Veno-venous extracorporeal membrane oxygenation in patients with SARS-CoV-2 pneumonia in Brazil: a case series.

OBJECTIVE: The world has been suffering from the COVID-19 pandemic. Some COVID-19 patients develop severe viral pneumonia, requiring mechanical ventilation and measures to treat refractory hypoxemia, such as a protective ventilation strategy, prone positioning, and the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO). We describe a case series of 30 COVID-19 patients who needed VV-ECMO at the Hospital Alemão Oswaldo Cruz, located in the city of São Paulo, Brazil. METHODS: We included all patients who required VV-ECMO due to COVID-19 pneumonia between March of 2020 and June of 2021. RESULTS: Prior to VV-ECMO, patients presented with the following median scores: SOFA score, 11; APPS score, 7; Respiratory ECMO Survival Prediction score, 2; and Murray score, 3.3. The 60-day-in-hospital mortality was 33.3% (n = 10). CONCLUSIONS: Although our patients had a highly severe profile, our results were similar to those of other cohort studies in the literature. This demonstrates that VV-ECMO can be a good tool even in a pandemic situation when it is managed in an experienced center.

Veno-venous extracorporeal membrane oxygenation in patients with SARS-CoV-2 pneumonia in Brazil: a case series / Oxigenação por membrana extracorpórea venovenosa em pacientes com pneumonia por SARS-CoV-2 no Brasil: série de casos

ABSTRACT Objective: The world has been suffering from the COVID-19 pandemic. Some COVID-19 patients develop severe viral pneumonia, requiring mechanical ventilation and measures to treat refractory hypoxemia, such as a protective ventilation strategy, prone positioning, and the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO). We describe a case series of 30 COVID-19 patients who needed VV-ECMO at the Hospital Alemão Oswaldo Cruz, located in the city of São Paulo, Brazil. Methods: We included all patients who required VV-ECMO due to COVID-19 pneumonia between March of 2020 and June of 2021. Results: Prior to VV-ECMO, patients presented with the following median scores: SOFA score, 11; APPS score, 7; Respiratory ECMO Survival Prediction score, 2; and Murray score, 3.3. The 60-day-in-hospital mortality was 33.3% (n = 10). Conclusions: Although our patients had a highly severe profile, our results were similar to those of other cohort studies in the literature. This demonstrates that VV-ECMO can be a good tool even in a pandemic situation when it is managed in an experienced center.

RESUMO Objetivo: O mundo vem sofrendo com a pandemia de COVID-19. Alguns pacientes com COVID-19 desenvolvem pneumonia viral grave, necessitando ventilação mecânica e medidas para tratar a hipoxemia refratária, como estratégias de ventilação protetora, posição prona e uso de oxigenação por membrana extracorpórea venovenosa (ECMO-VV). Descrevemos uma série de casos de 30 pacientes com COVID-19 que necessitaram de ECMO-VV no Hospital Alemão Oswaldo Cruz, localizado na cidade de São Paulo, Brasil. Métodos: Foram incluídos todos os pacientes que necessitaram de ECMO-VV devido à pneumonia por COVID-19 entre março de 2020 e junho de 2021. Resultados: Antes da ECMO-VV, os pacientes apresentavam as seguintes medianas: escore SOFA de 11; escore APPS de 7; escore Respiratory ECMO Survival Prediction de 2; e escore de Murray de 3,3. A mortalidade hospitalar em 60 dias foi de 33,3% (n = 10). Conclusões: Apesar de nossos pacientes apresentarem um perfil de alta gravidade, nossos resultados foram semelhantes aos de outros estudos de coorte na literatura. Isso demonstra que a ECMO-VV pode ser uma boa ferramenta mesmo em uma situação de pandemia quando administrada em um centro experiente.

Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery: The VANCS Randomized Controlled Trial.

BACKGROUND: Vasoplegic syndrome is a common complication after cardiac surgery and impacts negatively on patient outcomes. The objective of this study was to evaluate whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome. METHODS: This prospective, randomized, double-blind trial was conducted at the Heart Institute, University of Sao Paulo, Sao Paulo, Brazil, between January 2012 and March 2014. Patients with vasoplegic shock (defined as mean arterial pressure less than 65 mmHg resistant to fluid challenge and cardiac index greater than 2.2 l · min · m) after cardiac surgery were randomized to receive vasopressin (0.01 to 0.06 U/min) or norepinephrine (10 to 60 µg/min) to maintain arterial pressure. The primary endpoint was a composite of mortality or severe complications (stroke, requirement for mechanical ventilation for longer than 48 h, deep sternal wound infection, reoperation, or acute renal failure) within 30 days. RESULTS: A total of 330 patients were randomized, and 300 were infused with one of the study drugs (vasopressin, 149; norepinephrine, 151). The primary outcome occurred in 32% of the vasopressin patients and in 49% of the norepinephrine patients (unadjusted hazard ratio, 0.55; 95% CI, 0.38 to 0.80; P = 0.0014). Regarding adverse events, the authors found a lower occurrence of atrial fibrillation in the vasopressin group (63.8% vs. 82.1%; P = 0.0004) and no difference between groups in the rates of digital ischemia, mesenteric ischemia, hyponatremia, and myocardial infarction. CONCLUSIONS: The authors' results suggest that vasopressin can be used as a first-line vasopressor agent in postcardiac surgery vasoplegic shock and improves clinical outcomes.

Clinical characteristics and long-term progression of young patients with acute coronary syndrome in Brazil.

OBJECTIVE: In Brazil, there are few descriptions in the literature on the angiographic pattern and clinical characteristics of young patients with acute coronary syndrome, despite the evident number of cases in the population. The objective of this study was to evaluate which clinical characteristics are most closely related to the acute coronary syndrome in young patients, and what long-term outcomes are in this population. METHODS: This is a prospective observational study with 268 patients aged under 55 years with acute coronary syndrome, carried out between May 2010 and May 2013. Data were obtained on demographics, laboratory test and angiography results, and the coronary treatment adopted. Statistical analysis was presented as percentages and absolute values. RESULTS: Approximately 57% were men and the median age was 50 years (30 to 55). The main risk factors were arterial hypertension (68%), smoking (67%), and dyslipidemia (43%). Typical pain was present in 90% of patients. In young individuals, 25.7% showed ST segment elevation. Approximately 56.5% of patients presented with a single-vessel angiographic pattern. About 7.1% were submitted to coronary bypass surgery, and 42.1% to percutaneous coronary angioplasty. Intrahospital mortality was 1.5%, and the combined event rate (cerebrovascular accident/stroke, cardiogenic shock, reinfarction, and arrhythmias) was 13.8%. After a mean follow-up of 10 months, mortality was 9.8%, while 25.4% of the patients had new ischemic events, and 37.3% required readmission to hospital. CONCLUSION: In the short-term, young patients presented with mortality rates below what was expected when compared to the rates noted in other studies. However, there was a significant increase in the number of events in the 10-month follow-up.

Clinical characteristics and long-term progression of young patients with acute coronary syndrome in Brazil / Características clínicas e evolução em longo prazo de pacientes jovens com síndrome coronariana aguda no Brasil

Objective In Brazil, there are few descriptions in the literature on the angiographic pattern and clinical characteristics of young patients with acute coronary syndrome, despite the evident number of cases in the population. The objective of this study was to evaluate which clinical characteristics are most closely related to the acute coronary syndrome in young patients, and what long-term outcomes are in this population.Methods This is a prospective observational study with 268 patients aged under 55 years with acute coronary syndrome, carried out between May 2010 and May 2013. Data were obtained on demographics, laboratory test and angiography results, and the coronary treatment adopted. Statistical analysis was presented as percentages and absolute values.Results Approximately 57% were men and the median age was 50 years (30 to 55). The main risk factors were arterial hypertension (68%), smoking (67%), and dyslipidemia (43%). Typical pain was present in 90% of patients. In young individuals, 25.7% showed ST segment elevation. Approximately 56.5% of patients presented with a single-vessel angiographic pattern. About 7.1% were submitted to coronary bypass surgery, and 42.1% to percutaneous coronary angioplasty. Intrahospital mortality was 1.5%, and the combined event rate (cerebrovascular accident/stroke, cardiogenic shock, reinfarction, and arrhythmias) was 13.8%. After a mean follow-up of 10 months, mortality was 9.8%, while 25.4% of the patients had new ischemic events, and 37.3% required readmission to hospital.Conclusion In the short-term, young patients presented with mortality rates below what was expected when compared to the rates noted in other studies. However, there was a significant increase in the number of events in the 10-month follow-up.

Objetivo No Brasil, há poucas descrições na literatura referentes ao padrão angiográfico e a características clínicas em pacientes jovens com síndrome coronariana aguda, apesar do número evidente de casos nessa população. O objetivo deste trabalho foi avaliar quais as características clínicas que mais se associam com a síndrome coronariana aguda em pacientes jovens e quais os desfechos a longo prazo nessa população.Métodos Trata-se de estudo prospectivo observacional com 268 pacientes com menos de 55 anos de idade com síndrome coronariana aguda, realizado entre maio de 2010 e maio de 2013. Foram obtidos dados demográficos, laboratoriais, angiográficos e do tratamento coronário adotado. Análise estatística foi apresentada sob a forma de porcentagens e valores absolutos.Resultados Aproximadamente 57% eram homens e a mediana de idade foi de 50 anos (30 a 55). Observou-se como principais fatores de risco hipertensão (68%), tabagismo (67%) e dislipidemia (43%). Dor típica esteve presente em 90% dos pacientes. Nos indivíduos jovens, observou-se supradesnivelamento de ST em 25,7% dos casos. Aproximadamente 56,5% dos pacientes apresentaram padrão angiográfico uniarterial. Cerca de 7,1% foram submetidos à cirurgia de revascularização miocárdica e 42,1% à angioplastia coronária. A mortalidade intra-hospitalar encontrada foi de 1,5%, e o índice de desfechos combinados (acidente vascular cerebral, choque cardiogênico, reinfarto e arritmias) foi de 13,8%. Após seguimento médio de 10 meses, a mortalidade foi de 9,8%, enquanto 25,4% dos pacientes apresentaram novos eventos isquêmicos e 37,3%, necessidade de reinternação.Conclusão A curto prazo, pacientes jovens apresentam índices de mortalidade abaixo do esperado, quando comparados os índices observados em outros estudos. No entanto, observou-se aumento importante no número de eventos no seguimento de 10 meses.

Intracardiac embolization of inferior vena cava filter associated with right atrium perforation and cardiac tamponade.

Insertion of inferior vena cava filters has been well established in literature, reducing occurrence of pulmonary embolism after an episode of deep venous thrombosis in patients with contraindication to anticoagulation. There are a small number of complications related to procedure and embolization is rare. In this context, we described a case of intracardiac embolization associated with cardiac tamponade.

Intracardiac embolization of inferior vena cava filter associated with right atrium perforation and cardiac tamponade / Embolização de filtro de veia cava associado à perfuração de átrio direito e tamponamento cardíaco

Insertion of inferior vena cava filters has been well established in literature, reducing occurrence of pulmonary embolism after an episode of deep venous thrombosis in patients with contraindication to anticoagulation. There are a small number of complications related to procedure and embolization is rare. In this context, we described a case of intracardiac embolization associated with cardiac tamponade.

A colocação percutânea de filtro de veia cava inferior é bem estabelecida em literatura, reduzindo a chance de ocorrência de tromboembolismo pulmonar após um episódio de trombose venosa profunda em pacientes com contraindicações à anticoagulação. O índice de complicações relacionadas ao procedimento é pequeno, sendo embolização evento extremamente raro. Nesse contexto, descrevemos um caso de embolização intracardíaca de filtro de veia cava inferior associada ao tamponamento cardíaco.