Limb ischemia in patients with COVID-19 / Isquemia de membros em pacientes com COVID-19

Abstract This narrative review covers the life-threatening thromboembolic events associated with SARS-CoV-2 infection/COVID-19. It addresses the physical changes that cause vascular and arterial damage to limbs, laboratory management of coagulation, and management of anticoagulation. COVID-19's relationship with deep venous thrombosis and arterial thrombosis is also emphasized. The main thromboembolic events described in the literature are illustrated with examples from our experience with COVID-19 patients.

Resumo Esta revisão narrativa abrange os eventos tromboembólicos com risco de vida associados a infecção por SARS-CoV-2/COVID-19. Aborda as mudanças físicas que causam danos vasculares e arteriais aos membros, o manejo laboratorial da coagulação e o manejo da anticoagulação. A relação de COVID-19 com trombose venosa profunda e trombose arterial também é enfatizada. Os principais eventos tromboembólicos descritos na literatura são ilustrados a partir de nossa experiência com pacientes COVID-19.

Embolismos sépticos pulmonares y sistémicos como forma de presentación de la endocarditis infecciosa / Septic pulmonary and systemic embolisms as form of presentation of infective endocarditis

Introducción: A partir de los años 50, la presentación clínica clásica de la endocarditis infecciosa ha variado. Debido al uso de antibióticos, drogas ilícitas, catéteres venosos, etc., las manifestaciones tradicionales no son frecuentes. Objetivo: Presentar un caso con endocarditis infecciosa y comentar las manifestaciones embolígenas, así como las medidas preventivas con las nuevas técnicas. Caso clínico: Enfermo con insuficiencia renal crónica, diabético, hipertenso, con catéter venoso central, que presentó, después de una sección de hemodiálisis; escalofríos intensos, fiebre de 39,5 0C, cefalea intensa, toma del estado general, dolor torácico intenso punzante, tos, expectoración con sangre roja rutilante, disnea, soplo regurgitante holosistólico. Se le realizó ecocardiograma dópler que muestra múltiples vegetaciones pequeñas, hemocultivos positivos a estafilococos dorado. Fue tratado según los resultados del antibiograma durante 6 semanas y resolvió su extrema gravedad. Conclusiones: La endocarditis infecciosa puede tener manifestaciones muy diferentes al de décadas anteriores; puede aparecer como cuadro agudo fulminante por manifestaciones embólicas y sépticas múltiples(AU)

Introduction: Since the 1950s, the classical clinical presentation of infectious endocarditis (E.I) has varied. Due to the use of antibiotics, illicit drugs, venous catheters, traditional manifestations are not frequent. Objectives: To review the embolic presentation of endocarditis and pecify the preventive measures with the new techniques. Clinical case: A patient with chronic renal insufficiency, diabetic, hypertensive, with central venous catheter, intense chills, fever of 39.5 ° C, intense headache, general state, severe chest pain, cough, expectoration with bright red blood, dyspnea, holosystolic regurgitant murmur, after a section of hemodialysis. Doppler echocardiogram was performed, visualizing multiple small vegetation's, positive blood cultures to golden staphylococci, treatment according to antibiograms for 6 weeks, at the end of which the extreme severity was resolved. Comments: Infective endocarditis can have a very different behavior from previous decades; it can appear as an acute fulminating disease due to embolic, septic, multiple manifestations(AU)

Perfil clínico y etiológico de pacientes operados con endocarditis activa. Seguimiento a diez años / Clinical and etiological profile of patients operated on with active endocarditis. Follow-up at 10 years / Perfil clínico e etiológico dos pacientes operados com endocardite ativa. Acompanhamento aos 10 anos

Resumen: Antecedentes: la endocarditis infecciosa es una enfermedad con elevada morbimortalidad, la cual se encuentra en torno al 25%. Aproximadamente el 50% de los casos requiere tratamiento quirúrgico. En nuestro medio se desconocen las características clínicas y evolutivas de pacientes operados por endocarditis infecciosa activa. Objetivos: primario, determinar mortalidad operatoria (MO) y sobrevida a largo plazo; secundario, definir predictores de embolias, complicaciones locales (CL), MO y endocarditis protésica (EP) en la evolución. Métodos: trabajo retrospectivo y analítico. Se identificaron pacientes que recibieron cirugía cardíaca por endocarditis activa entre enero de 2006 y diciembre de 2017. Mediante regresión logística multivariada se identificaron predictores para los objetivos enunciados. Resultados: se incluyeron 101 pacientes. El microorganismo más frecuentemente encontrado fue Staphylococcus aureus (SA) (15,8%). La topografía fue protésica en 20,8%, aórtica en 46,5%, mitral en 23,8% y mitro-aórtica en 13,9%. La MO fue 11,3% y 29,5% (p=0,025), según ausencia o presencia de CL, único predictor independiente de mortalidad (OR=3,38). El 47,5% presentó CL, siendo la más frecuente el absceso (25,7%). Fueron predictores independientes: EP (OR=5,8), endocarditis valvular aórtica (OR=2,9) y sexo masculino (OR=3,5). La incidencia de EP precoz fue 3% y tardía 4%. El 30% de los pacientes adquirió la EI como consecuencia de un procedimiento médico invasivo en los 6 meses previos. De los siete pacientes con EP en la evolución, seis tenían CL (p<0,05). El 31,7% presentaba embolias, resultando predictores independientes: Staphylococcus aureus (OR=4,6), vegetación en el velo mitral posterior (OR=3,2) y antecedente de hipertensión arterial (OR=3,32). La sobrevida a cinco y diez años fue de 88,20%±0,04 y 81,50%±0,05 respectivamente. Conclusiones: la MO de la endocarditis activa en nuestro medio es similar a la reportada internacionalmente. La presencia de CL se asocia a EP en la evolución y resultó ser un predictor independiente de sobrevida a largo plazo, y de MO. La sobrevida a largo plazo es similar a la reportada internacionalmente. Se observó una alta incidencia de agentes intrahospitalarios y procedimientos invasivos como causas probables.

Summary: Introduction: infective endocarditis is a high morbidity and mortality disease, which is about 25%. About fifty percent of patients require heart surgery. In our environment, clinical and evolutionary characteristics of patients operated with active endocarditis are unknown. Objective: primary, determine operative mortality and long-term survival; secondary, define predictors of embolisms, local complications, operative mortality and prosthetic endocarditis in evolution. Methods: retrospective, analytical study. Patients who received cardiac surgery for active endocarditis between January 2006 and December 2017 were identified. Through multivariate logistic regression, predictors were identified for the stated objectives. Results: one hundred and one patients were included. The most frequently found microorganism was Staphylococcus aureus (15.8%). The topography was prosthetic in 20.8%, aortic 46.5%, mitral 23.8% and mitro-aortic 13.9%. The operative mortality was 11.3% and 29.5% (p = 0.025) according to the absence or presence of local complications , the only independent predictor of mortality (OR = 3.32). Local complications were present in 47.5%, the most frequent were abscess (25.7%), independent predictors were: prosthetic endocarditis (OR=5.8), aortic endocarditis (OR=2.9) and male sex (OR=3.5). The incidence of early prosthetic endocarditis was 3% and late 4%. Thirty percent of patients acquired infective endocarditis as a result of an invasive medical procedure in the previous 6 months. Of the seven patients with prosthetic endocarditis in evolution, six had local complications (p <0.05). Embolic events were present in 31.7% of patients, were independent predictors: Staphylococcus aureus (OR=4.6), presence of vegetation in the posterior mitral leaflet (OR=3.2) and history of hypertension (OR=3.32). Survival at 5 and 10 years was 88.20% ± 0.04 and 81.50% ± 0.05 respectively. Conclusions: operative mortality of active endocarditis in our environment is high and similar to that reported internationally. The presence of local complications is associated with prosthetic endocarditis in evolution and proved to be an independent predictor of long-term survival, and operative mortality. Long-term survival is similar to that reported internationally. A high incidence of in-hospital agents was observed and invasive procedures as probable causes.

Resumo: Antecedentes: a endocardite infecciosa é uma doença com alta morbimortalidade. Requerem tratamento cirúrgico o 50%. Em nosso meio, as características clínicas e evolutivas dos pacientes operados com endocardite ativa são desconhecidas. Objetivos: primário, determinar a mortalidade operatória e a sobrevida a longo prazo; secundário: Definir preditores de embolias, complicações locais, mortalidade operatória e endocardite protética na evolução. Métodos: trabalho retrospectivo, analítico. Foram identificados no banco de dados pacientes submetidos à cirurgia de endocardite ativa entre janeiro de 2006 e dezembro de 2017. Através de regressão logística multivariada, os preditores foram identificados para os objetivos estabelecidos. Resultados: cento e um pacientes foram incluídos. Staphylococcus aureus foi o microrganismo mais frequente (15,8%). A topografia foi protética em 20,8%, aórtica 46,5%, mitral 23,8% e mitroaórtica 13,9%. A mortalidade operatória foi de 11,3% e 29,5% (p = 0,025), de acordo com a ausência ou presença de complicações locais, o único preditor independente de mortalidade (OR). Um 47,5% apresentaram complicações locais, sendo o mais frequente o abscesso (25,7%). Os preditores independentes foram: endocardite protética (OR = 5,8), endocardite valvar aórtica (OR=2,9)) e sexo masculino (OR = 3,5). A incidência de endocardite protética precoce foi de 3% e tardia de 4%. Trinta por cento dos pacientes adquiriram endocardite infecciosa como resultado de um procedimento médico invasivo nos 6 meses anteriores. Dos pacientes com endocardite protética na evolução, 85,7% apresentava complicações locais (p <0,05). O 31,7% apresentava embolia, resultando em preditores independentes: Staphylococcus aureus (OR = 4,6), vegetação no véu mitral posterior (OR = 3,2) e história de hipertensão arterial (OR = 3,32). A sobrevida em 5 e 10 anos foi de 88,20% ± 0,04 e 81,50% ± 0,05, respectivamente. Conclusões: a mortalidade operatória da endocardite ativa em nosso ambiente é alto e semelhante ao relatado internacionalmente. A presença de complicações locais está associada à endocardite protética na evolução e provou ser um preditor independente de sobrevida a longo prazo e mortalidade operatória. A sobrevivência a longo prazo é semelhante à relatada internacionalmente. Foi observada alta incidência de agentes hospitalares e procedimentos invasivos como causas prováveis.

Mielitis isquémica como presentación de aorta shaggy en paciente con síndrome aórtico agudo concomitante / Ischaemic myelitis as a presentation of a shaggy aorta in a patient with concomitant acute aortic syndrome

Resumen La aorta shaggy se define como una degeneración ateromatosa agresiva y extensa de la aorta, cuya friabilidad predispone a ulceración y complicaciones embólicas, cursa con alto riesgo de embolia sistémica y no se conocen prevalencia ni incidencia en poblaciones de riesgo. La mayoría de casos publicados hacen referencia a complicaciones en procedimientos quirúrgicos. En la literatura no se hallaron reportes que asocien ateroembolia aórtica con obstrucción de la arteria de Adamkiewicz, cuyo diagnóstico no siempre es posible visualizando su oclusión por angiotomografía o por angiorresonancia, pues el defecto puede ser evanescente o puede existir compromiso distal con obstrucción microvascular, difícilmente aparente con arteriografía selectiva. Se presenta un caso de mielopatía isquémica embólica asociada a aorta shaggy con probable oclusión de la arteria de Adamkiewicz como responsable del deterioro neurológico agudo de la paciente, confirmado por resonancia magnética nuclear. Para caracterizar mejor esta enfermedad y para tener las estrategias diagnósticas y terapéuticas apropiadas en su abordaje oportuno, consideramos importante el reporte de casos similares aumentando así su sospecha diagnóstica.

Abstract A shaggy aorta is defined as an aggressive and extensive atheromatous degeneration of the aorta. Its friability predisposes to ulceration and embolic complications. It carries a high risk of systemic embolisms, and its prevalence and incidence in risk populations is unknown. The majority of published cases mention complications in surgical procedures. No reports have been found in the literature that associate aortic atheroembolism with obstruction of the artery of Adamkiewicz. Its diagnosis is not always possible by visualising its occlusion by computed tomography angiography or by magnetic resonance angiography, since the defects may be evanescent, or there may be a distal compromise with a microvascular obstruction, hardly apparent with selected angiography. A case is presented of embolic ischaemic myelitis associated with a shaggy aorta, with probable occlusion of the artery of Adamkiewicz being responsible form the acute neurological deterioration of the patient, confirmed by a nuclear magnetic resonance scan. In order to better describe the features of this disease and to have the appropriate diagnostic and therapeutic strategies for its timely approach, it is considered important to report all similar cases, thus increasing its diagnostic suspicion.

3D echocardiographic characteristic of embolism and in-hospital mortality in patients with infective endocarditis / 中国医学影像技术

Objective To assess the echocardiographic characteristics of embolism and in-hospital mortality in patients with infective endocarditis using three-dimensional transesophageal echocardiography (3D TEE).Methods Retrospective review of 124 patients with native valve infective endocarditis was performed to examine its characteristics by two-dimensional transthoracic echocardiography (2D TTE),multi-plane and 3D TEE.The primary endpoint was embolism and mortality that occurred within one month before or after operation.The combined simple score was calculated by assigning 1 point each for the presence of large vegetation,abscess or fistula,rupture of valvular chord,moderated or severe valvular regurgitation and perforation or serious valvular destruction.Hosmer and area under the curve was calculated to predict embolism and adverse events with the combined simple score,length of vegetation,serious valvular destruction with abnormal morphology.Results In 124 patients,embolic events occured in 27 cases (27/124,21.77％).Multi-plane and 3D TEE can identify the exact location and length of vegetation compared with 2D TTE,which miss-diagnosed vegetation in left atrium and papillary muscle.The clinical presentation of embolism patients was remarkable for lower hemoglobin level (P＜0.05).The ratio of multi-located vegetation,mortality and serious valvular destruction with abnormal morphology were higher in embolism and adverse events patients than those in non-embolism and adverse events patients (all P＜0.05).The area under the curve of combined simple score,lengh of vegetation for embolisms and adverse events and serious valve destruction with abnormal morphology for embolism and adverse events were 0.65 (P=0.06),0.60 (P=0.19)) and 0.70 (P=0.03).Conclusion Multi-plan and 3D TEE plays a key role in the diagnosis of patients with infecitive endocarditis,especially vegetations in occasional location.Serious valve destruction with abnormal morphology is associated with embolism and adverse events.

Endocarditis infecciosa en un paciente con válvula aórtica bicúspide: Reporte y revisión de un caso / Infective endocarditis in a patient with bicuspid aortic valve: a case report and review

Resumen La endocarditis infecciosa es una patología que requiere un diagnóstico y tratamiento oportuno para prevenir sus graves complicaciones y, ante todo, evitar la muerte del paciente. En el presente artículo, documentamos el abordaje diagnóstico y terapéutico de un caso de endocarditis, en el escenario de una cardiopatía congénita, válvula aórtica bicúspide, atendida en el Instituto Nacional de Cardiología "Ignacio Chávez".

Abstract Infective endocarditis is a condition that requires an early diagnosis and treatment to prevent its severe complications and, above all, avoid death. In this article we document the diagnosis and therapeutics of a case of infective endocarditis in the setting of a congenital heart disease, bicuspid aortic valve, referred to the National Institute of Cardiology "Ignacio Chávez".

Pulmonary Embolism Caused by Acrylic Cement: Report of Two Cases Developed as a Complication of Percutaneous Vertebroplasty

Percutaneous vertebroplasty is an effective, minimally invasive procedure for the treatment of vertebral compression fractures, and is a technique for treating lower back pain that appears to be increasingly popular throughout the world. We experienced two cases involving a rare complication of percutaneous vertebroplasty, namely pulmonary embolism caused by acrylic cement. One patient showed no subjective symptoms after vertebroplasty, while the other experienced chest pain. In the former, fluoroscopy demonstrated perivertebral venous leakage during vertebroplasty, and at chest radiography, tubular or branching high-density linear structures were observed. In addition, intravascular emboli were identified at CT. In the second patient, symptomatic therapy led to reduced chest pain.