monitoring in patients undergoing carotid endarterectomy with high surgical risk due to critical aortic valve stenosis.

A contrast echocardiography-based protocol to rule out thrombus in Venous-Arterial ECMO: A proof of concept.

Using an ultrasound-enhancing agent (UEA) has several indications, especially in diagnosing left ventricular thrombus. Herein, we present three cases of patients who were candidates for venous-arterial extracorporeal membrane oxygenation, among whom thrombus was ruled out via contrast echocardiography. The use of a UEA in these patients was a novel approach.

Chagas Heart Disease: Beyond a Single Complication, from Asymptomatic Disease to Heart Failure.

Chagas cardiomyopathy (CC), caused by the protozoan Trypanosoma cruzi, is an important cause of cardiovascular morbidity and mortality in developing countries. It is estimated that 6 to 7 million people worldwide are infected, and it is predicted that it will be responsible for 200,000 deaths by 2025. The World Health Organization (WHO) considers Chagas disease (CD) as a Neglected Tropical Disease (NTD), which must be acknowledged and detected in time, as it remains a clinical and diagnostic challenge in both endemic and non-endemic regions and at different levels of care. The literature on CC was analyzed by searching different databases (Medline, Cochrane Central, EMBASE, PubMed, Google Scholar, EBSCO) from 1968 until October 2022. Multicenter and bioinformatics trials, systematic and bibliographic reviews, international guidelines, and clinical cases were included. The reference lists of the included papers were checked. No linguistic restrictions or study designs were applied. This review is intended to address the current incidence and prevalence of CD and to identify the main pathogenic mechanisms, clinical presentation, and diagnosis of CC.

Saturación de oxígeno y lactato sérico venoso-arterial del posoperatorio de cirugía cardiaca / Venous-arterial oxygen saturation and serum lactate in the postoperative period of cardiac surgery

Resumen Introducción: La saturación de oxígeno y el lactato son marcadores de hipoxia tisular, se obtienen de muestra venosa mezclada en arteria pulmonar o venosa central. Se desconoce el comportamiento simultáneo de estos parámetros en el postoperatorio de cirugía cardiaca. Objetivo: Caracterizar la saturación de oxígeno y lactato del circuito venoso-arterial del paciente postoperado de cirugía cardiaca. Métodos: Diseño transversal analítico. En pacientes consecutivos postoperados de cirugía cardiaca se obtuvieron lactato sérico y saturación de oxígeno del circuito venoso-arterial. Las variables se informaron con mediana (percentiles 25 y 75). Se analizaron con ANOVA de Kruskal-Wallis y ajuste respectivo, correlación de Spearman, el estadístico descriptivo de Bland-Altman y coeficiente de correlación intraclase (intervalo de confianza al 95%). Una p < 0.05 se consideró significativa. Resultados: Se estudiaron 244 muestras sanguíneas de 61 pacientes. Mujeres 30 (49%). Saturación de oxígeno y lactato fueron: arterial 98 (95.3, 99.4)% y 1.7 (1,1, 2.1); venosa periférica 85 (75.4, 94)% y 1.9 (1.35, 2.3); venosa central 68.8 (58.74, 70.2)% y 1.8 (1.3, 2.3); venosa central mezclada 66.8 (61.2, 73.1)% y 1.8 (1.3, 2.2), p < 0.05. El mejor coeficiente de correlación intraclase para la saturación de oxígeno fue de vena central a vena central mezclada: 0.856 (0.760, 0.914); del lactato: 0.954 (0.923, 0.972). Conclusiones: La saturación de oxígeno difiere en el circuito venoso-arterial a diferencia del lactato, donde son similares. Los mejores valores del coeficiente de correlación intraclase para el lactato y la saturación de oxígeno fueron los obtenidos en vena central y vena central mezclada.

Abstract Introduction: Oxygen saturation and lactate are markers of tissue hypoxia; they are obtained from central venous and mixed venous sample of the pulmonary artery. The simultaneous behavior of these parameters in the postoperative period of cardiac surgery is unknown. Objective: To characterize the lactate and oxygen saturation of the venous-arterial circuit of the postoperative patient from cardiac surgery. Methods: Design: Analytical cross-sectional. In consecutive patients after cardiac surgery, serum lactate and oxygen saturation of the venous-arterial circuit were obtained. The variables were reported with median (25.75 percentiles). They were analyzed with Kruskal-Wallis ANOVA and respective adjustment, Spearman correlation, the descriptive Bland-Altman statistic and intraclass correlation coefficient (95% confidence interval). A p < 0.05 was considered significant. Results: 244 blood samples from 61 patients were studied. Women 30 (49%). (Oxygen saturation) [lactate] were: arterial 98 (95.3, 99.4%) and 1.7 (1.1, 2.1); peripheral venous 85 (75.4, 94%) and [1.9 (1.35, 2.3)]; central venous 68.8 (58.74, 70.2%) and 1.8 (1.3, 2.3); mixed central venous 66.8 (61.2, 73.1%) and 1.8 (1.3, 2.2), p < 0.05. The best intraclass correlation coefficient for oxygen saturation were from central vein to mixed central vein 0.856 (0.760,0.914); and lactate: 0.954 (0.923, 0.972). Conclusions: The oxygen saturation differs in the venous-arterial circuit unlike lactate where they are similar. The best values of the intraclass correlation coefficient for lactate and oxygen saturation were those obtained in central vein and mixed central vein.

Venous-arterial oxygen saturation and serum lactate in the postoperative period of cardiac surgery.

INTRODUCTION: Oxygen saturation and lactate are markers of tissue hypoxia; they are obtained from central venous and mixed venous sample of the pulmonary artery. The simultaneous behavior of these parameters in the postoperative period of cardiac surgery is unknown. OBJECTIVE: To characterize the lactate and oxygen saturation of the venous-arterial circuit of the postoperative patient from cardiac surgery. METHODS: Design: Analytical cross-sectional. In consecutive patients after cardiac surgery, serum lactate and oxygen saturation of the venous-arterial circuit were obtained. The variables were reported with median (25.75 percentiles). They were analyzed with Kruskal-Wallis ANOVA and respective adjustment, Spearman correlation, the descriptive Bland-Altman statistic and intraclass correlation coefficient (95% confidence interval). A p < 0.05 was considered significant. RESULTS: 244 blood samples from 61 patients were studied. Women 30 (49%). (Oxygen saturation) [lactate] were: arterial 98 (95.3, 99.4%) and 1.7 (1.1, 2.1); peripheral venous 85 (75.4, 94%) and [1.9 (1.35, 2.3)]; central venous 68.8 (58.74, 70.2%) and 1.8 (1.3, 2.3); mixed central venous 66.8 (61.2, 73.1%) and 1.8 (1.3, 2.2), p < 0.05. The best intraclass correlation coefficient for oxygen saturation were from central vein to mixed central vein 0.856 (0.760,0.914); and lactate: 0.954 (0.923, 0.972). CONCLUSIONS: The oxygen saturation differs in the venous-arterial circuit unlike lactate where they are similar. The best values of the intraclass correlation coefficient for lactate and oxygen saturation were those obtained in central vein and mixed central vein.

INTRODUCCIÓN: La saturación de oxígeno y el lactato son marcadores de hipoxia tisular, se obtienen de muestra venosa mezclada en arteria pulmonar o venosa central. Se desconoce el comportamiento simultáneo de estos parámetros en el postoperatorio de cirugía cardiaca. OBJETIVO: Caracterizar la saturación de oxígeno y lactato del circuito venoso-arterial del paciente postoperado de cirugía cardiaca. MÉTODOS: Diseño transversal analítico. En pacientes consecutivos postoperados de cirugía cardiaca se obtuvieron lactato sérico y saturación de oxígeno del circuito venoso-arterial. Las variables se informaron con mediana (percentiles 25 y 75). Se analizaron con ANOVA de Kruskal-Wallis y ajuste respectivo, correlación de Spearman, el estadístico descriptivo de Bland-Altman y coeficiente de correlación intraclase (intervalo de confianza al 95%). Una p < 0.05 se consideró significativa. RESULTADOS: Se estudiaron 244 muestras sanguíneas de 61 pacientes. Mujeres 30 (49%). Saturación de oxígeno y lactato fueron: arterial 98 (95.3, 99.4)% y 1.7 (1,1, 2.1); venosa periférica 85 (75.4, 94)% y 1.9 (1.35, 2.3); venosa central 68.8 (58.74, 70.2)% y 1.8 (1.3, 2.3); venosa central mezclada 66.8 (61.2, 73.1)% y 1.8 (1.3, 2.2), p < 0.05. El mejor coeficiente de correlación intraclase para la saturación de oxígeno fue de vena central a vena central mezclada: 0.856 (0.760, 0.914); del lactato: 0.954 (0.923, 0.972). CONCLUSIONES: La saturación de oxígeno difiere en el circuito venoso-arterial a diferencia del lactato, donde son similares. Los mejores valores del coeficiente de correlación intraclase para el lactato y la saturación de oxígeno fueron los obtenidos en vena central y vena central mezclada.

Metabolic Reprogramming in SARS-CoV-2 Infection Impacts the Outcome of COVID-19 Patients.

Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection triggers inflammatory clinical stages that affect the outcome of patients with coronavirus disease 2019 (COVID-19). Disease severity may be associated with a metabolic imbalance related to amino acids, lipids, and energy-generating pathways. The aim of this study was to characterize the profile of amino acids and acylcarnitines in COVID-19 patients. A multicenter, cross-sectional study was carried out. A total of 453 individuals were classified by disease severity. Levels of 11 amino acids, 31 acylcarnitines, and succinylacetone in serum samples were analyzed by electrospray ionization-triple quadrupole tandem mass spectrometry. Different clusters were observed in partial least squares discriminant analysis, with phenylalanine, alanine, citrulline, proline, and succinylacetone providing the major contribution to the variability in each cluster (variable importance in the projection >1.5). In logistic models adjusted by age, sex, type 2 diabetes mellitus, hypertension, and nutritional status, phenylalanine was associated with critical outcomes (odds ratio=5.3 (95% CI 3.16-9.2) in the severe vs. critical model, with an area under the curve of 0.84 (95% CI 0.77-0.90). In conclusion the metabolic imbalance in COVID-19 patients might affect disease progression. This work shows an association of phenylalanine with critical outcomes in COVID-19 patients, highlighting phenylalanine as a potential metabolic biomarker of disease severity.

Association of the Transmembrane Serine Protease-2 (TMPRSS2) Polymorphisms with COVID-19.

SARS-CoV-2 uses the ACE2 receptor and the cellular protease TMPRSS2 for entry into target cells. The present study aimed to establish if the TMPRSS2 polymorphisms are associated with COVID-19 disease. The study included 609 patients with COVID-19 confirmed by RT-PCR test and 291 individuals negative for the SARS-CoV-2 infection confirmed by RT-PCR test and without antibodies anti-SARS-CoV-2. Four TMPRSS2 polymorphisms (rs12329760, rs2298659, rs456298, and rs462574) were determined using the 5'exonuclease TaqMan assays. Under different inheritance models, the rs2298659 (pcodominant2 = 0.018, precessive = 0.006, padditive = 0.019), rs456298 (pcodominant1 = 0.014, pcodominant2 = 0.004; pdominant = 0.009, precessive = 0.004, padditive = 0.0009), and rs462574 (pcodominant1 = 0.017, pcodominant2 = 0.004, pdominant = 0.041, precessive = 0.002, padditive = 0.003) polymorphisms were associated with high risk of developing COVID-19. Two risks (ATGC and GAAC) and two protectives (GAGC and GAGT) haplotypes were detected. High levels of lactic acid dehydrogenase (LDH) were observed in patients with the rs462574AA and rs456298TT genotypes (p = 0.005 and p = 0.020, respectively), whereas, high heart rate was present in patients with the rs462574AA genotype (p = 0.028). Our data suggest that the rs2298659, rs456298, and rs462574 polymorphisms independently and as haplotypes are associated with the risk of COVID-19. The rs456298 and rs462574 genotypes are related to high levels of LDH and heart rate.

Aortic Perforation and Ascending Dissection Due to Intra-Aortic Balloon Counterpulsation Implantation in Cardiac Surgery.

The intra-aortic balloon pump continues to be a useful ventricular assist device in cardiac surgery. Complications are estimated to be 7% to 40%, significantly high to catastrophic. We describe an aortic injury associated with the use of the device and an interdisciplinary management for the diagnostic and therapeutic approach. (Level of Difficulty: Intermediate.).

Acute Mitral Regurgitation Due to Chordae Tendineae Rupture: A Rare Presentation of Cardiac Amyloidosis.

BACKGROUND In cardiac amyloidosis (CA), misfolded proteins deposit in the extracellular space of cardiac tissue. These deposits classically cause restrictive cardiomyopathy with diastolic dysfunction. Although there are at least 30 proteins known to cause amyloid aggregates, 2 main types make up most diagnosed cases: light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR). Since CA is considered a rare condition, it is often underdiagnosed or recognized in the advanced stages. Once amyloid deposits involve the heart tissue, they are associated with a worse outcome and higher mortality rates, especially in patients presenting symptoms of heart failure. CASE REPORT We report a case of a 22-year-old man presenting with acute severe mitral regurgitation, secondary to posterior mitral leaflet chordae tendineae rupture (CTR). Surgical mitral valve replacement with a mechanical prosthesis was performed, and cardiac tissue biopsy samples were obtained. After surgery, the patient improved significantly but suddenly presented with hemodynamic deterioration, until he died due to severe hemodynamic compromise and multiorgan failure. Although the etiology of the CTR was not established before surgical intervention, the histopathological analysis suggested CA. CONCLUSIONS CA diagnosis can be complex, especially in a 22-year-old-man with atypical clinical and imaging manifestations. In this patient, other differential diagnoses were considered, since CA presenting in a young patient is a rare phenomenon and acute mitral regurgitation secondary to CTR presents more frequently in other heart conditions. Furthermore, rapid postoperative deterioration resulted in the patient's death before biopsy samples were available because suspicion of amyloidosis had not been raised until that point.

Pulmonary artery cannulation during venovenous extracorporeal membrane oxygenation: An alternative to manage refractory hypoxemia and right ventricular dysfunction.

Venovenous extracorporeal membrane oxygenation (ECMO) has become a rescue therapy for acute respiratory distress syndrome (ARDS) secondary to COVID-19 for patients who are refractory to conventional therapy. However, this therapy comes with complications, and alternative cannulation strategies are needed to overcome these difficulties. In this article, we present a case of venovenous ECMO presenting with refractory hypoxemia and right ventricular dysfunction, which were corrected by cannulating the pulmonary artery. This situation is rarely reported in literature and may constitute an alternative for managing these patients.