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2.
J Am Heart Assoc ; 8(15): e010881, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31311438

RESUMO

Background Clinical characteristics and outcomes of takotsubo syndrome (TTS) patients with malignancy have not been fully elucidated. This study sought to explore differences in clinical characteristics and to investigate short- and long-term outcomes in TTS patients with or without malignancy. Methods and Results TTS patients were enrolled from the International Takotsubo Registry. The TTS cohort was divided into patients with and without malignancy to investigate differences in clinical characteristics and to assess short- and long-term mortality. A subanalysis was performed comparing long-term mortality between a subset of TTS patients with or without malignancy and acute coronary syndrome (ACS) patients with or without malignancy. Malignancy was observed in 16.6% of 1604 TTS patients. Patients with malignancy were older and more likely to have physical triggers, but less likely to have emotional triggers compared with those without malignancy. Long-term mortality was higher in patients with malignancy (P<0.001), while short-term outcome was comparable (P=0.17). In a subanalysis, long-term mortality was comparable between TTS patients with malignancies and ACS patients with malignancies (P=0.13). Malignancy emerged as an independent predictor of long-term mortality. Conclusions A substantial number of TTS patients show an association with malignancy. History of malignancy might increase the risk for TTS, and therefore, appropriate screening for malignancy should be considered in these patients. Clinical Trial Registration URL: http://www.clinicaltrial.gov. Unique identifier: NCT01947621.

3.
Arch Cardiovasc Dis ; 2019 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-31155464

RESUMO

BACKGROUND: Despite advances in intensive care medicine, management of cardiogenic shock (CS) remains difficult and imperfect, with high mortality rates, regardless of aetiology. Predictive data regarding long-term mortality rates in patients presenting CS are sparse. AIM: To describe prognostic factors for long-term mortality in CS of different aetiologies. METHODS: Two hundred and seventy-five patients with CS admitted to our tertiary centre between January 2013 and December 2014 were reviewed retrospectively. Mortality was recorded in December 2016. A Cox proportional-hazards model was used to determine predictors of long-term mortality. RESULTS: Most patients were male (72.7%), with an average age of 64±16 years and a history of cardiomyopathy (63.5%), mainly ischaemic (42.3%). Leading causes of CS were myocardial infarction (35.3%), decompensated heart failure (34.2%) and cardiac arrest (20.7%). Long-term mortality was 62.5%. After multivariable analysis, previous use of beta-blockers (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.41-0.89; P=0.02) and coronary angiography exploration at admission (HR 0.57, 95% CI 0.38-0.86; P=0.02) were associated with a lower risk of long-term mortality. Conversely, age (HR 1.02 per year, 95% CI 1.01-1.04; P<0.001), catecholamine support (HR 1.45 for each additional agent, 95% CI 1.20-1.75; P<0.001) and renal replacement therapy (HR 1.66, 95% CI 1.09-2.55; P=0.02) were associated with an increased risk of long-term mortality. CONCLUSIONS: Long-term mortality rates in CS remain high, reaching 60% at 1-year follow-up. Previous use of beta-blockers and coronary angiography exploration at admission were associated with better long-term survival, while age, renal replacement therapy and the use of catecholamines appeared to worsen the prognosis, and should lead to intensification of CS management.

4.
Int J Cardiol ; 291: 96-104, 2019 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-31155332

RESUMO

For patients with myocardial infarct-related cardiogenic shock (CS), urgent percutaneous coronary intervention is the recommended treatment strategy to limit cardiac and systemic ischemia. However, a specific therapeutic intervention is often missing in non-ischemic CS cases. Though drug treatment with inotropes and/or vasopressors may be required to stabilize the patient initially, their ongoing use is associated with excess mortality. Coronary intervention in unstable patients often leads to further hemodynamic compromise either during or shortly after revascularization. Support devices like the intra-aortic balloon pump failed to improve clinical outcomes in infarct-related CS. Currently, more powerful and active hemodynamic support devices unloading the left ventricle such as transvalvular microaxial pumps are available and are being increasingly used. However, as for other devices large randomized trials are not yet available, and device use is based on registry data and expert consensus. In this article, a multidisciplinary group of experienced users of transvalvular microaxial pumps outlines the pathophysiological background on hemodynamic changes in CS, the available mechanical support devices, and current guideline recommendations. Furthermore, different hemodynamic situations in several case-based scenarios are used to illustrate candidate settings and to provide the theoretic and scientific rationale for left-ventricular unloading in these scenarios. Finally, organization of shock networks, monitoring, weaning, and typical complications and their prevention are discussed.

5.
Am Heart J ; 214: 69-76, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31174053

RESUMO

BACKGROUND: Left ventricular assist device (LVAD)-associated infections may be life-threatening and impact patients' outcome. We aimed to identify the characteristics, risk factors, and prognosis of LVAD-associated infections. METHODS: Patients included in the ASSIST-ICD study (19 centers) were enrolled. The main outcome was the occurrence of LVAD-associated infection (driveline infection, pocket infection, or pump/cannula infection) during follow-up. RESULTS: Of the 652 patients enrolled, 201 (30.1%) presented a total of 248 LVAD infections diagnosed 6.5 months after implantation, including 171 (26.2%), 51 (7.8%), and 26 (4.0%) percutaneous driveline infection, pocket infection, or pump/cannula infection, respectively. Patients with infections were aged 58.7 years, and most received HeartMate II (82.1%) or HeartWare (13.4%). Most patients (62%) had implantable cardioverter-defibrillators (ICDs) before LVAD, and 104 (16.0%) had ICD implantation, extraction, or replacement after the LVAD surgery. Main pathogens found among the 248 infections were Staphylococcus aureus (n = 113' 45.4%), Enterobacteriaceae (n = 61; 24.6%), Pseudomonas aeruginosa (n = 34; 13.7%), coagulase-negative staphylococci (n = 13; 5.2%), and Candida species (n = 13; 5.2%). In multivariable analysis, HeartMate II (subhazard ratio, 1.56; 95% CI, 1.03 to 2.36; P = .031) and ICD-related procedures post-LVAD (subhazard ratio, 1.43; 95% CI, 1.03-1.98; P = .031) were significantly associated with LVAD infections. Infections had no detrimental impact on survival. CONCLUSIONS: Left ventricular assist device-associated infections affect one-third of LVAD recipients, mostly related to skin pathogens and gram-negative bacilli, with increased risk with HeartMate II as compared with HeartWare, and in patients who required ICD-related procedures post-LVAD. This is a plea to better select patients needing ICD implantation/replacement after LVAD implantation.

6.
Arch Cardiovasc Dis ; 112(5): 343-353, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30982720

RESUMO

BACKGROUND: Most data on the epidemiology of cardiogenic shock (CS) have come from patients with acute myocardial infarction admitted to intensive cardiac care units (ICCUs). However, CS can have other aetiologies, and could be managed in intensive care units (ICUs), especially the most severe forms of CS. AIM: To gather data on the characteristics, management and outcomes of patients hospitalized in ICCUs and ICUs for CS, whatever the aetiology, in France in 2016. METHODS: We included all adult patients with CS between April and October 2016 in metropolitan France. CS was defined (at admission or during hospitalization) by: low cardiac output, defined by systolic blood pressure<90mmHg and/or the need for amines to maintain systolic blood pressure>90mmHg and/or cardiac index<2.2L/min/m2; elevation of the left and/or right heart pressures, defined by clinical, radiological, biological, echocardiographic or invasive haemodynamic overload signs; and clinical and/or biological signs of malperfusion (lactate>2mmol/L, hepatic insufficiency, renal failure). RESULTS: Over a 6-month period, 772 patients were included in the survey (mean age 65.7±14.9 years; 71.5% men) from 49 participating centres (91.8% were public, and 77.8% of these were university hospitals). Ischaemic trigger was the most common cause (36.3%). CONCLUSIONS: To date, FRENSHOCK is the largest CS survey; it will provide a detailed and comprehensive global description of the spectrum and management of patients with CS in a high-income country.


Assuntos
Choque Cardiogênico , Idoso , Idoso de 80 Anos ou mais , Unidades de Cuidados Coronarianos , Feminino , França/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Dados Preliminares , Prognóstico , Estudos Prospectivos , Sistema de Registros , Projetos de Pesquisa , Fatores de Risco , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/epidemiologia , Choque Cardiogênico/fisiopatologia , Choque Cardiogênico/terapia , Fatores de Tempo
7.
Crit Care ; 23(1): 2, 2019 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-30616669

RESUMO

BACKGROUND: Prolonged weaning is a major issue in intensive care patients and tracheostomy is one of the last resort options. Optimized patient-ventilator interaction is essential to weaning. The purpose of this study was to compare patient-ventilator synchrony between pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA) in a selected population of tracheostomised patients. METHODS: We performed a prospective, sequential, non-randomized and single-centre study. Two recording periods of 60 min of airway pressure, flow, and electrical activity of the diaphragm during PSV and NAVA were recorded in a random assignment and eight periods of 1 min were analysed for each mode. We searched for macro-asynchronies (ineffective, double, and auto-triggering) and micro-asynchronies (inspiratory trigger delay, premature, and late cycling). The number and type of asynchrony events per minute and asynchrony index (AI) were determined. The two respiratory phases were compared using the non-parametric Wilcoxon test after testing the equality of the two variances (F-Test). RESULTS: Among the 61 patients analysed, the total AI was lower in NAVA than in PSV mode: 2.1% vs 14% (p < 0.0001). This was mainly due to a decrease in the micro-asynchronies index: 0.35% vs 9.8% (p < 0.0001). The occurrence of macro-asynchronies was similar in both ventilator modes except for double triggering, which increased in NAVA. The tidal volume (ml/kg) was lower in NAVA than in PSV (5.8 vs 6.2, p < 0.001), and the respiratory rate was higher in NAVA than in PSV (28 vs 26, p < 0.05). CONCLUSION: NAVA appears to be a promising ventilator mode in tracheotomised patients, especially for those requiring prolonged weaning due to the decrease in asynchronies.


Assuntos
Suporte Ventilatório Interativo/métodos , Vias Neurais/fisiologia , Respiração Artificial/normas , Traqueostomia/métodos , Idoso , Feminino , França , Humanos , Suporte Ventilatório Interativo/instrumentação , Suporte Ventilatório Interativo/normas , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/instrumentação , Ventilação não Invasiva/métodos , Respiração com Pressão Positiva/métodos , Estudos Prospectivos , Respiração Artificial/instrumentação , Respiração Artificial/métodos , Índice de Gravidade de Doença , Escala Psicológica Aguda Simplificada , Traqueostomia/normas , Desmame do Respirador/instrumentação , Desmame do Respirador/métodos
8.
Heart Rhythm ; 16(6): 853-860, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30550835

RESUMO

BACKGROUND: The relationships between hemodynamic consequences of premature ventricular contractions (PVCs) and development of premature ventricular contraction-induced cardiomyopathy (PVC-CM) have not been investigated. OBJECTIVE: The purpose of this study was to correlate concealed mechanical bradycardia and/or postextrasystolic potentiation (PEP) to PVC-CM. METHODS: Invasive arterial pressure measurements from 17 patients with PVC-CM and 16 controls with frequent PVCs were retrospectively analyzed. PVCs were considered efficient (ejecting PVCs) when generating a measurable systolic arterial pressure. PEP was defined by a systolic arterial pressure of the post-PVC beat ≥5 mm Hg higher than the preceding sinus beat. Every PVC was analyzed for 10 minutes before ablation, and the electromechanical index (EMi = number of ejecting PVCs/total PVC) and postextrasystolic potentiation index (PEPi = number of PVCs with PEP/total PVC) were calculated. RESULTS: EMi was 29% ± 31% in PVC-CM and 78% ± 20% in controls (P <.0001). PEPi was 41% ± 28% in PVC-CM and 14% ± 10% in controls (P = .001). There was no control in groups of low EMi or high PEPi. EMi and PEPi were not significantly correlated to left ventricular dimensions or function in PVC-CM patients. PVC coupling interval was related to both ejecting PVCs and PEP. CONCLUSION: Patients with PVC-CM more often display nonejecting PVCs and PEP compared to controls.

10.
Medicine (Baltimore) ; 97(40): e12677, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30290655

RESUMO

Geographic variation in admission to the intensive cardiac care unit (ICCU) might question about the efficiency and the equity of the healthcare system. The aim was to explain geographic variation in the rate of admission to ICCU for coronary artery disease (CAD) or heart failure (HF) in France.We conducted a retrospective study based on the French national hospital discharge database. All inpatient stays for CAD or HF with an admission to an ICCU in 2014 were included. We estimated population-based age and sex-standardized ICCU admission rates at the department level. We separately modeled the department-level admission rates for HF and CAD using generalized linear models.In all, 61,010 stays for CAD and 27,828 stays for HF had at least 1 ICCU admission. The ICCU admission rates were explained by the admission rate for CAD, by the diabetes prevalence, by the proportion of the population >75 years, and by the drive time to the ICCU.This work sheds light on the finding of substantial geographic variation in the ICCU admission rates for CAD and HF in France. This variation is explained by both the age and the health status of the population and also by the drive time to the closest ICCU for HF. Moreover, ICCU admission for HF might be more prone to unwarranted variations due to medical practice patterns.


Assuntos
Doença da Artéria Coronariana , Unidades de Cuidados Coronarianos/estatística & dados numéricos , Insuficiência Cardíaca , Admissão do Paciente/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Bases de Dados Factuais , Diabetes Mellitus/epidemiologia , Feminino , França/epidemiologia , Humanos , Tempo de Internação , Masculino , Estudos Retrospectivos , Fatores Socioeconômicos
11.
Presse Med ; 47(9): 804-810, 2018 Sep.
Artigo em Francês | MEDLINE | ID: mdl-30293850

RESUMO

Diagnosis of heart failure is too late. Symptoms of heart failure are non-specific. Brain natriuretic peptides allow the diagnosis of heart failure in pauci-symptomatic patients, with a threshold of 35pg/mL for BNP and 125pg/mL for NT-proBNP. Left ventricular dysfunction, either diastolic or systolic, remains asymptomatic for a long time. In diabetic and/or hypertensive patients, natriuretic peptides, can be used to diagnose asymptomatic left ventricular dysfunction, with a threshold of 125pg/mL NT-proBNP. Treatment blocking the renin-angiotensin-aldosterone system in diabetic patients with NT-proBNP levels of 125pg/mL can prevent onset of heart failure. Screening of subjects at risk of heart failure (diabetics, hypertensive) is possible thanks to natriuretic peptides.


Assuntos
Insuficiência Cardíaca/diagnóstico , Peptídeos Natriuréticos/fisiologia , Biomarcadores/sangue , Medicina Comunitária , Técnicas de Diagnóstico Cardiovascular , Diagnóstico Precoce , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/fisiopatologia , Testes de Função Cardíaca/métodos , Humanos , Peptídeos Natriuréticos/sangue , Disfunção Ventricular Esquerda/sangue , Disfunção Ventricular Esquerda/diagnóstico
12.
Intensive Care Med ; 44(9): 1460-1469, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30136139

RESUMO

PURPOSE: Thrombocytopenia is a frequent and serious adverse event in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. Similarly to postcardiac surgery patients, heparin-induced thrombocytopenia (HIT) could represent the causative underlying mechanism. However, the epidemiology as well as related mortality regarding HIT and VA-ECMO remains largely unknown. We aimed to define the prevalence and associated 90-day mortality of HIT diagnosed under VA-ECMO. METHODS: This retrospective study included patients under VA-ECMO from 20 French centers between 2012 and 2016. Selected patients were hospitalized for more than 3 days with high clinical suspicion of HIT and positive anti-PF4/heparin antibodies. Patients were classified according to results of functional tests as having either Confirmed or Excluded HIT. RESULTS: A total of 5797 patients under VA-ECMO were screened; 39/5797 met the inclusion criteria, with HIT confirmed in 21/5797 patients (0.36% [95% CI] [0.21-0.52]). Fourteen of 39 patients (35.9% [20.8-50.9]) with suspected HIT were ultimately excluded because of negative functional assays. Drug-induced thrombocytopenia tended to be more frequent in Excluded HIT at the time of HIT suspicion (p = 0.073). The platelet course was similar between Confirmed and Excluded HIT (p = 0.65). Mortality rate was 33.3% [13.2-53.5] in Confirmed and 50% [23.8-76.2] in Excluded HIT (p = 0.48). CONCLUSIONS: Prevalence of HIT among patients under VA-ECMO is extremely low at 0.36% with an associated mortality rate of 33.3%, which appears to be in the same range as that observed in patients treated with VA-ECMO without HIT. In addition, HIT was ultimately ruled out in one-third of patients with clinical suspicion of HIT and positive anti-PF4/heparin antibodies.

13.
Turk J Anaesthesiol Reanim ; 46(4): 268-271, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30140532

RESUMO

Objective: Hypotension frequently occurs during spinal anaesthesia (SA), especially in the elderly. This side effect could have a cardiac component per se (myocardial contractility impairment). Two-dimensional (2D) strain and strain rate imaging are new echocardiographic methods allowing an accurate assessment of myocardial function by quantifying myocardial deformation. Allowing quantification of minor myocardial dysfunction not detectable by standard echocardiography, strain imaging could bring new perspective on the cardiac effect of SA. Our objective was to evaluate the effects of SA on left ventricular function assessed by 2D strain echocardiography. Methods: In this prospective observational study, we enrolled 20 patients older than 60 years, who underwent elective lower-limb surgery under SA. Myocardial strain imaging were collected before and 20 minutes after SA (injection of 10 mg of isobaric bupivacaine with 5 µg of sufentanil). Results: We observed an increase in global longitudinal reconnoitering (Δ-0.2±0.3% s-1; p<0.005), whereas left ventricular ejection fraction was not modified by SA. Conclusion: This slight increase in myocardial contractility could be an adaptive mechanism to compensate the preload decrease and limit the blood pressure drop.

14.
Arch Cardiovasc Dis ; 111(10): 601-612, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29903693

RESUMO

Cardiogenic shock (CS) is a major challenge in contemporary cardiology. Despite a better understanding of the pathophysiology of CS, its management has only improved slightly. The prevalence of CS has remained stable over the past decade, but its outcome has seen few improvements, with the 1-month mortality rate still in the range of 40-60%. Inotropes and vasopressors are the first-line therapies for CS, but they are associated with significant hazards, and have well-known deleterious effects. Furthermore, a significant number of patients develop refractory CS with haemodynamic instability, causing critical organ hypoperfusion and/or pulmonary congestion, despite increasing doses of catecholamines. A major change has resulted from the recent advent and availability of potent mechanical circulatory support (MCS) devices. These devices, which ensure sustained blood flow, provide a great and long-awaited opportunity to improve the prognosis of CS. Several efficient MCS devices are now available, including left ventricle-to-aorta circulatory support devices and full pulmonary and circulatory support with venoarterial extracorporeal membrane oxygenation. However, evidence to support their indications, the timing of implantation and the selection of patients and devices is scarce. Because these devices are gaining momentum and are becoming readily available, the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology aims to propose practical algorithms for the use of these devices, to help intensive care unit and cardiac care unit physicians in this complex area, where evidence is limited.


Assuntos
Síndrome Coronariana Aguda/terapia , Circulação Assistida/normas , Cardiologia/normas , Unidades de Terapia Intensiva/normas , Choque Cardiogênico/terapia , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/fisiopatologia , Algoritmos , Circulação Assistida/efeitos adversos , Circulação Assistida/instrumentação , Circulação Assistida/mortalidade , Tomada de Decisão Clínica , Consenso , Técnicas de Apoio para a Decisão , Transplante de Coração/normas , Hemodinâmica , Humanos , Seleção de Pacientes , Recuperação de Função Fisiológica , Fatores de Risco , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Tempo para o Tratamento/normas , Resultado do Tratamento , Função Ventricular
15.
J Intensive Care Med ; : 885066618776937, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29768983

RESUMO

PURPOSE: Extra Corporeal Membrane Oxygenation (ECMO) is used in cases of severe respiratory and/or circulatory failure over periods of several days to several weeks. Its circuitry requires a closely monitored anticoagulation therapy that is empirically supported by activated clotting time (ACT)-a method often associated with large inter- and intraindividual variability. We aimed to compare the measurement of heparin activity with ACT and the direct measurement of the heparin activity (anti-Xa) in a large ECMO population. METHODS: All patients treated by venoarterial or venovenous ECMO in our intensive care unit between January 2014 and December 2015 were prospectively included. A concomitant measurement of the anti-Xa activity and ACT was performed on the same sample collected twice a day (morning-evening) for unfractionated heparin adaptation with an ACT target range of 180 to 220 seconds. RESULTS: One hundred and nine patients (men 69.7%, median age 54 years) treated with ECMO (70.6% venoarterial) were included. Spearman analysis found no correlation between anti-Xa and ACT (ρ < 0.4) from day 1 and worsened over time. Kappa analysis showed no agreement between the respective target ranges of ACT and anti-Xa. CONCLUSIONS: We demonstrate that concomitant measurement of ACT and anti-Xa activity is irrelevant in ECMO patients. Since ACT is poorly correlated with heparin dosage, anti-Xa activity appears to be a more suitable assay for anticoagulation monitoring.

16.
Arch Cardiovasc Dis ; 111(10): 555-563, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29478810

RESUMO

BACKGROUND: Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) occurs more frequently in women, but little is known about its potential specificities according to sex. AIMS: To analyse the incidence, management and 1-year mortality of CS according to sex using the FAST-MI programme. METHODS: The FAST-MI programme consists of four nationwide French surveys carried out 5 years apart from 1995 to 2010, including consecutive patients with AMI over a 1-month period, and with a 1-year follow-up. RESULTS: Among the 10,610 patients included in the surveys, the incidence of CS was 4.8% in men and 8.2% in women (P<0.001). Absolute incidence of CS decreased from 1995 to 2010 in both sexes. Mean age in patients with CS tended to decrease in men (from 72±12 to 69±13 years) and to increase in women (from 78±10 to 80±9 years). One-year mortality decreased significantly in men (from 70% in 1995 to 48% in 2010) and in women (from 81% to 54%). Using Cox multivariable analysis, female sex was not an independent correlate of 1-year mortality [hazard ratio (HR): 0.98, 95% confidence interval (CI): 0.78-1.22]. Early use of percutaneous coronary intervention was, however, an independent predictor of 1-year survival in women (HR: 0.55, 95% CI: 0.37-0.81), but showed only a non-significant trend in men (HR: 0.85, 95% CI: 0.61-1.19). CONCLUSIONS: The incidence of CS-AMI has decreased in both men and women, but remains higher in women. One-year mortality has significantly decreased for both men and women, and the role of early percutaneous coronary intervention as a potential mediator of decreased mortality seems greater in women than in men.


Assuntos
Nível de Saúde , Disparidades em Assistência à Saúde/tendências , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/tendências , Choque Cardiogênico/epidemiologia , Choque Cardiogênico/terapia , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Feminino , França/epidemiologia , Pesquisas sobre Serviços de Saúde , Humanos , Incidência , Estimativa de Kaplan-Meier , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Razão de Chances , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Prevalência , Modelos de Riscos Proporcionais , Fatores de Risco , Fatores Sexuais , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Fatores de Tempo , Resultado do Tratamento
17.
Int J Cardiol ; 253: 105-112, 2018 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-29306448

RESUMO

AIMS: Giant-cell myocarditis (GCM) is a rare and often fatal form of myocarditis. Only a few reports have focused on fulminant forms. We describe the clinical characteristics, management and outcomes of GCM patients rescued by mechanical circulatory support (MCS). METHODS AND RESULTS: The clinical features, diagnoses, treatments and outcomes of MCS-treated patients in refractory cardiogenic shock secondary to fulminant GCM admitted to eight French intensive care units (2002-2016) were analysed. We also conducted a systematic review of this topic. Thirteen patients (median age 44 [range 21-76]years, Simplified Acute Physiology Score II 55 [40-79]) in severe cardiogenic shock (median [range] left ventricular ejection fraction 15% [15-35%] and blood lactate 4 mmol/L) were placed on MCS 4 [0-28]days after hospital admission. Severe arrhythmic disturbances were frequent (77%), with six (46%) patients experiencing an electrical storm prior to MCS. Venoarterial extracorporeal membrane oxygenation was the first MCS option for 11 (85%) patients. GCM was diagnosed in five (38%) patients before transplant or death and treated with immunosuppressants; infections were the main complication (80%). Four patients died on MCS and no patient presented long-term survival free from heart transplant (nine patients, 69%). All transplanted patients were alive 1year later and no GCM recurrence was reported after median follow-up of 42 [12-145]months. CONCLUSION: Outcomes of fulminant GCMs may differ from those of milder forms. In this context, heart transplant might likely be the only long-term survival option.


Assuntos
Gerenciamento Clínico , Oxigenação por Membrana Extracorpórea/métodos , Células Gigantes , Miocardite/epidemiologia , Miocardite/terapia , Adulto , Idoso , Estudos de Coortes , Oxigenação por Membrana Extracorpórea/tendências , França/epidemiologia , Células Gigantes/patologia , Coração Auxiliar/tendências , Humanos , Pessoa de Meia-Idade , Miocardite/diagnóstico , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
18.
Arch Cardiovasc Dis ; 111(11): 678-685, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29290598

RESUMO

BACKGROUND: Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) remains a major concern. Failure of the left ventricular (LV) pump is the primary insult in most forms of CS, but other parts of the circulatory system and diastolic function contribute to shock. However, little is known of the clinical presentation, management and outcomes according to LV function in these patients. OBJECTIVES: To assess the presentation, management and clinical outcomes in patients admitted for AMI with CS according to early LV ejection fraction (LVEF), using long-term data from the French registry of Acute ST-elevation or non-ST-elevation Myocardial Infarction (FAST-MI) 2010. METHODS: We analysed baseline characteristics, management and 3-year mortality in patients with CS, according to LVEF (≤40% vs>40%). The analyses were replicated in the FAST-MI 2005 cohort. RESULTS: Among 4169 patients with AMI included in the survey, the incidence of CS was 3.3%. LVEF was>40% in 43%. Early PCI (≤24hours) was used more often in patients with LV dysfunction (61% vs 42%), as was the use of optimal medical therapy at discharge (66% vs 40%). CS remained associated with a major increase in 3-year mortality, both in patients with LVEF ≤40% (55%) and in those with LVEF>40% (44%). Using Cox multivariable analysis, LVEF ≤40% was associated with higher 3-year mortality (hazard ratio 2.08, 95% confidence interval 1.15-3.78) in patients with AMI with CS. Consistent results were found in the replication cohort. CONCLUSIONS: Despite the many circulatory system contributors to the physiopathology of CS in patients with AMI, the occurrence of early LV systolic dysfunction is associated with higher long-term mortality.

19.
Curr Vasc Pharmacol ; 16(5): 418-426, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29345584

RESUMO

Cardiogenic Shock (CS) is a major challenge in current cardiology. Over the last decade, cardiogenic shock mortality has decreased somewhat, but it still remains high, particularly when associated with ischaemic heart disease. The challenges are numerous and include prevention, accurate diagnosis, prompt management and effective therapies to support a failing heart and prevent multi-organ failure. Despite improvements in the care of Acute Coronary Syndrome (ACS), it remains the most common cause of CS. In addition to existing medical therapy, mechanical circulatory support has been proposed for the management of ventricular failure. The intra-aortic balloon pump was amongst the first widely used percutaneous mechanical support devices, and more recently, systems providing a higher level of support have been developed. Although the evidence supporting their use is limited, they have the potential to significantly reduce CS-associated mortality. In this narrative review, we summarize the available evidence and discuss the future directions regarding percutaneous mechanical circulatory support in patients with left ventricular dysfunction and CS complicating ACS.

20.
Injury ; 49(3): 538-542, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29162266

RESUMO

BACKGROUND: Metabolic response to severe trauma requires early nutritional resuscitation. Carnitine is essential for lipolysis, the energy source during this hypercatabolic phase. However l-carnitine is not present in nutritional replacement solutions. Furthermore, free carnitine depletion, defined as carnitine plasma level under 36µmol/L, was not adequately reported in adult patients with severe trauma. The aim of this study was to assess plasma free carnitine levels and factors of variation in severe trauma. METHOD: Our observational study concerned 38 trauma patients including 18 with traumatic brain injury (TBI). On the third day after trauma, plasma free carnitine concentration was determined (by enzymatic method) while patients received artificial nutrition. RESULTS: Low plasmatic free carnitine concentration was evidenced in 95% of the patients with a median value of 18µmol/L (11-47). Univariate analysis showed that mean arterial pressure, serum urea, CKD-EPI and patients with TBI were significantly associated with plasma free carnitine concentration less than 18µmol/L. Lower plasma free carnitine concentration was observed in the group of patients with TBI with 17.72µmol/L (11-36) versus 21.5µmol/L (11-47) for others patients (p=0.031). Logistic regression analysis showed that severe trauma with TBI and CKD-EPI above 94mL/min/1.73m2 appeared to be independent predictor of lower free carnitine plasmatic concentration (Goodness of fit=0.87 and AUC=0.89). CONCLUSION: Our observations support hypotheses that plasma free carnitine concentration is lowered in severe injured patients especially for TBI patients and patients with estimated GFR above 94mL/min/1.73m2.


Assuntos
Lesões Encefálicas Traumáticas/metabolismo , Carnitina/metabolismo , Terapia Nutricional , Adolescente , Adulto , Idoso , Área Sob a Curva , Biomarcadores/metabolismo , Lesões Encefálicas Traumáticas/fisiopatologia , Lesões Encefálicas Traumáticas/terapia , Ensaios Enzimáticos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estado Nutricional , Índices de Gravidade do Trauma , Adulto Jovem
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