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1.
Pan Afr Med J ; 35(Suppl 2): 141, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33193956

RESUMO

Novel coronavirus 2019 (COVID-19) is a severe respiratory infection leading to acute respiratory distress syndrome [ARDS] accounting for thousands of cases and deaths across the world. Several alternatives in treatment options have been assessed and used in this patient population. However, when mechanical ventilation and prone positioning are unsuccessful, venovenous extracorporeal membrane oxygenation [VV-ECMO] may be used. We present a case of a 62-year-old female, diabetic, admitted to the intensive care unit with fever, flu-like symptoms and a positive COVID-19 test. Ultimately, she worsened on mechanical ventilation and prone positioning and required VV-ECMO. The use of VV-ECMO in COVID-19 infected patients is still controversial. While some studies have shown a high mortality rate despite aggressive treatment, such as in our case, the lack of large sample size studies and treatment alternatives places healthcare providers against a wall without options in patients with severe refractory ARDS due to COVID-19.


Assuntos
Betacoronavirus , Terapia de Substituição Renal Contínua/métodos , Infecções por Coronavirus/complicações , Estado Terminal , Oxigenação por Membrana Extracorpórea/instrumentação , Pneumonia Viral/complicações , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Antibacterianos/uso terapêutico , Antivirais/uso terapêutico , Bacteriemia/complicações , Terapia Combinada , Terapia de Substituição Renal Contínua/instrumentação , Infecções por Coronavirus/tratamento farmacológico , Estado Terminal/terapia , Síndrome da Liberação de Citocina/etiologia , Diabetes Mellitus Tipo 2/complicações , Evolução Fatal , Feminino , Infecções por Bactérias Gram-Positivas/complicações , Humanos , Pessoa de Meia-Idade , Marrocos , Pandemias , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/etiologia
2.
PLoS One ; 15(11): e0242127, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33180830

RESUMO

BACKGROUND: Reported mortality of hospitalised Coronavirus Disease-2019 (COVID-19) patients varies substantially, particularly in critically ill patients. So far COVID-19 in-hospital mortality and modes of death under state of the art care have not been systematically studied. METHODS: This retrospective observational monocenter cohort study was performed after implementation of a non-restricted, dynamic tertiary care model at the University Medical Center Freiburg, an experienced acute respiratory distress syndrome (ARDS) and extracorporeal membrane-oxygenation (ECMO) referral center. All hospitalised patients with PCR-confirmed SARS-CoV-2 infection were included. The primary endpoint was in-hospital mortality, secondary endpoints included major complications and modes of death. A multistate analysis and a Cox regression analysis for competing risk models were performed. Modes of death were determined by two independent reviewers. RESULTS: Between February 25, and May 8, 213 patients were included in the analysis. The median age was 65 years, 129 patients (61%) were male. 70 patients (33%) were admitted to the intensive care unit (ICU), of which 57 patients (81%) received mechanical ventilation and 23 patients (33%) ECMO support. Using multistate methodology, the estimated probability to die within 90 days after COVID-19 onset was 24% in the whole cohort. If the levels of care at time of study entry were accounted for, the probabilities to die were 16% if the patient was initially on a regular ward, 47% if in the intensive care unit (ICU) and 57% if mechanical ventilation was required at study entry. Age ≥65 years and male sex were predictors for in-hospital death. Predominant complications-as judged by two independent reviewers-determining modes of death were multi-organ failure, septic shock and thromboembolic and hemorrhagic complications. CONCLUSION: In a dynamic care model COVID-19-related in-hospital mortality remained very high. In the absence of potent antiviral agents, strategies to alleviate or prevent the identified complications should be investigated. In this context, multistate analyses enable comparison of models-of-care and treatment strategies and allow estimation and allocation of health care resources.


Assuntos
Infecções por Coronavirus/mortalidade , Mortalidade Hospitalar , Pneumonia Viral/mortalidade , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus , Oxigenação por Membrana Extracorpórea , Feminino , Alemanha/epidemiologia , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Pandemias , Respiração Artificial , Estudos Retrospectivos , Atenção Terciária à Saúde
3.
Rev Med Liege ; 75(11): 699-702, 2020 Nov.
Artigo em Francês | MEDLINE | ID: mdl-33155441

RESUMO

Venlafaxine is a widely prescribed antidepressant drug acting as a reuptake inhibitor of serotonin and noradrenaline. An overdose of venlafaxine can cause cardiovascular toxicity and cardiogenic shock can occur. A 32-year-old man ingested 12g of sustained-release venlafaxine in a suicidal attempt and developed within 24h acute heart failure with refractory cardiogenic shock requiring support by ECMO. The blood toxicology showed persistence of high levels of venlafaxine at day 10. The patient fully recovered and showed normal cardiac function at 3-months follow-up.


Assuntos
Overdose de Drogas , Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca , Adulto , Overdose de Drogas/complicações , Overdose de Drogas/terapia , Humanos , Masculino , Choque Cardiogênico/induzido quimicamente , Choque Cardiogênico/terapia , Cloridrato de Venlafaxina
5.
ASAIO J ; 66(10): 1069-1072, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33136589

RESUMO

Extracorporeal membrane oxygenation (ECMO) is recognized as organ support for potentially reversible acute respiratory distress syndrome (ARDS). However, limited resource during the outbreak and the coagulopathy associated with coronavirus disease 2019 (COVID-19) make the utilization of venovenous (VV) ECMO highly challenging. We herein report specific considerations for cannulation configurations and ECMO management during the pandemic. High blood flow and anticoagulation at higher levels than usual practice for VV ECMO may be required because of thrombotic hematologic profile of COVID-19. Among our first 24 cases (48.8 ± 8.9 years), 17 patients were weaned from ECMO after a mean duration of 19.0 ± 10.1 days and 16 of them have been discharged from ICU.


Assuntos
Infecções por Coronavirus/terapia , Oxigenação por Membrana Extracorpórea/métodos , Pneumonia Viral/terapia , Anticoagulantes/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/complicações , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Heparina/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/complicações , Síndrome do Desconforto Respiratório do Adulto/virologia , Trombose/etiologia , Trombose/prevenção & controle
6.
ASAIO J ; 66(10): 1076-1078, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33136591

RESUMO

With the massive influx of patients during COVID-19 pandemic into intensive care unit, resources have quickly been stretched to the limit, including extracorporeal membrane oxygenation (ECMO). Gas blender attached to ECMO is used to allow precise adjustment of characteristics of fresh gas flow, that is, blood oxygen delivery and carbon dioxide removal. To cope with the gas blender shortage, we describe a back-up system set up in our French tertiary referral ECMO center using air and oxygen flowmeters. A table has been created to facilitate medical prescription but also nurse monitoring. This extraordinary situation forces physicians to adapt medical devices, and that could be useful in future viral pandemics.


Assuntos
Infecções por Coronavirus/terapia , Oxigenação por Membrana Extracorpórea/instrumentação , Oxigenadores de Membrana/provisão & distribução , Pneumonia Viral/terapia , Betacoronavirus , Humanos , Pandemias
7.
ASAIO J ; 66(10): 1079-1083, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33136592

RESUMO

Observational evidence suggests that excessive inflammation with cytokine storm may play a critical role in development of acute respiratory distress syndrome (ARDS) in COVID-19. We report the emergency use of immunomodulatory therapy utilizing an extracorporeal selective cytopheretic device (SCD) in two patients with elevated serum interleukin (IL)-6 levels and refractory COVID-19 ARDS requiring extracorporeal membrane oxygenation (ECMO). The two patients were selected based on clinical criteria and elevated levels of IL-6 (>100 pg/ml) as a biomarker of inflammation. Once identified, emergency/expanded use permission for SCD treatment was obtained and patient consented. Six COVID-19 patients (four on ECMO) with severe ARDS were also screened with IL-6 levels less than 100 pg/ml and were not treated with SCD. The two enrolled patients' PaO2/FiO2 ratios increased from 55 and 58 to 200 and 192 at 52 and 50 hours, respectively. Inflammatory indices also declined with IL-6 falling from 231 and 598 pg/ml to 3.32 and 116 pg/ml, respectively. IL-6/IL-10 ratios also decreased from 11.8 and 18 to 0.7 and 0.62, respectively. The two patients were successfully weaned off ECMO after 17 and 16 days of SCD therapy, respectively. The results observed with SCD therapy on these two critically ill COVID-19 patients with severe ARDS and elevated IL-6 is encouraging. A multicenter clinical trial is underway with an FDA-approved investigational device exemption to evaluate the potential of SCD therapy to effectively treat COVID-19 intensive care unit patients.


Assuntos
Infecções por Coronavirus/imunologia , Infecções por Coronavirus/terapia , Estado Terminal/terapia , Citaferese/métodos , Interleucina-6/sangue , Pneumonia Viral/imunologia , Pneumonia Viral/terapia , Adulto , Betacoronavirus , Infecções por Coronavirus/sangue , Cuidados Críticos/métodos , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Imunomodulação , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/sangue , Síndrome do Desconforto Respiratório do Adulto/terapia , Síndrome do Desconforto Respiratório do Adulto/virologia
12.
Medicina (Kaunas) ; 56(11)2020 Oct 29.
Artigo em Inglês | MEDLINE | ID: mdl-33137936

RESUMO

Coronavirus disease (COVID-19) started in Wuhan (China) at the end of 2019, and then increased rapidly. In patients with severe acute respiratory distress syndrome (ARDS) caused by COVID-19, venovenous extracorporeal membrane oxygenation (VV-ECMO) is considered a rescue therapy that provides adequate gas exchange. The way in which mechanical ventilation is applied during VV-ECMO is not clear, however it is associated with prognosis. Currently, the mortality rate of COVID-19 patients that receive VV-ECMO stands at approximately 50%. Here, we report three patients that successfully recovered from COVID-19-induced ARDS after VV-ECMO and implementation of an ultra-protective ventilation. This ventilation strategy involved maintaining a peak inspiratory pressure of ≤20 cmH2O and a positive end-expiratory pressure (PEEP) of ≤ 10 cmH2O, which are lower values than have been previously reported. Thus, we suggest that this ultra-protective ventilation be considered during VV-ECMO as it minimizes the ventilator-induced lung injury.


Assuntos
Infecções por Coronavirus/terapia , Oxigenação por Membrana Extracorpórea/métodos , Glucocorticoides/uso terapêutico , Pneumonia Viral/terapia , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório do Adulto/terapia , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle , Idoso , Antibacterianos/uso terapêutico , Antivirais/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/tratamento farmacológico , Feminino , Humanos , Imunização Passiva , Masculino , Pessoa de Meia-Idade , Pandemias
13.
Medicina (Kaunas) ; 56(10)2020 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-33008007

RESUMO

Patients with cardiopulmonary failure may not be fully supported with typical configurations of extracorporeal membrane oxygenation (ECMO), either veno-arterial (VA) or veno-venous (VV). Veno-arterial-venous (VAV)-ECMO is a technique used to support the cardiopulmonary systems during periods of inadequate gas exchange and perfusion. In the severe case of coronavirus disease 2019 (COVID-19), which simultaneously affects the heart and lung, VAV-ECMO may improve a patient's recovery potential. We report the case of a 72-year-old woman with acute respiratory distress syndrome and circulatory failure following COVID-19, who was treated with VAV-ECMO.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Infecções por Coronavirus/terapia , Oxigenação por Membrana Extracorpórea/métodos , Pneumonia Viral/complicações , Pneumonia Viral/terapia , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Idoso , Cuidados Críticos/métodos , Estado Terminal , Feminino , Humanos , Pandemias
14.
Am J Case Rep ; 21: e927521, 2020 Oct 28.
Artigo em Inglês | MEDLINE | ID: mdl-33110055

RESUMO

BACKGROUND There are few reports of coronavirus disease 2019 (COVID-19) in pregnant women. Although coagulation dysfunction was reported to affect the severity of COVID-19, the association between pregnancy, which is usually accompanied by changes in coagulation function, and the worsening of COVID-19 is unknown. We present a case of a 30-year-old woman in the 36th week of pregnancy who was diagnosed with severe COVID-19 pneumonia and required postpartum extracorporeal membrane oxygenation (ECMO) therapy. CASE REPORT A 30-year-old, 36-weeks pregnant woman presented to our hospital and was diagnosed with severe COVID-19 pneumonia soon after she had undergone a cesarean section. Her respiratory failure could not be managed by conventional therapeutic approaches. Therefore, ECMO was administered on day 7. Controlling coagulation function to maintain ECMO therapy was challenging. Nafamostat mesylate and cryoprecipitate were administered to treat the hypercoagulative status and severe hypofibrinogenemia, respectively. Since coagulopathy and her respiratory state improved, the ECMO therapy was terminated on day 15. CONCLUSIONS We report a case of severe COVID-19 pneumonia in a pregnant woman urgently treated with ECMO in the postpartum period. Thus, this case highlights the importance of close monitoring and appropriate medical care for pregnant women with severe COVID-19 pneumonia.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Oxigenação por Membrana Extracorpórea/métodos , Pneumonia Viral/terapia , Complicações Infecciosas na Gravidez/terapia , Adulto , Cesárea , Infecções por Coronavirus/epidemiologia , Feminino , Humanos , Pandemias , Pneumonia Viral/epidemiologia , Gravidez
15.
J Card Surg ; 35(10): 2821-2824, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33043655

RESUMO

A patient with acute pulmonary embolism suffered cardiac arrest, received manual and mechanical cardiopulmonary resuscitation and tissue plasminogen activator before extracorporeal cardiopulmonary resuscitation was initiated. She suffered a type B aortic dissection and retroperitoneal hemorrhage secondary to resuscitation measures. This case report describes high-risk anticoagulation management for contradicting treatment goals in preparation for pulmonary embolectomy on cardiopulmonary bypass.


Assuntos
Aneurisma Dissecante/etiologia , Aneurisma Aórtico/etiologia , Reanimação Cardiopulmonar/efeitos adversos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Hemorragia/etiologia , Embolia Pulmonar/etiologia , Espaço Retroperitoneal , Ponte Cardiopulmonar/efeitos adversos , Reanimação Cardiopulmonar/métodos , Contraindicações , Embolectomia , Feminino , Parada Cardíaca/etiologia , Humanos , Pessoa de Meia-Idade , Ativadores de Plasminogênio/administração & dosagem , Ativadores de Plasminogênio/efeitos adversos
16.
BMC Infect Dis ; 20(1): 794, 2020 Oct 27.
Artigo em Inglês | MEDLINE | ID: mdl-33109122

RESUMO

BACKGROUND: Pulmonary hemorrhage is an important complication of leptospirosis. Once acute respiratory distress syndrome (ARDS) occurs as a secondary condition, treatment is extremely difficult and the mortality rate is very high. CASE PRESENTATION: The patient was a 49-year-old. He was admitted to the hospital because he had experienced a fever and cough for 4 days. Hemorrhage, respiratory failure, ARDS and other symptoms appeared soon after admission. Due to severe pulmonary hemorrhage secondary to ARDS, mechanical ventilation was performed through tracheal intubation. During intubation, the patient suffered cardiac arrest, and the patient's condition worsened. He was confirmed to have leptospirosis through second-generation sequencing of the alveolar lavage fluid. Finally, we successfully treated the patient with penicillin as an anti-infective medication and venous-venous extracorporeal membrane oxygenation (v-vECMO). To the best of our knowledge, this report is the first to describe the successful application of ECMO in mainland China. CONCLUSIONS: Leptospirosis can induce serious but transient ARDS with a better prognosis than other causes of ARDS. Our patient was successfully treated with V-vECMO.


Assuntos
Oxigenação por Membrana Extracorpórea , Hemorragia/etiologia , Hemorragia/cirurgia , Leptospira/genética , Leptospirose/complicações , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/cirurgia , Antibacterianos/uso terapêutico , Líquido da Lavagem Broncoalveolar/microbiologia , China , Humanos , Leptospira/isolamento & purificação , Leptospirose/tratamento farmacológico , Leptospirose/microbiologia , Masculino , Pessoa de Meia-Idade , Penicilinas/uso terapêutico , Prognóstico , Respiração Artificial/efeitos adversos , Síndrome do Desconforto Respiratório do Adulto/tratamento farmacológico , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/cirurgia , Resultado do Tratamento
18.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 32(9): 1091-1095, 2020 Sep.
Artigo em Chinês | MEDLINE | ID: mdl-33081896

RESUMO

OBJECTIVE: To explore the changing trend of cardiac troponin T (cTnT) in patients with cardiogenic shock (CS) receiving veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and its predictive value. METHODS: A retrospective study was conducted. The data of patients with CS receiving V-A ECMO admitted to the First Affiliated Hospital of Nanjing Medical University from March 2015 to May 2020 were enrolled. The baseline data, ECMO related parameters, serum cTnT levels at 1, 2, 3 days after ECMO and intensive care unit (ICU) prognosis were recorded. The parameters with clinical significance and significant difference in univariate analysis were analyzed by binary multivariate Logistic regression analysis. Meanwhile, receiver operating characteristic (ROC) curve was drawn, area under ROC curve (AUC) was analyzed, and the threshold, sensitivity and specificity of serum cTnT level and its reduction rate for predicting clinical outcome were evaluated. RESULTS: A total of 72 patients were enrolled, of which 42 survived and 30 died at ICU discharge, and the ICU mortality was 41.7%. Univariate analysis results: compared with the survival group, the patients in the death group had higher acute physiology and chronic health evaluation II (APACHE II) score [32 (30, 34) vs. 29 (25, 30)], and the incidence of cardiac arrest before ECMO (70.0% vs. 31.0%), the ratios of invasive mechanical ventilation and continuous renal replacement therapy during ECMO were higher (96.7% vs. 66.7%, 83.3% vs. 42.9%), and the differences were statistically significant (all P < 0.05). Serum cTnT levels (ng/L) at 2 days and 3 days after ECMO in the death group were significantly higher than those in the survival group [2 days: 6 373.5 (898.3, 15 251.5) vs. 1 760.5 (933.0, 4 257.8), 3 day: 6 202.0 (758.9, 16 554.3) vs. 1 678.0 (623.3, 3 407.8), both P < 0.05], and the decrease rates of cTnT within 2 days and 3 days after ECMO were significantly lower than those in the survival group [2 days: 17.3% (-44.2%, 34.7%) vs. 36.8% (18.1%, 60.6%), 3 days: 32.4% (-30.0%, 55.5%) vs. 53.2% (38.3%, 72.3%), both P < 0.05]. Binary multivariate Logistic regression analysis showed that cardiac arrest before ECMO [odds ratio (OR) = 4.564, 95% confidence interval (95%CI) was 1.212-17.193, P = 0.025] and the decrease rate of cTnT level within 2 days after ECMO (OR = 1.617, 95%CI was 1.144-4.847, P = 0.026) were independent prognostic risk factors for the ICU death of CS patients receiving V-A ECMO. ROC curve analysis showed that the decline rate of cTnT within 2 days after ECMO transfer had a certain predictive value for the ICU death of CS patients receiving V-A ECMO. The AUC was 0.704 (95%CI was 0.584-0.824). The optimal diagnostic threshold was 40.0%, the sensitivity was 86.7%, the specificity was 52.4%, the positive predictive value was 66.9%, and the negative predictive value was 89.1%. CONCLUSIONS: The early decline rate of cTnT in CS patients who received V-A ECMO treatment in death group was lower than that of survival patients. The cTnT decline rate 2 days after ECMO was an independent risk factor for the death of such patients.


Assuntos
Oxigenação por Membrana Extracorpórea , Choque Cardiogênico , Humanos , Prognóstico , Estudos Retrospectivos , Choque Cardiogênico/terapia , Troponina T
19.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 32(9): 1145-1148, 2020 Sep.
Artigo em Chinês | MEDLINE | ID: mdl-33081908

RESUMO

Acute poisoning induced cardiac arrest (APCA) is an acute circulatory failure caused by severe poisoning, which is characterized by complicated mechanisms, limited treatment methods and poor prognosis. Recently, emerging evidence has demonstrated that extracorporeal membrane oxygenation (ECMO) could be a promising tool that may benefit the patients with APCA refractory to conventional resuscitation methods. However, further well-designed studies are needed to evaluate and resolve the emerged problems during the process of ECMO therapy in patients with APCA, such as population indications, optimal conditions, cost-effectiveness, etc. Therefore, this article reviews the epidemiology and mechanism of APCA, and the experimental and clinical studies of the application of ECMO in APCA, in order to explore the clinical value of ECMO in the treatment of APCA patients.


Assuntos
Oxigenação por Membrana Extracorpórea , Parada Cardíaca , Análise Custo-Benefício , Parada Cardíaca/terapia , Humanos , Ressuscitação
20.
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
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