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1.
J Cardiothorac Surg ; 15(1): 295, 2020 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-33008478

RESUMO

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being utilized in patients with massive pulmonary embolism (PE). However, the efficacy and the safety remain uncertain. This study aimed to investigate clinical courses and outcomes in ECMO-treated patients with acute PE. METHODS: Twenty-one patients with acute PE rescued by ECMO from January 2012 to December 2019 were retrospectively analysed. Clinical features, laboratory biomarkers, and imaging findings of these patients were reviewed, and the relationship with immediate outcome and clinical course was investigated. RESULTS: Sixteen patients (76.2%) experienced refractory circulatory collapse requiring cardiopulmonary resuscitation (CPR) or ECMO support within 2 h after the onset of cardiogenic shock, and none could receive definitive reperfusion therapy before ECMO initiation. Before or during ECMO support, more than 90% of patients had imaging signs of right ventricular (RV) dysfunction. In normotension patients, the computed tomography (CT) value was a valuable predictor of rapid disease progression compared with cardiac troponin I level. Ultimately, in-hospital death occurred in ten patients (47.6%) and 90% of them died of prolonged CPR-related brain death. Cardiac arrest was a significant predictor of poor prognosis (p = 0.001). CONCLUSIONS: ECMO appears to be a safe and effective circulatory support in patients with massive PE. Close monitoring in intensive care unit is recommended in patients with RV dysfunction and aggressive use of ECMO may reduce the risk of sudden cardiac arrest and improve clinical outcome.


Assuntos
Oxigenação por Membrana Extracorpórea , Embolia Pulmonar/terapia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Morte Encefálica , Reanimação Cardiopulmonar , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/complicações , Reperfusão , Estudos Retrospectivos , Choque Cardiogênico/terapia , Tomografia Computadorizada por Raios X , Disfunção Ventricular Direita/etiologia
2.
Emerg Med Clin North Am ; 38(4): 841-856, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981621
3.
Emerg Med Clin North Am ; 38(4): 945-959, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981628

RESUMO

Extracorporeal membrane oxygenation (ECMO) is a mechanical way to provide oxygenation, ventilation, and perfusion to patients with severe cardiopulmonary failure. Extracorporeal cardiopulmonary resuscitation (ECPR) describes the use of ECMO during cardiac arrest. ECPR requires an organized approach to resuscitation, cannula insertion, and pump initiation. Selecting the right patients for ECPR is an important aspect of successful programs. A solid understanding of the components of the ECMO circuit is critical to troubleshooting problems. Current evidence suggests a substantial benefit of ECPR compared with traditional CPR for refractory cardiac arrest but is limited by lack of randomized trials to date.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Débito Cardíaco , Contraindicações de Procedimentos , Serviço Hospitalar de Emergência , Parada Cardíaca/terapia , Humanos , Seleção de Pacientes , Insuficiência Respiratória/terapia , Ressuscitação/métodos , Choque Cardiogênico/terapia
4.
Yonsei Med J ; 61(10): 851-859, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32975059

RESUMO

PURPOSE: Thrombocytopenia (platelet count <150×10³/µL) is associated with poor outcomes in various critical illness settings. However, the prognostic value of platelet count in patients with cardiogenic shock (CS) remains unclear. MATERIALS AND METHODS: We enrolled 1202 patients between January 2014 and December 2018 from a multicenter retrospective-prospective cohort registry of CS. Clinical characteristics and treatment outcomes were compared between the patients with and without thrombocytopenia. RESULTS: At presentation with CS, 244 (20.3%) patients had thrombocytopenia. The patients with thrombocytopenia had lower blood pressure, hemoglobin level, and worse liver and renal functions compared to the patients without. During hospitalization, the patients with thrombocytopenia had more frequent gastrointestinal bleeding (10.5% vs. 3.8%, p=0.009), sepsis (8.3% vs. 2.6%, p=0.013), requirement of renal replacement therapy (36.5% vs. 18.9%, p<0.001), requirement of mechanical ventilation (65.2% vs. 54.4%, p=0.003), longer intensive care unit stay (8 days vs. 4 days, p<0.001), and thirty-day mortality (40.2% vs. 28.5%, p<0.001) compared to those without. In addition, the platelet count was an independent predictor of 30-day mortality (per 103/µL decrease; adjusted hazard ratio: 1.002, 95% confidence interval: 1.000-1.003, p=0.021). CONCLUSION: Thrombocytopenia at CS presentation was associated with worse clinical findings, higher frequencies of complications, and longer stay at the intensive care unit. Also, thrombocytopenia was independently associated with increased 30-day mortality. (Clinical trial registration No. NCT02985008).


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Choque Cardiogênico , Trombocitopenia , Adulto , Idoso , Estudos de Casos e Controles , Estudos de Coortes , Estado Terminal , Feminino , Hemorragia Gastrointestinal/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Contagem de Plaquetas , Prevalência , Prognóstico , Estudos Prospectivos , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Sepse/sangue , Sepse/epidemiologia , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Trombocitopenia/diagnóstico , Trombocitopenia/mortalidade , Trombocitopenia/terapia , Resultado do Tratamento
5.
Cardiol Rev ; 28(6): 308-311, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32941261

RESUMO

Cardiac involvement as a complication of severe acute respiratory syndrome coronavirus 2 infection in children is a relatively new entity. We present our initial experience managing children with coronavirus disease 2019-related acute myocardial injury. The 3 patients presented here represent a spectrum of the cardiac involvement noted in children with coronavirus disease 2019-related multisystem inflammatory syndrome, including myocarditis presenting as cardiogenic shock or heart failure with biventricular dysfunction, valvulitis, coronary artery changes, and pericardial effusion.


Assuntos
Betacoronavirus , Infecções por Coronavirus , Insuficiência Cardíaca , Doenças das Valvas Cardíacas , Miocardite , Pandemias , Administração dos Cuidados ao Paciente/métodos , Derrame Pericárdico , Pneumonia Viral , Síndrome de Resposta Inflamatória Sistêmica , Adolescente , Betacoronavirus/isolamento & purificação , Betacoronavirus/patogenicidade , Técnicas de Imagem Cardíaca/métodos , Criança , Pré-Escolar , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/terapia , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/virologia , Humanos , Miocardite/terapia , Miocardite/virologia , Derrame Pericárdico/terapia , Derrame Pericárdico/virologia , Pneumonia Viral/diagnóstico , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Síndrome de Resposta Inflamatória Sistêmica/diagnóstico , Síndrome de Resposta Inflamatória Sistêmica/fisiopatologia , Síndrome de Resposta Inflamatória Sistêmica/terapia , Resultado do Tratamento
6.
BMC Cardiovasc Disord ; 20(1): 389, 2020 08 26.
Artigo em Inglês | MEDLINE | ID: mdl-32842957

RESUMO

BACKGROUND: Fulminant (life-threatening) COVID-19 can be associated with acute respiratory failure (ARF), multi-system organ failure and cytokine release syndrome (CRS). We present a rare case of fulminant COVID-19 associated with reverse-takotsubo-cardiomyopathy (RTCC) that improved with therapeutic plasma exchange (TPE). CASE PRESENTATION: A 40 year old previous healthy male presented in the emergency room with 4 days of dry cough, chest pain, myalgias and fatigue. He progressed to ARF requiring high-flow-nasal-cannula (flow: 60 L/minute, fraction of inspired oxygen: 40%). Real-Time-Polymerase-Chain-Reaction (RT-PCR) assay confirmed COVID-19 and chest X-ray showed interstitial infiltrates. Biochemistry suggested CRS: increased C-reactive protein, lactate dehydrogenase, ferritin and interleukin-6. Renal function was normal but lactate levels were elevated. Electrocardiogram demonstrated non-specific changes and troponin-I levels were slightly elevated. Echocardiography revealed left ventricular (LV) basal and midventricular akinesia with apex sparing (LV ejection fraction: 30%) and depressed cardiac output (2.8 L/min) consistent with a rare variant of stress-related cardiomyopathy: RTCC. His ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen was < 120. He was admitted to the intensive care unit (ICU) for mechanical ventilation and vasopressors, plus antivirals (lopinavir/ritonavir), and prophylactic anticoagulation. Infusion of milrinone failed to improve his cardiogenic shock (day-1). Thus, rescue TPE was performed using the Spectra Optia™ Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA) without protective antibodies. Over 5 days he received daily TPE (each lasting 4 hours). His lactate levels, oxygenation, and LV function normalized and he was weaned off vasopressors. His inflammation markers improved, and he was extubated on day-7. RT-PCR was negative on day-17. He was discharged to home isolation in good condition. CONCLUSION: Stress-cardiomyopathy may complicate the course of fulminant COVID-19 with associated CRS. If inotropic therapy fails, TPE without protective antibodies may help rescue the critically ill patient.


Assuntos
Antivirais/uso terapêutico , Cardiotônicos/uso terapêutico , Infecções por Coronavirus/terapia , Síndrome da Liberação de Citocina/terapia , Troca Plasmática , Pneumonia Viral/terapia , Síndrome do Desconforto Respiratório do Adulto/terapia , Choque Cardiogênico/terapia , Cardiomiopatia de Takotsubo/terapia , Adulto , Betacoronavirus , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/tratamento farmacológico , Síndrome da Liberação de Citocina/complicações , Síndrome da Liberação de Citocina/diagnóstico , Combinação de Medicamentos , Ecocardiografia , Humanos , Lopinavir/uso terapêutico , Masculino , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/etiologia , Ritonavir/uso terapêutico , Choque Cardiogênico/etiologia , Cardiomiopatia de Takotsubo/diagnóstico por imagem , Cardiomiopatia de Takotsubo/etiologia
7.
PLoS One ; 15(8): e0238046, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32833995

RESUMO

BACKGROUND: There are limited data on the complications with a percutaneous left ventricular assist device (pLVAD) vs. intra-aortic balloon pump (IABP) in acute myocardial infarction-cardiogenic shock (AMI-CS). OBJECTIVE: To assess the trends, rates and predictors of complications. METHODS: Using a 17-year AMI-CS population from the National Inpatient Sample, AMI-CS admissions receiving pLVAD and IABP support were evaluated for vascular, lower limb amputation, hematologic, neurologic and acute kidney injury (AKI) complications. In-hospital mortality, hospitalization costs and length of stay in pLVAD and IABP cohorts with complications was studied. RESULTS: Of 168,645 admissions, 7,855 (4.7%) receiving pLVAD support. The pLVAD cohort had higher comorbidity, cardiac arrest (36.1% vs. 29.7%) and non-cardiac organ failure (74.7% vs. 56.9%) rates. Complications were higher in pLVAD compared to IABP cohort-overall 69.0% vs. 54.7%; vascular 3.8% vs. 2.1%; lower limb amputation 0.3% vs. 0.3%; hematologic 36.0% vs. 27.7%; neurologic 4.9% vs. 3.5% and AKI 55.4% vs. 39.1% (all p<0.001 except for amputation). Non-White race, higher comorbidity, organ failure, and extracorporeal membrane oxygen use were predictors of complications for both cohorts. The pLVAD cohort with complications had higher in-hospital mortality (45.5% vs. 33.1%; adjusted odds ratio 1.65 [95% confidence interval 1.55-1.75]), shorter duration of hospital stay, and higher hospitalization costs compared to the IABP cohort with complications (all p<0.001). These results were consistent in propensity-matched pairs. CONCLUSIONS: AMI-CS admissions receiving pLVAD had higher rates of complications compared to the IABP, with worse in-hospital outcomes in the cohort with complications.


Assuntos
Coração Auxiliar/efeitos adversos , Balão Intra-Aórtico/efeitos adversos , Infarto do Miocárdio/complicações , Complicações Pós-Operatórias/etiologia , Choque Cardiogênico/complicações , Choque Cardiogênico/cirurgia , Doença Aguda , Idoso , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Choque Cardiogênico/terapia
8.
Lancet ; 396(10250): 545-552, 2020 08 22.
Artigo em Inglês | MEDLINE | ID: mdl-32828186

RESUMO

BACKGROUND: Patients with sepsis-induced cardiomyopathy with cardiogenic shock have a high mortality. This study assessed venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for sepsis-induced cardiogenic shock refractory to conventional treatments. METHODS: In this retrospective, multicentre, international cohort study, we compared outcomes of 82 patients (aged ≥18 years) with septic shock who received VA-ECMO at five academic ECMO centres, with 130 controls (not receiving ECMO) obtained from three large databases of septic shock. All patients had severe myocardial dysfunction (cardiac index 3 L/min per m2 or less or left ventricular ejection fraction [LVEF] 35% or less) and severe haemodynamic compromise (inotrope score at least 75 µg/kg per min or lactic acidaemia at least 4 mmol/L) at time of inclusion. The primary endpoint was survival at 90 days. A propensity score-weighted analysis was done to control for confounders. FINDINGS: At baseline, patients treated with VA-ECMO had more severe myocardial dysfunction (mean cardiac index 1·5 L/min per m2vs 2·2 L/min per m2, LVEF 17% vs 27%), more severe haemodynamic impairment (inotrope score 279 µg/kg per min vs 145 µg/kg per min, lactataemia 8·9 mmol/L vs 6·5 mmol/L), and more severe organ failure (Sequential Organ Failure Assessment score 17 vs 13) than did controls, with p<0·0001 for each comparison. Survival at 90 days for patients treated with VA-ECMO was significantly higher than for controls (60% vs 25%, risk ratio [RR] for mortality 0·54, 95% CI [0·40-0·70]; p<0·0001). After propensity score weighting, ECMO remained associated with improved survival (51% vs 14%, adjusted RR for mortality 0·57, 95% CI [0·35-0·93]; p=0·0029). Lactate and catecholamine clearance were also significantly enhanced in patients treated with ECMO. Among the 49 survivors treated with ECMO, 32 who had been treated at the largest centre reported satisfactory Short Form-36 evaluated health-related quality of life at 1-year follow-up. INTERPRETATION: Patients with severe sepsis-induced cardiogenic shock treated with VA-ECMO had a large and significant improvement in survival compared with controls not receiving ECMO. However, despite the careful propensity-weighted analysis, we cannot rule out unmeasured confounders. FUNDING: None.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Choque Cardiogênico/terapia , Choque Séptico/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Qualidade de Vida , Estudos Retrospectivos , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Resultado do Tratamento
9.
J Korean Med Sci ; 35(27): e258, 2020 Jul 13.
Artigo em Inglês | MEDLINE | ID: mdl-32657091

RESUMO

A 60-year-old male patient with coronavirus disease-2019 showed new onset ST-segment elevation in V1-V2 leads on electrocardiogram and cardiac enzyme elevation in intensive care unit. He had a history of type 2 diabetes mellitus, hypertension, and dyslipidemia. He was receiving mechanical ventilation and veno-venous extracorporeal membrane oxygenation treatment for severe hypoxia. Two-D echocardiogram showed regional wall motion abnormalities. We performed primary percutaneous coronary intervention for acute myocardial infarction complicating cardiogenic shock under hemodynamic support. He expired on the 16th day of admission because of cardiogenic shock and multi-organ failure. Active surveillance and intensive treatment strategy are important for saving lives of COVID-19 patients with acute myocardial infarction.


Assuntos
Infecções por Coronavirus/patologia , Intervenção Coronária Percutânea/métodos , Pneumonia Viral/patologia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Betacoronavirus , Eletrocardiografia , Oxigenação por Membrana Extracorpórea , Humanos , Hipóxia/terapia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Pandemias , Choque Cardiogênico/complicações
11.
Medicine (Baltimore) ; 99(29): e21272, 2020 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-32702916

RESUMO

There are limited data regarding the association between brain natriuretic peptide (BNP) levels obtained after weaning from extracorporeal membrane oxygenation (ECMO) and the outcomes of patients with acute coronary syndrome (ACS)-associated cardiogenic shock.We prospectively obtained data regarding patients (aged ≥ 19 years) with ACS-associated cardiogenic shock who received ECMO and were subsequently weaned off the treatment. BNP levels were collected at 5 time points: pre-ECMO implantation, post-ECMO implantation, pre-ECMO weaning, day 1 after ECMO weaning, and day 5 after ECMO weaning.Of 48 patients with ACS-related cardiogenic shock, 33 were included in this analysis. Mean patient age was 59.0 (50.0-66.5) years, and 5 patients (15.2%) were women. Eight patients had asystole/pulseless electrical activity before ECMO and 14 (42.4%) had 3-vessel disease on coronary angiography. During the 6-month follow up, 12 (36.4%) patients died. BNP levels after ECMO weaning were significantly different between 6-month survivors and non-survivors. Cox proportional hazards model revealed that BNP levels (tertiles) on days 1 and 5 after ECMO weaning were significantly associated with 6-month mortality (hazard ratio, 7.872; 95% confidence interval, 1.870-32.756; 8.658 and 1.904-39.365, respectively). According to the Kaplan-Meier curves, the first tertile had significantly longer survival compared to the third tertile for both days 1 and 5 after ECMO weaning.Post-ECMO weaning BNP levels (days 1 and 5) were significantly associated with increased 6-month mortality in patients with ACS complicated by refractory cardiogenic shock who were weaned off ECMO.


Assuntos
Oxigenação por Membrana Extracorpórea , Peptídeo Natriurético Encefálico/sangue , Choque Cardiogênico/mortalidade , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/mortalidade , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores de Risco , Choque Cardiogênico/sangue , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia
12.
Lancet ; 396(10245): 199-212, 2020 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-32682486

RESUMO

Cardiogenic shock can occur due to acute ischaemic or non-ischaemic cardiac events, or from progression of long-standing underlying heart disease. When addressing the cause of underlying disease, the management of cardiogenic shock consists of vasopressors and inotropes; however, these agents can increase myocardial oxygen consumption, impair tissue perfusion, and are frequently ineffective. An alternative approach is to temporarily augment cardiac output using mechanical devices. The use of these devices-known as temporary circulatory support systems-has increased substantially in recent years, despite being expensive, resource intensive, associated with major complications, and lacking high-quality evidence to support their use. This Review summarises the physiological basis underlying the use of temporary circulatory support for cardiogenic shock, reviews the evidence informing indications and contraindications, addresses ethical considerations, and highlights the need for further research.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Balão Intra-Aórtico/métodos , Choque Cardiogênico/terapia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Coração Auxiliar/efeitos adversos , Humanos , Balão Intra-Aórtico/efeitos adversos
13.
Methodist Debakey Cardiovasc J ; 16(2): 158-161, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32670477

RESUMO

The incidence of primary cardiac tumors is exceedingly rare, whereas secondary cardiac tumors are more common in the global population. Cardiac involvement is seen in approximately 18% of patients with non-Hodgkin's lymphoma at the time of autopsy. Clinical manifestations of cardiac involvement are subtle and often go unrecognized until advanced stages of the disease. We present a rare case of metastatic cardiac lymphoma that presented as an ST-segment elevation myocardial infarction complicated by left ventricular free wall rupture and cardiogenic shock due to transmural myocardial necrosis from malignant cell infiltration.


Assuntos
Neoplasias Cardíacas/complicações , Ruptura Cardíaca Pós-Infarto/etiologia , Linfoma Extranodal de Células T-NK/complicações , Miocárdio/patologia , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Choque Cardiogênico/etiologia , Evolução Fatal , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/patologia , Neoplasias Cardíacas/terapia , Ruptura Cardíaca Pós-Infarto/diagnóstico por imagem , Ruptura Cardíaca Pós-Infarto/patologia , Ruptura Cardíaca Pós-Infarto/terapia , Humanos , Linfoma Extranodal de Células T-NK/diagnóstico por imagem , Linfoma Extranodal de Células T-NK/patologia , Linfoma Extranodal de Células T-NK/terapia , Necrose , Recidiva , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/patologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/terapia
14.
Rev Med Chil ; 148(3): 409-413, 2020 Mar.
Artigo em Espanhol | MEDLINE | ID: mdl-32730388

RESUMO

We report a 55-year-old woman with a history of hypothyroidism and type 2 diabetes mellitus who consulted at the emergency room because of intermittent oppressive chest discomfort. At admission, electrocardiogram showed a complete atrioventricular block. A transthoracic echocardiogram disclosed severe left ventricular dysfunction. The patient developed cardiogenic shock that required the installation of the Impella system. An emergency coronary angiography showed an ostial occlusion of the anterior descending artery. Despite successful primary angioplasty, she persisted with refractory shock and progressive hypoxemia. A concomitant connection to the extracorporeal membrane oxygenation system (ECMO) was decided. The support of both devices allowed the stabilization of the patient and the improvement of perfusion parameters.


Assuntos
Coração Auxiliar , Choque Cardiogênico/terapia , Disfunção Ventricular Esquerda , Diabetes Mellitus Tipo 2 , Oxigenação por Membrana Extracorpórea , Feminino , Humanos , Pessoa de Meia-Idade
15.
Am J Cardiol ; 128: 127-133, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650906

RESUMO

We sought to study the feasibility of axillary artery as alternative access for mechanical circulatory support (MCS) in cardiogenic shock and high-risk percutaneous coronary intervention (HR-PCI) patients with severe occlusive peripheral artery disease (PAD). In patients with severe PAD, the iliofemoral artery may be so diseased preventing deployment of MCS, precluding the use of lifesaving therapy. In such circumstances, the axillary artery may be a viable access site. Records of all patients presenting with cardiogenic shock or HR-PCI requiring MCS through axillary artery access at our institution from January 2016 to September 2018 were examined. Demographics, clinical, procedural, and outcomes data were collected on all patients. A total of 48 patients presented with cardiogenic shock (60%) or HR-PCI (40%) requiring MCS via axillary artery due to prohibitive PAD (mean age 66 ± 11 years). Admission diagnoses were non-ST segment elevation myocardial infarction (38%), unstable angina (23%), ST segment elevation myocardial infarction (19%), and cardiac arrest (21%). Time from axillary access to activation of Impella was 11.9 ± 4 minutes. Four patients required concomitant Impella RP for right ventricular support due to biventricular cardiogenic shock. Twenty-two patients died before Impella was explanted due to multiorgan failure, stroke, and infection. None of the patients who died had vascular complications related to axillary access. Axillary artery appears to be a viable alternative access for large bore devices in patients with prohibitive PAD. As experience of the field with this approach grows, it may be the default access for deployment of large bore sheaths in the future.


Assuntos
Angina Instável/terapia , Artéria Axilar , Parada Cardíaca/terapia , Coração Auxiliar , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Choque Cardiogênico/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angina Instável/complicações , Estudos de Viabilidade , Feminino , Artéria Femoral , Parada Cardíaca/complicações , Humanos , Artéria Ilíaca , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/complicações , Doença Arterial Periférica/complicações , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Choque Cardiogênico/etiologia , Volume Sistólico , Adulto Jovem
16.
Cochrane Database Syst Rev ; 6: CD013002, 2020 06 04.
Artigo em Inglês | MEDLINE | ID: mdl-32496607

RESUMO

BACKGROUND: Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion due to a primary cardiac disorder. For people with refractory CS despite maximal vasopressors, inotropic support and intra-aortic balloon pump, mortality approaches 100%. Mechanical assist devices provide mechanical circulatory support (MCS) which has the ability to maintain vital organ perfusion, to unload the failing ventricle thus reduce intracardiac filling pressures which reduces pulmonary congestion, myocardial wall stress and myocardial oxygen consumption. This has been hypothesised to allow time for myocardial recovery (bridge to recovery) or allow time to come to a decision as to whether the person is a candidate for a longer-term ventricular assist device (VAD) either as a bridge to heart transplantation or as a destination therapy with a long-term VAD. OBJECTIVES: To assess whether mechanical assist devices improve survival in people with acute cardiogenic shock. SEARCH METHODS: We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and Web of Science Core Collection in November 2019. In addition, we searched three trials registers in August 2019. We scanned reference lists and contacted experts in the field to obtain further information. There were no language restrictions. SELECTION CRITERIA: Randomised controlled trials on people with acute CS comparing mechanical assist devices with best current intensive care management, including intra-aortic balloon pump and inotropic support. DATA COLLECTION AND ANALYSIS: We performed data collection and analysis according to the published protocol. Primary outcomes were survival to discharge, 30 days, 1 year and secondary outcomes included, quality of life, major adverse cardiovascular events (30 days/end of follow-up), dialysis-dependent (30 days/end of follow-up), length of hospital stay and length of intensive care unit stay and major adverse events. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta-analyses for the prespecified outcomes Summary statistics for the primary endpoints were risk ratios (RR), hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs). MAIN RESULTS: The search identified five studies from 4534 original citations reviewed. Two studies included acute CS of all causes randomised to treatment using TandemHeart percutaneous VAD and three studies included people with CS secondary to acute myocardial infarction who were randomised to Impella CP or best medical management. Meta-analysis was performed only to assess the 30-day survival as there were insufficient data to perform any further meta-analyses. The results from the five studies with 162 participants showed mechanical assist devices may have little or no effect on 30-day survival (RR of 1.01 95% CI 0.76 to 1.35) but the evidence is very uncertain. Complications such as sepsis, thromboembolic phenomena, bleeding and major adverse cardiovascular events were not infrequent in both the MAD and control group across the studies, but these could not be pooled due to inconsistencies in adverse event definitions and reporting. We identified four randomised control trials assessing mechanical assist devices in acute CS that are currently ongoing. AUTHORS' CONCLUSIONS: There is no evidence from this review of a benefit from MCS in improving survival for people with acute CS. Further use of the technology, risk stratification and optimising the use protocols have been highlighted as potential reasons for lack of benefit and are being addressed in the current ongoing clinical trials.


Assuntos
Coração Auxiliar , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Doença Aguda , Unidades de Cuidados Coronarianos/estatística & dados numéricos , Coração Auxiliar/efeitos adversos , Humanos , Tempo de Internação , Qualidade de Vida , Diálise Renal/estatística & dados numéricos
17.
Am Heart J ; 225: 55-59, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32474205

RESUMO

Cardiogenic shock (CS) complicating acute myocardial infarction (MI) is associated with high mortality. In the absence of data to support coronary revascularization beyond the infarct artery and selection of circulatory support devices or medications, clinical practice may vary substantially. METHODS: We distributed a survey to interventional cardiologists and cardiothoracic surgeons through relevant professional societies to determine contemporary coronary revascularization and circulatory support strategies for MI with CS and multi-vessel coronary artery disease (CAD). RESULTS: A total of 143 participants completed the survey between 1/2019 and 8/2019. Overall, 55.2% of participants reported that the standard approach to coronary revascularization was single vessel PCI of the infarct related artery (IRA) with staged PCI of non-culprit lesions. Single vessel PCI of the IRA only (28.0%), emergency multi-vessel PCI (11.9%), and coronary artery bypass grafting (CABG) (4.9%) were standard approaches at some centers. A plurality of survey respondents (46.9%) believed initial PCI with staged CABG for multi-vessel CAD would be associated with the most favorable outcomes. A minority of respondents believed PCI-only strategies (23.1%) and CABG alone (6.3%) provided optimal care, and 23.1% were unsure of the best strategy. After PCI for CS, Impella (76.9%), intra-aortic balloon pump (IABP) (12.8%), and extra-corporeal membrane oxygenation (ECMO) (7.7%) were preferred. After CABG, IABP (34.3%), Impella (32.2%), and ECMO (28%) were preferred. CONCLUSIONS: This survey indicates substantial heterogeneity in clinical care in CS. There is evidence of provider uncertainty and clinical equipoise regarding the optimal management of patients with MI, multi-vessel CAD, and CS. SHORT ABSTRACT: We sought to determine contemporary practice patterns of coronary revascularization and circulatory support in patients with MI, multi-vessel coronary artery disease (CAD), and cardiogenic shock. A survey was distributed to interventional cardiologists and cardiothoracic surgeons through relevant professional societies. Survey respondents identified substantial heterogeneity in clinical care and evidence of provider uncertainty and clinical equipoise regarding the optimal management of patients with MI, multi-vessel CAD, and CS.


Assuntos
Ponte de Artéria Coronária/estatística & dados numéricos , Doença da Artéria Coronariana/terapia , Infarto do Miocárdio/terapia , Revascularização Miocárdica/métodos , Intervenção Coronária Percutânea/estatística & dados numéricos , Padrões de Prática Médica , Choque Cardiogênico/terapia , Cardiotônicos/uso terapêutico , Catecolaminas/uso terapêutico , Terapia Combinada , Doença da Artéria Coronariana/complicações , Pesquisas sobre Serviços de Saúde , Humanos , Internacionalidade , Infarto do Miocárdio/complicações , Revascularização Miocárdica/normas , Padrões de Prática Médica/estatística & dados numéricos , Choque Cardiogênico/etiologia
18.
Circ Heart Fail ; 13(7): e007220, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32500721

RESUMO

The novel coronavirus disease 2019, otherwise known as COVID-19, is a global pandemic with primary respiratory manifestations in those who are symptomatic. It has spread to >187 countries with a rapidly growing number of affected patients. Underlying cardiovascular disease is associated with more severe manifestations of COVID-19 and higher rates of mortality. COVID-19 can have both primary (arrhythmias, myocardial infarction, and myocarditis) and secondary (myocardial injury/biomarker elevation and heart failure) cardiac involvement. In severe cases, profound circulatory failure can result. This review discusses the presentation and management of patients with severe cardiac complications of COVID-19 disease, with an emphasis on a Heart-Lung team approach in patient management. Furthermore, it focuses on the use of and indications for acute mechanical circulatory support in cardiogenic and/or mixed shock.


Assuntos
Síndrome Coronariana Aguda/terapia , Arritmias Cardíacas/terapia , Infecções por Coronavirus/terapia , Insuficiência Cardíaca/terapia , Miocardite/terapia , Pneumonia Viral/terapia , Síndrome Coronariana Aguda/complicações , Antibacterianos/efeitos adversos , Antivirais/uso terapêutico , Arritmias Cardíacas/induzido quimicamente , Arritmias Cardíacas/complicações , Azitromicina/efeitos adversos , Betacoronavirus , Cardiotônicos/uso terapêutico , Doença Crônica , Infecções por Coronavirus/complicações , Síndrome da Liberação de Citocina/complicações , Síndrome da Liberação de Citocina/terapia , Inibidores Enzimáticos/efeitos adversos , Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca/etiologia , Coração Auxiliar , Humanos , Hidroxicloroquina/efeitos adversos , Balão Intra-Aórtico , Infarto do Miocárdio/complicações , Infarto do Miocárdio/terapia , Miocardite/complicações , Pandemias , Intervenção Coronária Percutânea , Pneumonia Viral/complicações , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Tromboembolia
20.
Heart Fail Clin ; 16(3): 283-293, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32503752

RESUMO

The incidence of cardiogenic shock and the utilization of mechanical circulatory support devices are increasing in the US. In this review we discuss the pathophysiology of cardiogenic shock through basic hemodynamic and myocardial energetic principles. We also explore the commonly used platforms for temporary mechanical circulatory support, their advantages, disadvantages and practical considerations relating to implementation and management. It is through the translation of underlying physiological principles that we can attempt to maximize the clinical utility of circulatory support devices and improve outcomes in cardiogenic shock.


Assuntos
Circulação Assistida/instrumentação , Fenômenos Fisiológicos Cardiovasculares , Cuidados Críticos/métodos , Coração Auxiliar , Choque Cardiogênico , Circulação Assistida/métodos , Humanos , Choque Cardiogênico/fisiopatologia , Choque Cardiogênico/terapia , Pesquisa Médica Translacional
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