RESUMO
Conservative management is the first-line treatment for spontaneous coronary artery dissection (SCAD) with stable haemodynamic status and thrombolysis in myocardial infarction three flow on angiography. However, in a few very specific patients, recurrent ischemia, or haemodynamic instability necessitates revascularization. Here, we describe a case of successful optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) with a cutting balloon. We performed fenestration at multiple decompression sites prior to stenting in an intramural haematoma with luminal compression. Rescue management of SCAD with luminal compression is a critical issue, because SCAD is an emergent clinical condition affecting young patients with a severe prognosis. To our knowledge, there are no large published series evaluating procedural success rates and long-term follow-up of this technique.
Assuntos
Angioplastia Coronária com Balão , Infarto Miocárdico de Parede Anterior/terapia , Oclusão Coronária/terapia , Anomalias dos Vasos Coronários/terapia , Hematoma/terapia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Doenças Vasculares/congênito , Adulto , Angioplastia Coronária com Balão/instrumentação , Infarto Miocárdico de Parede Anterior/diagnóstico por imagem , Infarto Miocárdico de Parede Anterior/etiologia , Infarto Miocárdico de Parede Anterior/fisiopatologia , Angiografia Coronária , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/etiologia , Oclusão Coronária/fisiopatologia , Anomalias dos Vasos Coronários/complicações , Anomalias dos Vasos Coronários/diagnóstico por imagem , Anomalias dos Vasos Coronários/fisiopatologia , Feminino , Hematoma/diagnóstico por imagem , Hematoma/etiologia , Hematoma/fisiopatologia , Humanos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Stents , Tomografia de Coerência Óptica , Resultado do Tratamento , Doenças Vasculares/complicações , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/fisiopatologia , Doenças Vasculares/terapiaRESUMO
BACKGROUND: Even though COVID-19 clinical features, pathogenesis, complications, and therapeutic options have been largely described in the literature, long-term consequences in patients remain poorly known. METHODS: The French, multicentre, non-interventional SISCOVID study evaluated lung impairment three (M3) and six months (M6) after hospital discharge in patients recovered from COVID-19. Evaluation was based on clinical examination, pulmonary function tests, and chest computed tomography (CT-scan). RESULTS: Of the 320 included patients (mean age: 61 years; men: 64.1%), 205 had had a severe form of COVID-19, being hospitalised in an intensive care unit (ICU), and requiring high flow nasal cannula, non-invasive ventilation, or invasive mechanical ventilation. At M6, 54.1% of included patients had persistent dyspnoea (mMRC score ≥1), 20.1% severe impairment in gas diffusing capacity (DLCO <60% pred.), 21.6% restrictive ventilatory pattern (total lung capacity <80% pred.), and 40% a fibrotic-like pattern at CT-scan. Fibrotic-like pattern and restrictive ventilatory pattern were significantly more frequent in patients recovered from severe than non-severe COVID-19. Improved functional and radiological outcomes were observed between M3 and M6. At M6, age was an independent risk factor for severe DLco impairment and fibrotic-like pattern and severe COVID-19 form was independent risk factor for restrictive ventilatory profile and fibrotic-like pattern. CONCLUSION: Six months after discharge, patients hospitalised for COVID-19, especially those recovered from a severe form of COVID-19, frequently presented persistent dyspnoea, lung function impairment, and persistent fibrotic-like pattern, confirming the need for long-term post-discharge follow-up in these patients and for further studies to better understand long-term COVID-19 lung impairment.
Assuntos
COVID-19 , Masculino , Humanos , Pessoa de Meia-Idade , COVID-19/complicações , COVID-19/epidemiologia , Assistência ao Convalescente , Alta do Paciente , Hospitalização , Progressão da Doença , Dispneia , Pulmão/diagnóstico por imagemRESUMO
We describe a patient with coronavirus disease 2019 (COVID-19) and multiple concomitant thromboses occurring on the 9th day of hospital stay. Thromboses were found in distinct zones of the aorta, as well as in the renal, humeral, and pulmonary arteries. The extensive biological workup performed following this catastrophic thrombotic syndrome found no evidence for underlying prothrombotic disease. In light of current evidence regarding endothelium abnormalities related to COVID-19, this extreme case of catastrophic thrombotic syndrome suggests that COVID-19 can induce severe arterial thrombosis following intense endothelial activation.
Nous décrivons le cas d'un patient atteint de la maladie à coronavirus 2019 (COVID-19) et présentant de multiples thromboses concomitantes survenant au 9e jour d'hospitalisation. Les thromboses ont été identifiées dans des zones distinctes de l'aorte, ainsi que dans les artères rénales, humérales et pulmonaires. Un examen biologique approfondi effectué à la suite de ce syndrome thrombotique catastrophique n'a révélé aucun signe de maladie prothrombotique sous-jacente. À la lumière de ces éléments concernant les anomalies de l'endothélium liées à la COVID-19, ce cas extrême de syndrome thrombotique catastrophique suggère que la COVID-19 peut induire une thrombose artérielle sévère suite à une activation endothéliale intense.
RESUMO
BACKGROUND: Obstructive sleep apnea (OSA) is a potential cardiovascular risk factor. However, there is currently no prominent screening strategy for its diagnosis in patients with acute coronary syndrome (ACS). The aim of this study was to establish the impact of apneic events in case of OSA associated with ACS. METHODS: Between January 1st and June 30th, fifty-three subjects with ACS (first acute myocardial infarction) were prospectively evaluated for OSA. Each patient was evaluated by polysomnography (PSG) two months after the ACS. RESULTS: Mean age of 59±9,6 years, 81,1% males, BMI at 28,5±4,2 kg/m2, neck circumference of 42,5±12,6 cm, and waist circumference os 102,5±16,5 cm. The majority of patients (73,6%) had moderate to severe OSA (apnea-hypopnea index (AHI) ≥ 15/h and arousal index ≥ 10/h). We defined the apneic coefficient (AC) as the ratio between apnea index (AI) and AHI. We chose as cut-off the median value of apnea coefficient in our population which was at 37%. The patients with a higher AC (AC ≥ 37% versus AC < 37%) had higher levels of Troponin-I (63,4±63,2 versus 29,7±36,1 ng/mL, p=0,016), higher levels of NT-proBNP (1879,8±2141,8 versus 480±621,3 pg/mL, p=0,001), higher SYNTAX score (15,8±11,5 versus 10,2±5,9, p=0,049), and lower left ventricle ejection fraction (LVEF 53,3±11,4 versus 59,4±6,4%, p=0,023) and were more likely to have a STEMI (21 patients (77,7%) vesus 14 patients (53,8%), p=0,031). CONCLUSION: An apneic coefficient (AI/AHI) ≥ 37% is correlated with more severe cardiac impairment, as well as higher hypoxemia and arousal index.
RESUMO
Acute respiratory distress syndrome (ARDS) is a diffuse lung injury that leads to a severe acute respiratory failure. Traditional diagnostic criteria for pulmonary hypertension (PH), in this situation, may be unreliable due to the effects of positive pressure ventilation and vasoactive agents. The aim of this study is to describe the hemodynamic characteristics of PH secondary to ARDS, in relation with respiratory parameters. We assessed the hemodynamic, respiratory function, and ventilator parameters in a cohort of 38 individuals with ARDS-associated PH defined by mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg. Individual characteristics: PaO2/FiO2 = 110 ± 60 mmHg, alveolar-arterial oxygen gradient (A-aO2) = 549 ± 148.9 mmHg, positive end-expiratory pressure (PEEP) = 8.7 ± 3.5 cmH2O, pulmonary static compliance (Cstat) = 30 ± 12.1 L*cmH2O-1, mPAP = 35.4 ±6.6 mmHg, pulmonary artery wedge pressure (PAWP) = 15.6 ± 5.5 mmHg, cardiac index (CI) = 3.4 ± 1.2 L/min/m2, pulmonary vascular resistance (PVR) = 3.3 ± 1.6 Wood units (WU), right atrial pressure (RAP) = 13.4 ± 5.4 mmHg, diastolic pulmonary gradient (DPG) = 12.6 ± 6.5 mmHg, and trans-pulmonary gradient (TPG) = 19.7 ± 7.7 mmHg. The composite marker-DPG >7 mmHg and PVR > 3 WU-is associated with lower CI ( P = 0.016), higher mPAP ( P = 0.003), and lower pulmonary static compliance ( P = 0.028). We confirmed a poor prognosis of ARDS associated with PH, with a 50% survival rate after 17 days. We observed that the survival rate at 28 days was better in the case of improvement in the PaO2/FiO2 ratio in the first 24 h (log rank P = 0.003). ARDS associated with PH is a severe condition with a very poor survival rate. The composite marker DPG > 7 mmHg and PVR > 3 WU seemed to better describe the hemodynamic and respiratory dysfunction. The improvement in PaO2/FiO2 ratio in the first 24 h defined a better survival in our cohort of patients.
RESUMO
In this article we describe, to our knowledge, the first case of a potentially lethal dysfunction of a subcutaneous implantable cardioverter-defibrillator (S-ICD). A 70-year-old patient underwent primary S-ICD implantation. Nine months after, communication could not be established with the device. Chest radiography revealed that the lead had moved and wrapped around the generator. After equipment extraction, we observed the lead wound around the sagittal axis of the generator. A burn mark with melted metal was found inside the generator. Our hypothesis is an electric arc occurred between the retracted lead and the generator. This could be the first reported Reel syndrome secondary to S-ICD implantation.
Assuntos
Desfibriladores Implantáveis/efeitos adversos , Remoção de Dispositivo/métodos , Prevenção Secundária/métodos , Taquicardia Ventricular/prevenção & controle , Idoso , Falha de Equipamento , Humanos , MasculinoRESUMO
Once initiated for pulmonary arterial hypertension (PAH), epoprostenol treatment usually needs to be delivered for an indefinite duration. It is possible that some participants could be transitioned from epoprostenol to oral therapies. We retrospectively evaluated eight PAH participants transitioned from epoprostenol to PAH oral drugs. The criteria for epoprostenol withdrawal were: (1) persistent improvement of clinic and hemodynamic status; (2) stable dose of epoprostenol for the last three months; and (3) the participant's preference for oral therapy after evaluation of risk-benefit. We evaluated the clinical, functional, and hemodynamic status at baseline, at withdrawal, and after the transition to oral PAH therapy. The transition was completed in all eight participants. Four participants had a complete successful transition (CT) with a stable clinical and hemodynamic course and four participants had a partial successful transition (PT) remaining stable clinically, with a mild hemodynamic worsening, but without need to re-initiate epoprostenol therapy. The four CT participants were treated with epoprostenol for a shorter period of time (CT group: 35 ± 30 versus PT group: 79 ± 49 months, P = 0.08). Mean epoprostenol dosage was lower in the CT group (CT group: 15 ± 1.5 ng/kg/min versus PT group: 24 ± 11 ng/kg/min, P = 0.09). Safe withdrawal of epoprostenol treatment and transition to oral PAH therapy was possible in a small and highly selected group of participants. The majority of these participants had a porto-pulmonary PAH or PAH associated to HIV infection.