Management of cardiogenic shock in acute decompensated chronic heart failure: The ALTSHOCK phase II clinical trial.

Management of acute decompensated heart failure patients presenting with cardiogenic shock (CS) is not straightforward, as few data are available from clinical trials. Stabilization before left ventricle assist device (LVAD) or heart transplantation (HTx) is strongly advocated, as patients undergoing LVAD implant or HTx in critical status have worse outcomes. This was a multicenter phase II study with a Simon 2-stage design, including 24 consecutive patients treated with low-moderate epinephrine doses, whose refractory CS prompted implantation of intra-aortic balloon pump (IABP) which was subsequently upgraded with peripheral venoarterial extracorporeal membrane oxygenation. At admission, patients had severe left ventricular dysfunction and overt CS, 7 patients could be managed only with inotropic therapy, and 16 patients were transitioned to IABP and 1 to IABP and venoarterial extracorporeal membrane oxygenation; the median duration of epinephrine therapy was 7 days (interquartile range 6-15), and the median dose was 0.08 µg/kg/min (interquartile range 0.05-0.1); 21 patients (87.5%) survived at 60 days (primary outcome); among them, 13 (61.9%) underwent LVAD implantation, 2 (9.5%) underwent HTx, and 6 (28.6%) improved on medical treatment, indicating that early and intensive treatment of CS in chronic advanced heart failure patients with low-dose epinephrine and timely short-term mechanical circulatory support leads to satisfactory outcomes.

Self-expanding y stent for the treatment of malignant tracheobronchial stenosis. Retrospective study. / Stent en y autoexpandible para el tratamiento de la estenosis traqueobronquial maligna. Estudio retrospectivo.

Palliation of malignant tracheobronchial stenosis is challenging. Published experience with self-expanding Y-shaped stents is limited and it seems necessary to evaluate whether they improve clinical results with respect to alternative prostheses. We present a retrospective case series of 20 consecutive patients with malignant tracheobronchial stenosis that underwent placement of a single-unit, Y-shaped covered metallic stent. Outcomes were: safety of the procedure, palliation of dyspnea, complications, and survival. All stents were safely and easily placed using a rigid tracheoscope within 24hours of admission. Dyspnea was effectively palliated in all patients, and no early or late adverse stent-related events were observed. Thirty-day mortality was 40%. Median survival was 12.2 weeks. Placement of Y-shaped self-expanding stents is a safe and effective procedure for the palliation of malignant tracheobronchial stenosis, and is currently our stent of choice for this subgroup of patients.

Direct Flow valve-in-valve implantation in a degenerated mitral bioprosthesis.

AIMS: Mitral valve reoperations due to failing bioprostheses, in patients affected by multiple comorbidities, are associated with high morbidity and mortality. Transcatheter techniques may evolve as complementary approaches to surgery in these patients at high risk for surgery. METHODS AND RESULTS: We describe a case of Direct Flow 25 mm transcatheter valve implantation as valve-in-valve in a degenerated mitral bioprosthesis through a transapical approach in a 63-year-old man affected by dilated cardiomyopathy. The patient was affected by Carpentier-Edwards 29 mm severe regurgitation. The 25 mm Direct Flow bioprosthesis was advanced through the mitral bioprosthesis into the left atrium and then positioned using the three independent positioning wires. Transoesophageal echocardiography evidenced normal Direct Flow function with no paravalvular regurgitation and a low transmitral gradient of 4 mmHg. CONCLUSIONS: Our successful experience, characterised by a Heart Team approach and multidisciplinary patient care, demonstrated the technical feasibility and procedural safety of Direct Flow valve-in-valve mitral implantation.

Stent en y autoexpandible para el tratamiento de la estenosis traqueobronquial maligna. Estudio retrospective / Self-expanding y stent for the treatment of malignant tracheobronchial stenosis. Retrospective study

El tratamiento paliativo de la estenosis traqueobronquial maligna es difícil. Las experiencias publicadas con stent en Y autoexpandibles son escasas, por lo que es necesario evaluar si los resultados que ofrecen son mejores que los de otras prótesis alternativas. Presentamos una serie retrospectiva de 20 pacientes consecutivos con estenosis traqueobronquial maligna, a los que se insertó un stent en Y metálico y recubierto. Las variables analizadas fueron las siguientes: alivio de la disnea, complicaciones y supervivencia. Los stent se insertaron a través de un traqueoscopio rígido en las 24h siguientes al ingreso del paciente, de forma segura y sin dificultades. Todos los pacientes lograron un alivio eficaz de la disnea y no se observaron efectos adversos, tempranos o tardíos, relacionados con el stent. La mortalidad a los 30 días fue del 40%, con una mediana de supervivencia de 12,2 semanas. La inserción de stent en Y autoexpandibles es un procedimiento seguro y eficaz para el tratamiento paliativo de la estenosis traqueobronquial maligna. En la actualidad, este es nuestro stent de elección para este subgrupo de pacientes

Palliation of malignant tracheobronchial stenosis is challenging. Published experience with self-expanding Y-shaped stents is limited and it seems necessary to evaluate whether they improve clinical results with respect to alternative prostheses. We present a retrospective case series of 20 consecutive patients with malignant tracheobronchial stenosis that underwent placement of a single-unit, Y-shaped covered metallic stent. Outcomes were: safety of the procedure, palliation of dyspnea, complications, and survival. All stents were safely and easily placed using a rigid tracheoscope within 24hours of admission. Dyspnea was effectively palliated in all patients, and no early or late adverse stent-related events were observed. Thirty-day mortality was 40%. Median survival was 12.2 weeks. Placement of Y-shaped self-expanding stents is a safe and effective procedure for the palliation of malignant tracheobronchial stenosis, and is currently our stent of choice for this subgroup of patients