Desfechos Hospitalares do Infarto do Miocárdio com Supradesnivelamento do Segmento ST em Pacientes Positivos para COVID-19 que Passaram por Intervenção Percutânea Primária / In-Hospital Outcomes of ST-Segment Elevation Myocardial Infarction in COVID-19 Positive Patients Undergoing Primary Percutaneous Intervention

Resumo Fundamento A infecção concomitante por coronavírus 2019 (COVID-19) e o infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST) estão associados ao aumento de desfechos adversos hospitalares. Objetivos O estudo teve como objetivo avaliar as diferenças angiográficas, de procedimentos, laboratoriais e prognósticas em pacientes positivos e negativos para COVID-19 com IAMCSST submetidos à intervenção coronária percutânea primária (ICP). Métodos Realizamos um estudo observacional retrospectivo e unicêntrico entre novembro de 2020 e agosto de 2022 em um hospital de nível terciário. De acordo com o seu estado, os pacientes foram divididos em dois grupos (positivo ou negativo para COVID-19). Todos os pacientes foram internados por IAMCSST confirmado e foram tratados com ICP primária. Os desfechos hospitalares e angiográficos foram comparados entre os dois grupos. P-valores bilaterais <0,05 foram aceitos como estatisticamente significativos. Resultados Dos 494 pacientes com IAMCSST inscritos nesse estudo, 42 foram identificados como positivos para COVID-19 (8,5%) e 452, como negativos. Os pacientes que testaram positivos para COVID-19 tiveram um tempo isquêmico total maior do que os pacientes que testaram negativos para COVID-19 (p = 0,006). Além disso, esses pacientes apresetaram um aumento na trombose de stent (7,1% vs. 1,7%, p = 0,002), no tempo de internação (4 dias vs. 3 dias, p = 0,018), no choque cardiogênico (14,2% vs. 5,5%, p = 0,023) e na mortalidade hospitalar total e cardíaca (p <0,001 e p = 0,032, respectivamente). Conclusões Pacientes com IAMCSST com infecções concomitantes por COVID-19 foram associados ao aumento de eventos cardíacos adversos maiores. Mais estudos são necessários para compreender os mecanismos exatos dos desfechos adversos nesses pacientes.

Abstract Background Concomitant coronavirus 2019 (COVID-19) infection and ST-segment elevation myocardial infarction (STEMI) are associated with increased adverse in-hospital outcomes. Objectives This study aimded to evaluate the angiographic, procedural, laboratory, and prognostic differences in COVID-19-positive and negative patients with STEMI undergoing primary percutaneous coronary intervention (PCI). Methods A single-center, retrospective, observational study was conducted between November 2020 and August 2022 in a tertiary-level hospital. According to their status, patients were divided into two groups (COVID-19 positive and negative). All patients were admitted due to confirmed STEMI and treated with primary PCI. In-hospital and angiographic outcomes were compared between the two groups. Two-sided p-values < 0.05 were accepted as statistically significant. Results Of the 494 STEMI patients enrolled in this study, 42 were identified as having a positive dagnosis for COVID-19 (8.5%), while 452 were negative. The patients who tested positive for COVID-19 had a longer total ischemic time than did those who tested negative for COVID-19 (p=0.006). Moreover, these patients presented an increase in stent thrombosis (7.1% vs. 1.7%, p=0.002), length of hospitalization (4 days vs. 3 days, p= 0.018), cardiogenic shock (14.2% vs. 5.5 %, p= 0.023), and in-hospital total and cardiac mortality (p<0.001 and p=0.032, respectively). Conclusions Patients with STEMI with concomitant COVID-19 infections were associated with increased major adverse cardiac events. Further studies are needed to understand the exact mechanisms of adverse outcomes in these patients.

Registro multicéntrico Impella CP para shock cardiogénico o angioplastía de alto riesgo protegida en Chile

Antecedentes: El Shock Cardiogénico (SC) y las Angioplastías de Alto Riesgo (AAR) están asociadas con altas tasas de mortalidad. El uso del dispositivo Impella CP podría reducir el riesgo de muerte en estos escenarios. En Chile no existen reportes evaluando el uso del dispositivo Impella CP. Objetivo: Analizar los desenlaces clínicos en pacientes que fueron sometidos al uso del dispositivo Impella CP por SC o por AAR. Métodos: Se realizó un estudio retrospectivo en 17 pacientes, los cuales representan el total de implantes realizados en el país, entre octubre 2021 y agosto 2023. Se describió las características, demográficas, procedimentales y después del implante. Se estimó la mortalidad general y se identificaron factores asociados. Resultados: La edad de los pacientes fue 69± 3,7 años y 88,2% fueron hombres. El 64,7% recibió el dispositivo por SC y 35,3% por AAR. Dentro de las comorbilidades estudiadas, la hipertensión arterial fue la más frecuente, 94,1%. Un 58,8% de los pacientes fueron revascularizados a través de la arteria radial. El 29,4% recibió el dispositivo previo a la angioplastía y 70,6% lo recibió después. El 47,1% de las angioplastías fue guiada por imágenes. En 11,8% de ellos se realizó litotricia intracoronaria y 5,9% por ablación intracoronaria. Los pacientes estuvieron 13 ±3,4 días con el soporte. La mortalidad global fue de 41,2%. Conclusiones: El uso del dispositivo Impella presentó pocas complicaciones vasculares. La mortalidad asociada con su colocación en Chile fue relativamente similar con la reportada en la literatura.

Background: Cardiogenic shock and high-risk Angioplasty are associated with a high mortality rate. Using the Impella CP device could reduce the risk of death in these scenarios. In Chile, there are no studies evaluating the use of the Impella CP device. Objective: To analyse the clinical outcomes in patients who have undergone placement of the Impella CP device for cardiogenic shock and high-risk angioplasties. Methods: A retrospective study was carried out on 17 patients, which represent the total number of implants performed in the country, between October 2021 and August 2023. The demographic, procedural and post-implant characteristics were described. Overall mortality and associated factors were identified. Results: The age was 69± 3.7 years, where 88.2% were men. 64.7% of patients received the device by SC and 35.3% by AAR. Among the comorbidities studied, arterial hypertension was the most frequent with 94.1%. 58.8% of patients were revascularized through the radial artery. 29.4% of patients received the device before angioplasty and 70.6% received it afterwards. 47.1% of angioplasties were image-guided, 11.8% had intracoronary lithotripsy, and 5.9% had intracoronary ablation. The patients spent 13 ±3.4 days with the support. Overall mortality was 41.2%. Conclusion: use of the Impella device was associated with few vascular complications. Mortality associated with use of the Impella device in Chile was similar to that previously reported in other studies.

Shock cardiogénico en el contexto de los síndromes coronarios agudos en Argentina: resultados del Registro ARGEN SHOCK 2 / Cardiogenic Shock in the Setting of Acute Coronary Syndromes in Argentina: Results from the ARGEN SHOCK 2 Registry

RESUMEN El shock cardiogénico (SC) es una complicación grave del infarto agudo de miocardio (IAM) y constituye una de sus principales causas de muerte. Objetivos: Conocer las características clínicas, estrategias de tratamiento, evolución intrahospitalaria y mortalidad a 30 días del SC en Argentina. Material y métodos: Se trata de un registro prospectivo, multicéntrico, de pacientes internados con SC en el contexto de los IAM con y sin elevación del segmento ST durante 14 meses (1 de agosto 2021 al 30 de septiembre 2022) en 23 centros de Argentina. Resultados: Se incluyeron 114 pacientes, edad 64 (58-73) años, 72% hombres. El 76,3% de los casos corresponden a IAM con elevación del segmento ST, 12,3% a IAM sin elevación del segmento ST, el 7% a infarto de ventrículo derecho y el 4,4% a complicaciones mecánicas. El SC estuvo presente desde el ingreso en el 66,6% de los casos. Revascularización: 91,1%, uso de inotrópicos: 98,2%, asistencia respiratoria mecánica: 59,6%, SwanGanz: 33,3%, balón de contrapulsación intraaórtico: 30,1%. La mortalidad intrahospitalaria global fue 60,5%, sin diferencias entre los IAM con o sin elevación del segmento ST, y a 30 días del 62,6%. Conclusiones: La morbimortalidad del SC es muy elevada a pesar de la alta tasa de reperfusión empleada.

ABSTRACT Background: Cardiogenic shock (CS) is a life-threatening complication of acute myocardial infarction (AMI) and constitutes one of the leading causes of death. Objective: The aim of this study was to investigate the clinical characteristics, treatment strategies, hospital outcome and 30-day mortality of CS in Argentina. Methods: We conducted a prospective, and multicenter registry of patients with acute myocardial infarction (AMI) with and without ST-segment elevation complicated with CS that were hospitalized in 23 centers in Argentina for 14 months (between August 1, 2021, and September 30, 2022). Results: The cohort was made up of 114 patients; median age was 64 years (58-73) and 72% were women; 76.3% corresponded to ST-segment elevation AMI, 12.3% to non-ST-segment elevation AMI, 7% had right ventricular infarction and 4.4% had mechanical complications. In 66.6% of cases CS was present on admission. Revascularization: 91.1%, use of inotropic agents: 98.2%, mechanical ventilation: 59.6%, Swan-Ganz catheter: 33.3%, intra-aortic balloon pump: 30.1%. Overall in-hospital mortality was 60.5%, with no differences between AMI with or without ST-segment elevation, and was 62.6% at 30 days. Conclusion: Morbidity and mortality of CS are high despite the high rate of reperfusion therapy used.

Determinación del riesgo de muerte por afecciones vasculares en hipertensos de la población peruana 2021-2022

Objetivo: determinar el riesgo de muerte inmediata por eventos vasculares en hipertensos de la población peruana en el periodo 2021-2022 Metodología: estudio observacional, de casos y controles basado en datos del sistema nacional de defunciones del instituto nacional de estadística e informática del Perú entre enero de 2021 a agosto de 2022. Fueron incluidos todos los pacientes, hipertensos y no hipertensos, que fallecieron por alguna de las afecciones vasculares seleccionadas en las variables las cuales fueron, además de la presencia de hipertensión: paro cardiaco, accidente cerebrovascular isquémico y hemorrágico, choque cardiogénico, Se realizó la prueba de Chi-cuadrado de Pearson y la razón de probabilidades para la estimación del riesgo. Resultados: de 5385 muertes por infarto de miocardio, 54,80% tuvieron hipertensión arterial; de 1425 muertes por choque cardiogénico, 45,12% fueron hipertensos; de 434 fallecidos por accidente cerebrovascular isquémico, 52,76% padecieron hipertensión arterial; de los 746 fallecidos por accidente cerebrovascular hemorrágico, 56,97% fueron hipertensos; de los 4401 fallecidos por paro cardiaco, 25,61% también tuvieron hipertensión arterial. Se encontró que los hipertensos tuvieron un riesgo 7,52 veces mayor de morir por infarto agudo de miocardio, 3,39 veces por choque cardiogénico, 5,75 veces por accidente cerebrovascular isquémico, 10,27 accidente cerebrovascular hemorrágico y 1,94 veces por paro cardiaco. Conclusiones: las afecciones vasculares de mayor a menor riesgo de provocar la muerte en hipertensos son el accidente cerebrovascular, el infarto de miocardio, el accidente cerebrovascular isquémico, el choque cardiogénico y el paro cardiaco.

Objective: To determine the risk of immediate death due to vascular events in hypertensive patients in the Peruvian population in the period 2021-2022. Methodology: Observational, case-control study based on data from the national death system of the National Institute of Statistics and Informatics of Peru between January 2021 and August 2022. All patients, hypertensive and non-hypertensive, who died from any of the vascular affections selected in the variables which were, in addition to the presence of hypertension: cardiac arrest, ischemic and hemorrhagic cerebrovascular accident, cardiogenic shock. The Pearson's Chi-square test and the odds ratio were performed for the estimation of the risk. Results: Of 5385 deaths due to myocardial infarction, 54.80% had arterial hypertension; of 1425 deaths due to cardiogenic shock, 45.12% were hypertensive; of 434 deaths from ischemic stroke, 52.76% suffered arterial hypertension; of the 746 who died from hemorrhagic stroke, 56.97% were hypertensive; of the 4,401 deaths from cardiac arrest, 25.61% also had arterial hypertension. It was found that hypertensive patients had a 7.52 times higher risk of dying from acute myocardial infarction, 3.39 times from cardiogenic shock, 5.75 times from ischemic stroke, 10.27 times from hemorrhagic stroke and 1.94 times from heart attack. Conclusions: Vascular conditions from highest to lowest risk of causing death in hypertensives are cerebrovascular accident, myocardial infarction, ischemic cerebrovascular accident, cardiogenic shock and cardiac arrest.

Catéter de arteria pulmonar en shock cardiogénico: novedades acerca de su valor pronóstico y marcadores derivados

El uso del catéter de arteria pulmonar es un método eficaz para la monitorización de los pacientes críticos. Aunque ampliamente utilizado en las Unidades de Cuidados Críticos Cardiológicos, no se ha demostrado en estudios previos el beneficio de su uso. Registros recientes y numerosos en pacientes graves cursando shock cardiogénico muestran un beneficio en términos de mortalidad asociada, sobre todo relacionado con una adecuada interpretación. Además, nuevos parámetros relacionados con insuficiencia ventricular como son el poder cardíaco y el índice de pulsatilidad de arteria pulmonar, así como el conocimiento de las presiones de llenado ventriculares, tanto izquierdas, como derechas, ayudan en la toma de decisiones, las opciones de tratamiento y estimación del pronóstico. Complementando lo anterior, la modernización en la tecnología del catéter de arteria pulmonar permite la medición del gasto cardíaco de forma continua a través de un sistema termodilución integrada. Este sistema también permite la monitorización más precisa del ventrículo derecho por medio de la valoración continua de su fracción de eyección y volumen de fin de diástole. La información obtenida por medio del catéter de arteria pulmonar en shock cardiogénico ha llevado a que su uso comience a ser cada vez más frecuente en unidades de cuidados críticos cardiológicos y que se empleen estos valores por equipos de shock cardiogénico para la toma de decisiones complejas. La evidencia descrita sobre el valor pronóstico relacionada al uso del catéter de arteria pulmonar se resume en esta revisión.

The pulmonary artery catheter is an effective tool for monitoring critically ill patients; however, the evidence showed limited value and a posible increased risk. Recently, numerous registries in critical ill patients in cardiogenic shock have shown a benefit in mortality, especially related to an adequate interpretation of findings. In addition, new parameters related to ventricular failure, such as cardiac power output and pulmonary artery pulsatility index have shown to be useful for a better treatment and estimation of prognosis. Besides, determination of filling pressures (right and/or left side) have an important role in terms of prognosis and management. Advances in pulmonary artery catheter technology allows us to continuously measure cardiac output through an integrated thermodilution system. This system also allows the continuous assessment of right ventricular ejection fraction and end-diastolic volume. The information obtained has led to an increased use of the pulmonary artery catheter monitoring in cardiac Intensive Care Units allowing improvements in treatment and complex decision-making.

Management of Harlequin Syndrome Under ECPELLA Support: A Report of Two Cases and a Proposed Approach

The use of ECPELLA in patients with severe lung disease may result in an unfavorable phenomenon of differential hypoxia. The simultaneous evaluation of three arterial blood samples from different arterial line (right radial artery, left radial artery, ECMO arterial line) in patients at risk of Harlequin syndrome (also called differential hypoxemia (DH)) can localize the 搈ixing cloud� along the aorta. Focusing the attention on the 搈ixing cloud� position instead of on isolated flows of Veno?Arterial Extracorporeal Membrane Oxygenation (VA ECMO) and Impella CP makes the decision making easier about how to modify MCSs flows according to the clinical context. Herein, we present two cases in which ECPELLA configuration was used to treat a cardiogenic shock condition and how the ECPELLA-induced hypoxia was managed.

Multiparameters Associated to Successful Weaning from VA ECMO in Adult Patients with Cardiogenic Shock or Cardiac Arrest: Systematic Review and Meta?Analysis

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is a form of temporary mechanical circulatory support and simultaneous extracorporeal gas exchange for acute cardiorespiratory failure, including refractory cardiogenic shock (CS) and cardiac arrest (CA). Few studies have assessed predictors of successful weaning (SW) from VA ECMO. This systematic review and meta-analysis aimed to identify a multiparameter strategy associated with SW from VA ECMO. PubMed and the Cochrane Library and the International Clinical Trials Registry Platform were searched. Studies reporting adult patients with CS or CA treated with VA ECMO published from the year 2000 onwards were included. Primary outcomes were hemodynamic, laboratory, and echocardiography parameters associated with a VA ECMO SW. A total of 11 studies (n=653) were included in this review. Pooled VA ECMO SW was 45% (95%CI: 39�%, I2 7%) and in?hospital mortality rate was 46.6% (95%CI: 33�%; I2 36%). In the SW group, pulse pressure [MD 12.7 (95%CI: 7.3�) I2 = 0%] and mean blood pressure [MD 20.15 (95%CI: 13.8�.4 I2 = 0) were higher. They also had lower values of creatinine [MD �59 (95%CI: �9 to �2) I2 = 7%], lactate [MD �1 (95%CI: �4 to �7) I2 = 89%], and creatine kinase [�79.5 (95%CI: �87 to �1) I2 = 38%]. And higher left and right ventricular ejection fraction, MD 17.9% (95%CI: �2�.2) I2 = 91%, and MD 15.9% (95%CI 11.9�) I2 = 0%, respectively. Different hemodynamic, laboratory, and echocardiographic parameters were associated with successful device removal. This systematic review demonstrated the relationship of multiparametric assessment on VA ECMO SW.

Use of Impella Devices for Acute Cardiogenic Shock in the Perioperative Period of Cardiac Surgery

ABSTRACT Introduction: The Impella ventricular support system is a device that can be inserted percutaneously or directly across the aortic valve to unload the left ventricle. The purpose of this study is to determine the role of Impella devices in patients with acute cardiogenic shock in the perioperative period of cardiac surgery. Methods: A retrospective single-surgeon review of 11 consecutive patients who underwent placement of Impella devices in the perioperative period of cardiac surgery was performed. Patient records were evaluated for demographics, indications for placement, and postoperative outcomes. Results: Impella devices were placed for refractory cardiogenic shock preoperatively in 6 patients, intraoperatively in 4 patients, and postoperatively as a rescue in 1 patient. Seven patients received Impella CP, 1 Impella RP, 1 Impella CP and RP, and 2 Impella 5.0. Additionally, 3 patients required preoperative venovenous extracorporeal membrane oxygenation (VV-ECMO), and 1 patient required intraoperative venoarterial extracorporeal membrane oxygenation (VA-ECMO). All Impella devices were removed 1 to 28 days after implantation. Length of stay in the intensive care unit stay ranged from 2 to 53 days (average 23.9±14.6). The 30-day and 1-year mortality were 0%. Ten of 11 patients were alive at 2 years. Also, 1 patient died 18 months after surgery from complications of coronavirus disease (Covid-19). Device-related complications included varying degrees> of hemolysis in 8 patients (73%) and device malfunction in 1 patient (9%). Conclusions: The Impella ventricular support system can be combined with other mechanical support devices for additional hemodynamic support. All patients demonstrated myocardial recovery with no deaths in the perioperative period and in 1-year of follow-up. Larger studies are necessary to validate these findings.

Venoarterial Extracorporeal Membrane Oxygenation as A Bridge to Surgery in Post-Myocardial Infarction Ventricular Septal Defect with Cardiogenic Shock: Case Report

ABSTRACT We describe a 60-year-old woman with post-myocardial infarction (MI) ventricular septal defect (VSD) and cardiogenic shock who was successfully stabilized with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge therapy for the surgical closure of her VSD. This case highlights the role of VA-ECMO in the management of post-MI VSD to improve the results of surgical repair and patient survival.

Protocol-based Surgical Intervention to Manage Ventricular Septal Rupture from a Tier Two City

ABSTRACT Introduction: This study analyzes the outcome of a protocol-based surgical approach for ventricular septal rupture (VSR). The study also clarifies the appropriate time for intervention. Methods: This is a single-center retrospective analysis of all VSR cases evaluated between February 2006 and March 2020. Cases were managed using the same protocol. Patients were divided into two cohorts - early (those in whom our protocol was instituted within 24 hours of diagnosis) and delayed (intervention between 24 hours and seven days after diagnosis). All-cause mortality was considered as the outcome. Results: The mean age of presentation was 60.1 years, and 75.9% of the patients were men. Cardiogenic shock was the most common mode of presentation. Our analysis validates that once a patient develops VSR, age, sex, comorbidities, left ventricular function, and renal failure at the time of presentation do not have a statistically significant impact on the outcome. The sole factor to have an impact on the outcome was time of intervention. All patients in the delayed cohort expired after surgery, which dragged the overall mortality to 34.5%, whereas 95% of patients in the early cohort are still on follow-up. The mortality in this group was 5% (P≤0.001). Conclusion: Early surgical intervention has proven benefits over delayed approach. Surgical intervention in the early part of the disease reduces the risk and thus improves the outcome. The extreme rarity makes VSR an uncommon entity among surgeons. A protocol-based approach makes the team adapt to this unfamiliar situation better.

Acute inferior myocardial infarction combined with papillary muscle rupture: A case report / 中南大学学报(医学版)

The incidence of acute myocardial infarction (AMI) is increasing. Acute papillary muscle rupture is one of the serious and rare mechanical complications of AMI, which occurs mostly in inferior and posterior myocardial infarction. A patient with acute inferior myocardial infarction developed pulmonary edema and refractory shock, followed by cardiac arrest. After cardiopulmonary resuscitation (CPR), revascularization of criminal vessels was carried out by emergency percutaneous transluminal coronary angioplasty (PTCA) under the support of intra-aortic balloon pump (IABP) and extra corporeal membrane oxygenation (ECMO). Although the patient was given a chance for surgery, his family gave up treatment due to unsuccessful brain resuscitation. It reminds that mechanical complications such as acute papillary muscle rupture, valvular dysfunction and rupture of the heart should be highly suspected when cardiogenic pulmonary edema and cardiogenic shock are difficult to correct in acute inferior myocardial infarction. Echocardiogram and surgery should be put forward when revascularization of criminal vessels is available.

Application of cardiopulmonary ultrasound in adult acute dyspnea: construction of differential diagnosis model between cardiogenic pulmonary edema and pneumonia / 中华超声影像学杂志

Objective:To analyze the cardio-pulmonary ultrasound features of cardiogenic pulmonary edema (CPE) and pneumonia in adults with acute dyspnea, and to construct a differential diagnosis model.Methods:Seven hundred and forty-three patients with sudden acute dyspnea admitted to Hebei General Hospital from November 2018 to May 2022 were retropectively included. Ultrasonographer A performed lung ultrasound with 12 zone method, and interpreted and recorded the ultrasonic signs (including A-lines area, B-lines area, consolidation area and pleural effusion area) together with ultrasonographer B. According to the ultrasonic characteristics of the whole lung, it was divided into A-profile and B-profile. According to the continuity and symmetry of the distribution of B-lines in bilateral lung fields, it could be divided into bilateral lung continuous and discontinuous B-profile, bilateral lung symmetric and asymmetric B-profile. Left ventricular ejection fraction (LVEF), left ventricular filling pressure (E/e′), right ventricular dilatation, tricuspid annular systolic displacement (TAPSE) and inferior vena cava diameter (IVCD) were evaluated by echocardiography, and all the indexes were transformed into binary variables. According to the final clinical diagnosis and treatment results, the disease was divided into CPE group and pneumonia group. Binary Logistic regression model was used to screen independent influencing factors, and partial regression coefficient β value was used as a weight to assign a score, and a differential diagnosis model was established based on the total score. The predictive value of the model was evaluated by the receiver operating characteristic curve (ROC) and area under curve (AUC). After the model was built, 30 patients with CPE or pneumonia were independently collected by ultrasonographer C as external validation data, which were included in the model to draw ROC curve and evaluate the differential diagnosis efficiency of the model. The consistencies between ultrasonographer A and B, A and C in observing lung ultrasound were explored.Results:A total of 743 patients from 43 clinical departments were included, including 246 cases in CPE group and 497 cases in pneumonia group. Multivariate logistic regression analysis showed that bilateral lung continuous B-profile, bilateral lung symmetric B-profile, ≥1 pleural effusion area, LVEF<50%, E/e′>14 were the risk factors for CPE (all OR>1, P<0.05), and ≥1 consolidation area and ≥1 pleural sliding disappearance area were the protective factors for CPE (all OR>1, P<0.05). The sensitivity, specificity and AUC of combined cardio-pulmonary ultrasound index β value weight score in the differential diagnosis of CPE and pneumonia were 0.939, 0.956 and 0.986, respectively. The AUC of external validation data was 0.904. Ultrasonographer A and B, A and C had good consistency in the interpretation of lung ultrasound signs ( P<0.05). Conclusions:The differential diagnosis model based on combined cardio-pulmonary ultrasound indexes has high differential diagnosis efficiency for CPE and pneumonia, and can be used in bedside cardio-pulmonary ultrasound practice.

Mechanism of action of Shen-Fu decoction on cardiogenic shock based on network pharmacology and experimental validation / 中国药理学通报

Aim To investigate the mechanism of action of Shen-Fu decoction in the prevention and treatment of cardiogenic shock based on network pharmacology and animal experiments. Methods The relevant targets and signaling pathways of cardiogenic shock of Shen-Fu decoction were predicted by network pharmacology, and a cardiogenic shock rat model was created by coronary artery ligation. Before modeling, rats were given the appropriate dose of Shen-Fu decoction or saline by gavage for 14 days according to the group, and real-time mean arterial pressure (MAP) changes were recorded after successful modeling. HE method was used to detect the myocardial histopathological changes of cardiogenic shock. TUNEL method was employed to detect rat myocardial cell apoptosis, and Western blotting was applied to determine the expression levels of rat myocardial Bax, Bcl-2, caspase-3, cleaved caspase-3 proteins. Results A total of 51 potential active ingredients of Shen-Fu decoction were screened out by network pharmacology, 80 targets of co-action with cardiogenic shock, and 43 core targets of close relationship between proteins, and GO enrichment analysis revealed that the core proteins were involved in the biology process (BP), mainly involving positive regulation of apoptotic process. KEGG enrichment analysis showed signaling pathways involving atherosclerosis-related, apoptosis and other signaling pathways. The results of animal model validation showed that Shen-Fu decoction could increase the shock blood pressure of rats with cardiogenic shock and alleviate the pathological changes of myocardial tissue, reduce the degree of apoptosis of rat cardiomyocytes, reduce the expression level of caspase-3, cleaved caspase-3 and Bax protein in rat myocardial tissue, and improve the expression level of Bcl-2 protein in myocardial tissue of rats. Conclusions The potential active ingredient of Shen-Fu decoction may play a role in the prevention and control of cardiogenic shock rats by acting on the target Bax, Bcl-2 to regulate the apoptosis signaling pathway of cardiomyocytes.

Mechanical Circulatory Support (MCS) for Cardiogenic Shock / 日本心臓血管外科学会雑誌

Mechanical Circulatory Support (MCS) is established to salvage cases with cardiogenic shock. MCS includes intra-aortic balloon pumping (IABP), veno-arterial extracorporeal membrane oxygenation (VA-ECMO), or pump-catheter. Prompt introduction of these devices enables 1) unloading of left and/or right ventricles, 2) sufficient supply of oxygenated blood to end-organs, and 3) maintenance of pulmonary circulation. Under MCS, then, cause of cardiogenic shock is explored and appropriate treatments are given to wean-off the MCS. In this review, selection of the MCS devices, technical tips of each MCS, and management of the cases under MCS are explained.

Severe primary hypothyroidism presenting as polymorphic ventricular tachycardia / Hipotiroidismo primario grave que se presenta como taquicardia ventricular polimórfica

Abstract Introduction: Hypothyroidism may have various cardiovascular manifestations due to morphological, functional and electrical alterations in the heart. The usual electrocardiographic findings being sinus bradycardia, low voltage complexes, and slowed intraventricular conduction. Hypothyroidism manifesting as polymorphic ventricular tachycardia has only been reported in a few case reports. Clinical case. A 60-year-old lady presented to us in the emergency department in an unresponsive and unconscious state and electrocardiogram showed a polymorphic ventricular tachycardia. After initial resuscitation with direct current cardioversion and supportive care, she found to have severe hypothyroidism and responded well to thyroid replacement therapy. Conclusion. Polymorphic ventricular tachycardia is a life threatening emergency that can have various etiologies. Polymorphic ventricular tachycardia secondary to primary hypothyroidism is a rare presentation but it is treatable and reversible with thyroid replacement therapy. In patients presenting with QT interval prolongation and ventricular tachycardia, hypothyroidism should be one of the differential diagnosis.

Resumen Introducción: El hipotiroidismo puede presentar diferentes manifestaciones cardiovasculares dadas por alteraciones morfológicas, funcionales y eléctricas en el corazón, siendo los hallazgos electrocardiográficos usuales son la bradicardia sinusal, los complejos de bajo voltaje y la conducción intraventricular lenta. El hipotiroidismo manifestado como taquicardia ventricular polimórfica solo se ha descrito en unos pocos reportes de caso. Caso clínico: Se trata de una mujer de 60 años que acudió que acurdió al servicio de urgencias en un estado inconsciente y sin respuesta a estímulos, y el electrocardiograma reveló taquicardia ventricular polimórfica. Luego de la reanimación inicial con cardioversión con corriente directa y tratamiento sintomático se le encontró un hipotiroidismo grave, el cual se trató con terapia de reemplazo con hormona tiroidea. y se obtuvo una buena respuesta Conclusión. La taquicardia ventricular polimórfica es una emergencia vital que puede tener varias etiologías. La taquicardia ventricular polimórfica secundaria a un hipotiroidismo primario es una presentación poco común, pero es tratable y reversible con la terapia de reemplazo con hormona tiroidea. En los pacientes que presentan una prolongación del intervalo QT y taquicardia ventricular, es pertinente incluir el hipotiroidismo en el diagnóstico diferencial.

Choque cardiogénico por síndrome coronario agudo en el servicio de cardiología de Las Tunas / Cardiogenic shock due to acute coronary syndrome in the cardiology service of Las Tunas

RESUMEN Introducción: el choque cardiogénico es la forma más grave de insuficiencia cardíaca aguda y la principal causa de muerte en pacientes con infarto agudo de miocardio. Objetivo: caracterizar a los pacientes con choque cardiogénico por síndrome coronario agudo en el servicio de cardiología de Las Tunas en el período octubre de 2017 a junio de 2021. Métodos: se realizó un estudio descriptivo y transversal con un universo de 325 pacientes y una muestra conformada de forma intencionada por 296 pacientes con el diagnóstico de insuficiencia cardíaca aguda por síndrome coronario agudo. Se estudiaron las variables edad, sexo, antecedentes patológicos personales, obesidad, tabaquismo, valvulopatías asociadas, frecuencia cardíaca, presión arterial sistólica, uso previo de fármacos, eventos adversos, variables ecocardiográficas y electrocardiográficas. Resultados: El 16,5 % de los pacientes estudiados desarrollaron choque cardiogénico; con prevalencia de la edad > 60 años (67,3 % grupo I vs. 80,3 % grupo II), el sexo masculino y los antecedentes de HTA (87,8 %). El uso previo de IECA o ARA II mostró una asociación inversamente proporcional a la presencia de choque cardiogénico (61,5 %). Ecocardiográficamente predominó la FEVI reducida (61,2 %), relación E/e´ alterada (32,6 %), velocidad de la onda S <5,4 cm/seg (42,9 %) y VFS elevados (46,9 %). Prevaleció el IMACEST (81,6 %) y la topografía anterior (51,1 %). Conclusiones: los pacientes con síndrome coronario agudo que con mayor frecuencia evolucionan al choque cardiogénico son los de edad avanzada, sin tratamiento farmacológico previo, con infartos de topografía anterior y fracción de eyección del ventrículo izquierdo reducida.

ABSTRACT Introduction: cardiogenic shock is the most severe form of acute heart failure and the main cause of death in patients with acute myocardial infarction. Objective: to characterize patients with cardiogenic shock due to acute coronary syndrome in the cardiology service of Las Tunas in the period October 2017 to June 2021. Methods: a descriptive and cross-sectional study was carried out with a universe of 325 patients and a sample intentionally formed by 296 patients with the diagnosis of acute heart failure due to acute coronary syndrome. The variables studied were age, sex, personal pathological history, obesity, smoking, associated valvulopathies, heart rate, systolic blood pressure, previous drug use, adverse events, echocardiographic and electrocardiographic variables. Results: 16,5 % of the patients studied developed cardiogenic shock; age > 60 years (67,3 % group I vs. 80,3 % group II), male sex and history of HT (87,8 %) prevailed. Previous use of ACEI or ARA II showed an inversely proportional association with the presence of cardiogenic shock (61,5 %). Echocardiographically, reduced LVEF (61,2 %), altered E/e' ratio (32,6 %), S-wave velocity <5,4 cm/sec (42,9 %) and elevated SFV (46,9 %) predominated. STEMI (81,6%) and anterior topography (51,1%) prevailed. Conclusions: patients with acute coronary syndrome who most frequently progress to cardiogenic shock are those of advanced age, without previous pharmacological treatment, with anterior topography infarctions and reduced left ventricular ejection fraction.

Dispositivos de asistencia ventricular en el shock cardiogénico posinfarto: importancia del soporte hemodinámico: reporte de caso / Ventricular assist devices in post-infarction cardiogenic shock: importance of hemodynamic support: case report / Dispositivos de assistência ventricular no choque cardiogênico pós-infarto: importância do suporte hemodinâmico: relato de caso

El shock cardiogénico posinfarto caracterizado por un estado de insuficiencia circulatoria sistémica requiere de un tratamiento precoz en vistas a restablecer la estabilidad hemodinámica y la función ventricular. Este consta de la reperfusión coronaria mediante revascularización miocárdica; en algunos casos es necesaria la utilización de dispositivos de asistencia ventricular. El ECMO venoarterial es un sistema de circulación extracorpórea que permite un soporte biventricular oxigenando la sangre y reintroduciéndola mediante un flujo continuo hacia la circulación arterial sistémica. El uso de dicho dispositivo en pacientes con shock cardiogénico ha mostrado una mejoría significativa de la sobrevida a 30 días en comparación con el uso del balón de contrapulsación intraaórtico. No obstante, sus potenciales complicaciones, como dificultad en el vaciamiento ventricular izquierdo, síndrome de Arlequín, sangrados e infecciones, hacen fundamental la formación y el trabajo en equipo del heart team. Un porcentaje no menor de estos pacientes presentarán una severa disfunción ventricular permanente, por lo que podrían ser candidatos a dispositivos de asistencia ventricular izquierda de larga duración tipo Heartmate III como puente al trasplante cardíaco, el cual ha mostrado resultados satisfactorios con una excelente sobrevida a mediano plazo.

Post-infarction cardiogenic shock characterized by a state of systemic circulatory failure requires early treatment in order to restore hemodynamic stability and ventricular function. This consists of coronary reperfusion through myocardial revascularization, requiring in some cases the use of ventricular assist devices. Veno-arterial ECMO is an extracorporeal circulation system that allows biventricular support by oxygenating the blood and reintroducing it through a continuous flow towards the systemic arterial circulation. The use of this device in patients with cardiogenic shock has shown a significant improvement in survival at 30 days compared to the use of intra-aortic balloon pump. However, its potential complications, such as difficulty in left ventricular emptying, Harlequin syndrome, bleeding and infections, make the training and teamwork of the heart team essential. A great percentage of these patients will present a severe permanent ventricular dysfunction, so they could be candidates for long-term mechanical circulatory support devices like Heartmate III as a bridge to transplant or myocardial recovery, or destination therapy, which has shown satisfactory results with excellent medium-term survival.

O choque cardiogênico pós-infarto caracterizado por um estado de insuficiência circulatória sistêmica requer tratamento precoce para restabelecer a estabilidade hemodinâmica e a função ventricular. Esta consiste na reperfusão coronariana por meio de revascularização miocárdica, necessitando, em alguns casos, do uso de dispositivos de assistência ventricular. A ECMO venoarterial é um sistema de circulação extracorpórea que permite o suporte biventricular oxigenando o sangue e reintroduzindo-o através de um fluxo contínuo para a circulação arterial sistêmica. O uso desse dispositivo em pacientes com choque cardiogênico mostrou melhora significativa na sobrevida em 30 dias em relação ao uso de contrapulsação com balão intra-aórtico. No entanto, suas potenciais complicações, como dificuldade de esvaziamento ventricular esquerdo, síndrome de Harlequin, sangramentos e infecções, tornam imprescindível o treinamento e o trabalho em equipe do time do coração. Não uma pequena porcentagem desses pacientes apresentará uma condição ventricular permanente grave, podendo ser candidatos a dispositivos de assistência ventricular esquerda de longa duração do tipo Heartmate III como ponte para o transplante cardíaco, que tem demonstrado resultados satisfatórios com excelente sobrevida em médio prazo.

Effect of Mild Hypothermia on Morbidity and Mortality in Post AMI Cardiogenic Shock

Background: Acute myocardial infarction (AMI) complicated with cardiogenic shock is still associated with a significant death rate. Other interventions, including intra-aortic balloon counter pulsation and medical therapy, failed to improve prognosis in large-scale randomised studies, with the exception of early revascularization. Recently, mild therapeutic hypothermia, in which patients are lowered to 33°C over the course of 24 hours, has been proposed as a therapy option for cardiogenic shock patients. The purpose of this study is to determine the impact of mild hypothermia on morbidity and mortality associated with post-AMI cardiogenic shock. Methods: This randomized, controlled, unblinded trial was conducted on 50 patients with AMI complicated by CS. Patients were randomly allocated into two equal groups; group I received MTH to 33°C for 24-36 h and group II (control group) did not receive MTH. Patients were subjected to full history taking, general and clinical examination, laboratory examination, echo, chest ultrasound (US), coronary angiography data and mild therapeutic hypothermia protocol. Results: Stroke until day 30, duration of mechanical ventilation, length of ICU stay, duration of inotropic support, mortality and pulmonary congestion by US were insignificantly different between both groups. Arterial lactate and mean arterial blood pressure (MAP) at 4h, 6h, 8h, 10h, 12h, 14h, 16h, 18h, 20h were significantly increased in group I than Group II (P value<0.05). and were insignificantly different between both groups at 0h, 2h, 22h, 24h, 26h, 28h, 30h. Serum creatinine at 24h, 48h was significantly increased in group I than Group II (p value <0.05) and was insignificantly different between both groups at 0h. Conclusions: Therapeutic hypothermia (TH) didn’t improve short term outcomes in patients with post AMI cardiogenic shock.

Valor pronóstico del índice de shock en el infarto de miocardio. Datos del Registro Argentino de infarto con elevación del segmento ST (ARGEN IAM-ST) / Prognostic value of the shock index in myocardial infarction. Data from Argentine Registry of ST-segment elevation infarct (ARGEN IAM-ST)

Resumen El índice de shock (IS) se obtiene mediante un cálculo simple del cociente entre la frecuencia cardíaca (FC) y la tensión arterial sistólica (PAS) (IS: FC/TAS) y el índice de shock ajustado por edad (ISA) multiplicando el IS x edad. Evaluamos su valor predictivo para el evento combinado intrahospitalario (EC) muerte y/o shock cardiogénico (SC) y de los eventos individuales en los pacientes incluidos en el registro argentino de infarto con elevación del segmento ST (ARGEN-IAM-ST). Se excluyeron 248 con SC de ingreso. Se realizaron curvas ROC para ambos índices utilizando el mejor punto de corte para dicotomizar la población. Se incluyeron 2928 pacientes. Edad (mediana) 60 años (RIC 25-75% 53-68), varones 80%, EC: 6.4%. Un 30.5% tuvo IS ≥ 0.67 y éstos presentaron mayor incidencia de EC: 11% vs. 4% (p < 0.001), shock cardiogénico (8% vs. 2.6%, p <0.0001) y muerte (7.3% vs. 3%, p < 0.0001) que los pacientes con IS < 0.67. Un 28% tuvo ISA ≥ 41.5. Estos presentaron más EC: 14% vs. 3%, p < 0.001, SC: 10% vs. 2%, (p < 0.001) y muerte: 9.5% vs. 2.3%, (p < 0.001) comparados con los pacientes con valores ISA < 41.5. El área bajo la curva ROC del ISA para EC fue significativamente mejor que la del IS (0.72 vs. 0.62, p < 0.001).En los modelos de análisis multivariados reali zados, el IS tuvo un OR de 2.56 (IC95% 1.56-4.02; p < 0.001) y el ISA de 3.43 (IC95% 2.08-5.65; p<0.001) para EC. El IS y el ISA predicen muerte y/o el desarrollo de shock cardiogénico intrahospitalario en una población no seleccionada de infartos con elevación del ST.

Abstract The shock index (IS) is the quotient between the heart rate (HR) and the systolic blood pressure (SBP) (IS: HR / SBT), and the age-adjusted shock index (ISA) multiplying the IS by age. We evaluated its predictive value for the combined in-hospital event (EC), death and / or cardiogenic shock (CS) and for individual events in the patients included in the Argentine registry of ST-segment elevation infarction (ARGEN-ST-AMI); 248 with CS on admission were excluded. ROC curves were made for both indices using the best cut-off point to dichotomize the population. The analysis included 2928 subjects. Age (median) 60 years (IQR 25-75% 53-68), men 80%, EC: 6.4%; 30.5% had IS ≥ 0.67, and they had a higher incidence of EC: 11% vs. 4% (p < 0.001), cardiogenic shock (8% vs. 2.6%, p <0.0001) and death (7.3% vs. 3%), p <0.0001) than patients with IS < 0.67. A 28% had ISA ≥ 41.5. These presented plus EC: 14% vs. 3%, p < 0.001, SC: 10% vs. 2%, (p < 0.001) and death: 9.5% vs. 2.3%, (p < 0.001) compared with patients with values < 41.5. The area under the ROC curve of the ISA for EC was significantly better than that of the IS (0.72 vs. 0.62, p < 0.001). In the multivariate analysis models performed, the IS had an OR: 2.56 (95% CI 1.56-4.02; p < 0.001) and the ISA: 3.43 (95% CI 2.08-5.65; p < 0.001) for EC. The IS and ISA predict death and / or the development of in-hospital cardiogenic shock in an unselected population of ST elevation infarcts.