Risk of Bleeding after Transcatheter Aortic Valve Replacement: impact of Preoperative Antithrombotic Regimens

Abstract Introduction: Bleeding after transcatheter aortic valve replacement (TAVR) has a negative impact on the outcome of the procedure. Risk factors for bleeding vary widely in the literature, and the impact of preoperative antithrombotic agents has not been fully established. The objectives of our study were to assess bleeding after TAVR as defined by the Valve Academic Research Consortium-2 (VARC-2), identify its risk factors, and correlate with antithrombotic treatment in addition to its effect on procedural mortality. Methods: The study included 374 patients who underwent TAVR from 2009 to 2018. We grouped the patients into four groups according to the VARC-2 definition of bleeding. Group 1 included patients without bleeding (n=265), group 2 with minor bleeding (n=22), group 3 with major bleeding (n=61), and group 4 with life-threatening bleeding (n=26). The median age was 78 (25th-75th percentiles: 71-82), and 226 (60.4%) were male. The median EuroSCORE was 3.4 (2-6.3), and there was no difference among groups (P=0.886). The TAVR approach was transfemoral (90.9%), transapical (5.6%), and trans-subclavian (1.9%). Results: Predictors of bleeding were stroke (OR: 2.465; P=0.024) and kidney failure (OR: 2.060; P=0.046). Preoperative single and dual antiplatelet therapy did not increase the risk of bleeding (P=0.163 and 0.1, respectively). Thirty-day mortality occurred in 14 patients (3.7%), and was significantly higher in patients with life-threatening bleeding (n=8 [30.8%]; P<0.001). Conclusion: Bleeding after TAVR is common and can be predicted based on preprocedural comorbidities. Preprocedural antithrombotic therapy did not affect bleeding after TAVR in our population.

Trombolisis sistémica complicada en embolia cerebral múltiple por trombo intraventricular / Systemic thrombolysis following multiple embolic cerebral lesions in a patient with myocardial infarction and intraventricular thrombus

RESUMEN Se presenta un caso de trombólisis sistémica complicada con transformación hemorrágica en paciente con evento isquémico cerebral sintomático por embolia múltiple a partir de trombo intraventricular en contexto de infarto agudo de miocardio por oclusión total de arteria descendente anterior con deterioro severo de función sistólica de ventrículo izquierdo.

ABSTRACT: We describe a case of complicated systemic thrombolysis with hemorrhagic transformation in a patient with a cerebral ischemic event due to multiple embolisms from intraventricular thrombus in the context of acute myocardial infarction due to total occlusion of the anterior descending artery and severe deterioration of left ventricular systolic function.

Desfechos clínicos de pacientes após uso de terapia fibrinolítica pré-hospitalar: revisão sistemática / Resultados clínicos de pacientes después del uso de terapia fibrinolítica prehospitalaria: revisión sistemática / Clinical outcomes of patients after using prehospital fibrinolytic therapy: a systematic review

Resumo Objetivo: Comparar desfechos clínicos de óbito, reinfarto e Acidente Vascular Encefálico (AVE) em estudos primários que avaliaram o uso da Terapia Fibrinolítica (TF) em relação à Intervenção Coronariana Percutânea Primária (ICPP) para reperfusão miocárdica em pacientes com Infarto Agudo do Miocárdio com supradesnivelamento do segmento ST (IAMCST) no atendimento pré-hospitalar. Método: Revisão sistemática de literatura com busca realizada nas bases de dados CINAHL, MEDLINE, PUBMED, Science Direct, SCOPUS e Web of Science no período de outubro a dezembro de 2017. Foram incluídos Ensaios Clínicos Randomizados, disponíveis na íntegra, em qualquer idioma, sem recorte temporal. A avaliação da elegibilidade foi realizada em duas etapas e aplicada a Escala de Jadad para avaliação metodológica dos estudos encontrados. Resultados: Foram incluídos cinco Ensaios Clínicos Randomizados. A TF pré-hospitalar apresentou taxas de mortalidade em 30 dias após a intervenção semelhantes à ICPP, enquanto que em cinco anos foram encontrados valores menores para a TF. O tratamento instituído em um período menor que duas horas dos sintomas iniciais apresentou associação com a diminuição da mortalidade quando foi utilizada a TF. O reinfarto não-fatal, acidente vascular encefálico e a hemorragia intracraniana foram maiores quando utilizada a TF, enquanto que o choque cardiogênico apresentou menor frequência. Conclusão: A TF foi mais eficaz no tratamento pré-hospitalar para a redução dos óbitos após cinco anos, entretanto, o reinfarto e o AVE ocorreram de forma semelhante na amostra analisada. O fator tempo reduziu os desfechos clínicos, principalmente quando a terapia implementada ocorreu em até duas horas após a ocorrência do IAMCST. Assim, apesar das intervenções terem apresentado desfechos semelhantes, entretanto, a TF pode representar um tratamento viável em locais onde a ICPP não pode ser alcançada em tempo hábil.

Resumen Objetivo: Comparar resultados clínicos de fallecimiento, reinfarto y accidente vascular encefálico (AVE) en estudios primarios que analizaron el uso de la terapia fibrinolítica (TF) respecto a la intervención coronaria percutánea primaria (ICPP) para reperfusión miocárdica en pacientes con infarto agudo de miocardio con supradesnivel del segmento ST (IAMCST) en la atención prehospitalaria. Método: Revisión sistemática de literatura con búsqueda realizada en las bases de datos CINAHL, MEDLINE, PUBMED, Science Direct, SCOPUS y Web of Science en el período de octubre a diciembre de 2017. Se incluyeron ensayos clínicos aleatorizados, con texto completo disponible, en cualquier idioma, sin recorte temporal. El análisis de elegibilidad se realizó en dos etapas y se aplicó la escala de Jadad para una evaluación metodológica de los estudios encontrados. Resultados: Se incluyeron cinco ensayos clínicos aleatorizados. La TF prehospitalaria presentó índices de mortalidad 30 días después de la intervención semejantes a la ICPP, mientras que en cinco años se encontraron valores menores en la TF. El tratamiento aplicado en un período menor a dos horas desde los síntomas iniciales presentó una relación con la reducción de la mortalidad cuando se utilizó la TF. Los reinfartos no fatales, los accidentes vasculares encefálicos y las hemorragias intracerebrales fueron mayores cuando se utilizó la TF, mientras que los choques cardiogénicos presentaron menor frecuencia. Conclusión: La TF fue más eficaz en el tratamiento prehospitalario para reducir los fallecimientos después de cinco años, sin embargo, los reinfartos y los AVE ocurrieron de forma semejante en la muestra analizada. El factor tiempo redujo los resultados clínicos, principalmente cuando la terapia implementada ocurrió hasta dos horas después del episodio del IAMCST. De esta forma, a pesar de que las intervenciones presentaron resultados semejantes, la TF puede representar un tratamiento viable en lugares donde la ICPP no puede realizarse a tiempo.

Abstract Objective: To compare clinical outcomes of death, reinfarction, and stroke in primary studies assessing Fibrinolytic Therapy (FT) use in relation to Primary Percutaneous Coronary Intervention (PPCI) for myocardial reperfusion in patients with ST-Elevation Myocardial Infarction (STEMI) in prehospital care. Method: A systematic literature review conducted in the CINAHL, MEDLINE, PUBMED, Science Direct, SCOPUS, and Web of Science databases from October to December 2017. Randomized Clinical Trials, available in full, in any language, without temporal clipping were included. The eligibility assessment was carried out in two stages and applied to the Jadad Scale for methodological assessment of the studies found. Results: Five Randomized Clinical Trials were included. Prehospital FT presented mortality rates at 30 days after the intervention similar to PPCI, while in five years lower values were found for FT. The treatment instituted in a period of less than two hours of the initial symptoms was associated with the decrease in mortality when FT was used. Non-fatal reinfarction, stroke and intracranial hemorrhage were higher when FT was used, while cardiogenic shock showed lower frequency. Conclusion: FT was more effective in prehospital treatment to reduce deaths after five years, however, reinfarction and stroke occurred similarly in the sample analyzed. The time factor reduced clinical outcomes, especially when the implemented therapy occurred within two hours after the occurrence of STEMI. Thus, although the interventions presented similar outcomes. However, FT may represent a viable treatment in places where PPCI cannot be achieved in a timely manner.

Comparative Analysis between Transferred and Self-Referred STEMI Patients Undergoing Primary Angioplasty / Análise Comparativa entre Pacientes com IAMCSST Transferidos e Pacientes de Demanda Espontânea Submetidos à Angioplastia Primária

Abstract Background: Studies have shown the benefits of rapid reperfusion therapy in acute myocardial infarction. However, there are still delays during transport of patients to primary angioplasty. Objective: To evaluate whether there is a difference in total ischemic time between patients transferred from other hospitals compared to self-referred patients in our institution. Methods: Historical cohort study including patients with acute myocardial infarction treated between April 2014 and September 2015. Patients were divided into transferred patients (group A) and self-referred patients (group B). Clinical characteristics of the patients were obtained from our electronic database and the transfer time was estimated based on the time the e-mail requesting patient's transference was received by the emergency department. Results: The sample included 621 patients, 215 in group A and 406 in group B. Population characteristics were similar in both groups. Time from symptom onset to arrival at the emergency department was significantly longer in group A (385 minutes vs. 307 minutes for group B, p < 0.001) with a transfer delay of 147 minutes. There was a significant relationship between the travel distance and increased transport time (R = 0.55, p < 0.001). However, no difference in mortality was found between the groups. Conclusion: In patients transferred from other cities for treatment of infarction, transfer time was longer than that recommended, especially in longer travel distances.

Resumo Fundamento: Estudos mostram o benefício da terapia de reperfusão rápida no infarto agudo do miocárdio. No entanto, ainda ocorrem atrasos durante o transporte de pacientes para angioplastia primária. Objetivo: Definir se existe uma diferença no tempo total de isquemia entre pacientes transferidos de outro hospital comparados aos que procuram o serviço espontaneamente. Método: Estudo de coorte histórico, incluindo pacientes atendidos com infarto entre abril de 2014 e setembro de 2015. Os pacientes foram divididos em pacientes transferidos (grupo A) e por demanda espontânea (grupo B). As características clínicas dos pacientes foram retiradas do banco de dados de infarto e o tempo de transferência foi estimado tendo como base o correio eletrônico de acordo com o horário de contato. O nível de significância adotado foi um p < 0,05%. Resultados: A amostra incluiu 621 pacientes, 215 no grupo A e 406 no grupo B. As características populacionais foram semelhantes nos dois grupos. O delta T foi significativamente maior no grupo de pacientes transferidos (385 minutos vs. 307 minutos para o grupo B, p < 0,001) com um atraso decorrente do transporte de 147 minutos. Houve relação significativa da distância de transferência e aumento do tempo de transporte (R = 0,55; p < 0,001). Entretanto, não houve diferença na mortalidade entre os grupos. Conclusão: Pacientes transferidos de outras cidades para tratamento de infarto tem Delta T de transferência acima do recomendado, com tempo ainda mais longo quanto maior a distância a ser percorrida.

Infarto agudo de miocardio lejos de los centros de hemodinamia, percepción de la calidad de vida postratamiento con fibrinolíticos y factores relacionados / Acute myocardial infarction away from the centers of hemodynamics, perception of quality of life post treatment with fibrinolytics and related factors / Infarto agudo do miocárdio longe dos centros de hemodinâmia, percepção da qualidade de vida pós-tratamento com fibrinoliticos e fatores relacionados

Resumen: Introducción: la mortalidad en el infarto agudo de miocardio con elevación del segmento ST (IAMCEST) ha disminuido, pese a ello, existe evidencia que sugiere un deterioro de la calidad de vida (CV) a largo plazo en estos pacientes. Objetivo: evaluar la CV percibida y los factores relacionados en pacientes que presentaron un IAMCEST y recibieron tratamiento de reperfusión con fibrinolíticos. Material y métodos: aplicación de cuestionario EQ-5D-5L para valorar CV de pacientes con IAMCEST seleccionados entre los ingresados en el período junio de 2007 a junio de 2017 en una unidad de cuidados intensivos (UCI) privada del interior del país. Resultados: se analizaron 86 pacientes con una mediana de edad de 67,5 años (intervalo intercuartil= 59-77,5). El 77% recibió fibrinolíticos, de los cuales 74% presentó criterios de reperfusión. El tratamiento fue iniciado antes de los 120 minutos en el 74% de los casos. Entre los sobrevivientes al iniciar el estudio se seleccionaron al azar 30 pacientes para evaluación de la CV. La media de seguimiento fue de 6 años (4-8) desde el IAMCEST. Los aspectos de CV alterados fueron: movilidad 6/23 (26%), autocuidado 4/23 (17%), actividades usuales 6/23 (26%), dolor 4/23 (17%) y una CV global alterada 8/30 (27%). En una escala de 0-100, el nivel de CV global percibido fue de 90 (70-99). La CV global alterada se asocia a insuficiencia cardíaca (IC) posterior al evento (67% con IC vs 17% sin IC, p: 0,05) y a un tiempo desde el IAMCEST menor a cinco años (38% vs 6%, p:0,02). Las alteraciones en la movilidad son más frecuentes en mujeres (57%) que en hombres (12%), p: 0,02, y en pacientes con dolor (43%) vs sin dolor (6%), p: 0,03. Una mayor edad se asocia con autocuidado alterado (69 años;58-78; vs 92 años ;87-93; p=0,013). El retraso en el tratamiento (>120 minutos) se asocia a alteraciones en la movilidad (80% vs 13%, p: 0,005), en el autocuidado (60% vs 7%, p: 0,01) y a limitación en actividades usuales (60% vs 13%, p: 0,03). Conclusiones: los pacientes con IAMCEST que reciben tratamiento de reperfusión con fibrinolíticos en nuestro medio pueden presentar compromiso de la CV. El retraso en el tratamiento se asociaría a CV alterada a largo plazo.

Summary: Introduction: mortality in acute myocardial infarction with ST-segment elevation has decreased, despite this, there is evidence suggesting a long-term deterioration of quality of life in these patients. Objective: to evaluate the perceived quality of life and related factors in patients who had an ST-segment elevation myocardial infarction and received reperfusion treatment with fibrinolytics. Material and methods: application of EQ-5D-5L questionnaire to assess quality of life in patients with ST-segment elevation myocardial infarction selected among those admitted in the period from June 2007 to June 2017 in a private intensive care unit outside the country's capital. Results: 86 patients were analyzed with a median age of 67.5 years (interquartile range = 59-77.5). 77% received fibrinolytics of which 74% presented reperfusion criteria. The treatment was initiated before 120 minutes in 74% of the cases. Among the survivors at the start of the study, 30 patients were selected at random for evaluation of the quality of life. The mean follow-up was 6 years (4-8) from the event. The altered aspects in quality of life were: mobility 6/23( 26%), self-care 4/23 (17%), usual activities 6/23( 26%), pain 4/23(17%) and an altered global quality of life 8/30( 27%). On a scale of 0-100, the perceived global quality of life level was 90 (70-99). The altered global quality of life is associated with heart failure after the event (67% vs 17%, p: 0.05) and at a time from the event less than five years (38% vs 6%, p: 0.02). Alterations in mobility are more frequent in women (57%) than in men (12%), p: 0.02, as well as in patients with pain (43%) vs without pain (6%), p: 0.03. Older age is associated with altered self-care (69 years ;58-78; vs 92 years ;87-93, p: 0.013). The delay in treatment (>120 minutes) is associated with alterations in mobility (80% vs 13%, p: 0.005), self-care (60% vs 7%, p: 0, 01) and limitation in usual activities (60% vs 13%, p: 0.03). Conclusions: patients with ST-segment elevation myocardial infarction who receive reperfusion treatment with fibrinolytics in our environment may have an alteration in the quality of life. The delay in treatment is associated with long-term altered quality of life.

Resumo: Introdução: a mortalidade no infarto agudo do miocárdio com supradesnivelamento do segmento ST tem diminuiu, apesar disso, há evidências que sugerem uma deterioração da qualidade de vida a longo prazo. Objetivo: avaliar a qualidade de vida percebida e fatores relacionados em pacientes com infarto do miocárdio e tratamento de reperfusão com fibrinolíticos. Material e métodos: aplicação do questionário EQ-5D-5L para avaliação da qualidade de vida em pacientes com infarto agudo do miocárdio com supradesnivelamento do ST selecionados entre os admitidos no período de junho de 2007 a junho de 2017 em uma unidade de terapia intensiva privada no interior do país. Resultados: 86 pacientes foram analisados com mediana de idade de 67,5 anos (intervalo interquartil = 59-77,5). 77% receberam fibrinolíticos e dos quais 74% apresentaram critérios de reperfusão. O tratamento foi iniciado antes de 120 minutos em 74% dos casos. Entre os sobreviventes no início do estudo, 30 pacientes foram selecionados aleatoriamente para avaliação da qualidade de vida. O seguimento médio foi de 6 anos (4-8) do evento. Os aspectos alterados foram: mobilidade 23/06 (26%), auto-cuidado 4/23 (17%), actividades habituais 23/06 (26%), dor 4/23 (17%) e um qualidade de vida geral alterada 8/30 (27%). Em uma escala de 0 a 100, o nível de qualidade de vida global percebido foi de 90 (70-99). A qualidade de vida global alterada está associada à insuficiência cardíaca após o evento (67% vs 17%, p: 0,05) e a um tempo inferior a cinco anos (38% vs 6%, p: 0,02). Alterações na mobilidade são mais freqüentes em mulheres (57%) do que em homens (12%), p: 0,02, e em pacientes com dor (43%), vs sem dor (6%), p: 0,03. A idade avançada está associada ao autocuidado alterado (69 anos ;58-78; vs 92 anos ;87-93, p: 0,013). O atraso no tratamento (>120 minutos) está associado a alterações na mobilidade (80% vs 13%, p: 0,005), no autocuidado (60% vs 7%, p: 0,01) e com limitação nas atividades habituais (60% vs 13%, p: 0,03). Conclusões: pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST que recebem tratamento de reperfusão com fibrinolíticos em nosso meio podem apresentar comprometimento na qualidade de vida.O atraso no tratamento está associado à qualidade de vida alterada a longo prazo.

Application of tirofiban in reperfusion treatment of acute ischemic stroke / 国际脑血管病杂志

Vascular recanalization is an important treatment method for acute ischemic stroke. Antiplatelet drugs combined with intravenous thrombolysis and endovascular therapy have become the research hotspots in recent years. Platelet glycoprotein Ⅱb/Ⅲa receptor antagonist is a new class of antiplatelet drugs that work by inhibiting the last common pathway in the platelet aggregation process. Its safety and effectiveness in the treatment of acute coronary syndrome have been proven, but its application in patients with acute ischemic stroke is still in the exploratory stage. This article reviews the application of tirofiban in the treatment of acute ischemic stroke reperfusion.

Disfunción de prótesis mitral mecánica: ¿Intervención quirúrgica o tratamiento inmediato con fibrinolíticos? / Mechanical mitral prosthesis dysfunction: Surgical intervention or immediate treatment with fibrinolytics?

Resumen: Existe en la actualidad controversia acerca del mejor tratamiento para los pacientes portadores de trombosis valvular protésica. Muchos factores deben ser tenidos en cuenta al momento de decidir entre la resolución quirúrgica o el tratamiento con fibrinolíticos sistémicos. Las guías americanas recomiendan en plano de igualdad ambas terapéuticas, poniendo énfasis en el análisis de cada caso en particular. Las guías europeas, en cambio, le dan mayor nivel de recomendación a la cirugía, dejando la fibrinólisis para aquellos pacientes con alto riesgo quirúrgico. Se presenta el caso de una paciente de 54 años, portadora de prótesis mitral mecánica implantada hace 15 años, disfuncionante, en clase funcional II de la New York Heart Association, y se discuten las opciones diagnósticas y terapéuticas.

Summary: There is ongoing debate regarding the optimal treatment for patients with prosthetic valve thrombosis. Several issues must be taken into consideration before defining either surgical or fibrinolytic treatment. North American guidelines place both therapeutic modalities under the same recommendation grade with special emphasis on the analysis of each individual case. European guidelines place surgical treatment as the preferred option except in patients with high surgical risk. Thereby, we present the clinical case of a 54 year old female with dysfunctional mechanical mitral prosthesis implanted 15 years ago and functional class II of the New York Heart Association. Diagnostic and therapeutic approaches are discussed.

Uso de estreptoquinasa recombinante intrapleural en una mujer embarazada con empiema pleural / Use of intrapleural recombinant streptokinase in a pregnant woman with pleural empyema

RESUMEN Fundamento: la neumonía complica el 0,78-2,7 por 1 000 embarazos al estar en riesgo la madre y el feto. El empiema como complicación de una neumonía en una paciente embarazada agrega un alto índice de morbimortalidad para la madre y el feto si no se actúa de forma rápida. Objetivo: describir el caso de una mujer de 33 semanas de embarazo, la cual desarrolló un empiema pleural producto de una complicación de una neumonía adquirida en la comunidad tratada con fibrinólisis intrapleural. Caso clínico: paciente gestada de 33 semanas, asmática ingresada en el servicio de terapia intensiva del Hospital Universitario Manuel Ascunce Domenech con el diagnóstico de neumonía grave adquirida en la comunidad complicada con derrame paraneumónico el cual evolucionó hacia el empiema. El mismo fue tratado con tubo de toracostomía y terapia fibrinolítica, con buena evolución clínica y radiológica. Conclusiones: la estreptoquinasa recombinante se puede utilizar de manera segura y efectiva para el manejo del empiema pleural, como agente fibrinolítico intrapleural, durante el embarazo.

ABSTRACT Background: pneumonia complicates 0,78-2,7 per 1 000 pregnancies placing the mother and the fetus at risk. Empyema as a complication of pneumonia in a pregnant patient adds a high rate of morbidity and mortality to the mother and the fetus if one does not act quickly. Objective: to present the case of a pregnant woman of 33 weeks who developed a pleural empyema resulting from acquired pneumonia. Clinical case: 33-week gestated patient, asthmatic admitted to the intensive care unit of the University Hospital Manuel Ascunce Domenech with the diagnosis of severe pneumonia acquired in the community complicated with para-pneumonic effusion, which evolved into empyema. It was treated with a thoracotomy tube and fibrinolytic therapy, with good clinical and radiological evolution. Conclusions: Recombinant streptokinase can be used safely and effectively for the management of PE, as an intrapleural fibrinolytic agent, during pregnancy.

Minimally invasive treatment of complex collections: safety and efficacy of recombinant tissue plasminogen activator as an adjuvant to percutaneous drainage / Tratamento minimamente invasivo de coleções complexas: segurança e eficácia do ativador tissular de plasminogênio no tratamento adjuvante nas drenagens percutâneas

Abstract Objective: To analyze the efficacy of recombinant tissue plasminogen activator (r-TPA) injection in the evolution of percutaneous drainage of thick collections. Materials and Methods: This was a single-center study involving the retrospective analysis of hospitalized patients undergoing percutaneous drainage of thick (superficial or intracavitary) fluid collections, followed by injection of a fibrinolytic agent (r-TPA) into the affected space. Results: A total of 53 percutaneous drainage procedures, with r-TPA injection, were performed in 51 patients. Abdominal and pelvic collections were the most common, being seen in 38 (73%) of the procedures; in 35 (66%), the etiology of the collection was attributed to postoperative complications. A total of 61 catheters were used in order to drain the 53 collections. Of those 61 catheters, 52 (85%) were large (12-16 Fr) and 9 (15%) were small (4-10 Fr). The mean r-TPA dose was 5.7 mg/collection per day, and the mean time from r-TPA injection to drain removal was 7.7 days. Percutaneous drainage in combination with r-TPA injection was successful in 96% of the cases. None of the patients showed coagulation changes during the study period. Conclusion: The use of once-daily, low-dose r-TPA for up to three consecutive days, as an adjunct to percutaneous drainage of thick collections, with or without loculation, appears to be an effective technique.

Resumo Objetivo: Analisar a eficácia da injeção do agente fibrinolítico ativador tissular de plasminogênio (r-TPA) na evolução da drenagem percutânea de coleções espessas. Materiais e Métodos: Estudo unicêntrico com análise retrospectiva de pacientes internados submetidos a drenagem percutânea de coleções espessas, superficiais ou intracavitárias, seguida da injeção de agente fibrinolítico (r-TPA) no interior da coleção. Resultados: Foram realizadas 53 drenagens percutâneas com injeção de r-TPA em 51 pacientes. Coleções intra-abdominais e pélvicas foram as mais frequentes (n = 38; 73%) e a causa predominante foi complicação pós-operatória (n = 35; 66%). Foram utilizados 61 drenos para acessar as 53 coleções, dos quais 52 (85%) foram drenos mais calibrosos (12-16 Fr) e 9 (15%) de pequeno calibre (4-10 Fr). A dose média de r-TPA empregada foi 5,7 mg/coleção/dia, o tempo médio entre a injeção de r-TPA e a retirada do dreno foi 7.7 dias e o sucesso da drenagem percutânea em associação com agente fibrinolítico foi observado em 96% dos casos. Alterações de coagulação não foram observadas nos pacientes durante o estudo. Conclusão: O uso de baixas doses diárias de r-TPA por até três dias consecutivos, como adjuvante terapêutico na drenagem percutânea de coleções espessas e/ou loculadas, demonstrou ser uma técnica efetiva.

Hemoptise maciça tratada com oxigenação por membrana extracorpórea e trombolítico endobrônquico com sucesso / Massive hemoptysis successfully treated with extracorporeal membrane oxygenation and endobronchial thrombolysis

RESUMO A oxigenação por membrana extracorpórea tem sido utilizada para tratamento de hipoxemia refratária em muitos cenários clínicos. Os princípios fundamentais do manejo do paciente com hemoptise maciça são a proteção da via aérea e do pulmão sadio, a localização da fonte de sangramento e o controle da hemorragia. Relatamos o caso de uma paciente com insuficiência respiratória aguda associada à hemoptise maciça secundária à laceração pulmonar durante cirurgia cardíaca. O uso da oxigenação por membrana extracorpórea venoarterial permitiu a sobrevivência da paciente, porém, devido à grande dificuldade no manejo dos coágulos pulmonares após hemoptise, foi necessário o uso de terapia incomum, com infusão endobrônquica de trombolítico, conforme descrito em raros casos na literatura.

ABSTRACT Extracorporeal membrane oxygenation has been used to treat refractory hypoxemia in numerous clinical scenarios. The fundamental principles for the management of massive hemoptysis patients include protecting the airway and healthy lung, locating the source of bleeding and controlling the hemorrhage. We report the case of a patient with acute respiratory failure associated with massive hemoptysis secondary to lung laceration during cardiac surgery. The use of extracorporeal membrane oxygenation allowed patient survival. However, due to the great difficulty in managing pulmonary clots after hemoptysis, it was necessary to use an unusual therapy involving endobronchial infusion of a thrombolytic agent as described in rare cases in the literature.

Cerebral microbleeds, atrial fibrillation and stroke prevention / 国际脑血管病杂志

Cerebral microbleeds (CMBs) are a imaging manifestation of small vessel disease, and have a marked impact on the recurrence and on hemorrhagic transformation of ischemic stroke. Atrial fibrillation (AF) is a common arrhythmia,w hich significantly increases the risk of stroke,and the incidence of CMB in AF patients is also significantly higher than that in non-AF patients.Antithrombotic therapy is the cornerstone of stroke prevention,but it also increases the risk of bleeding.The benefit of stroke prevention and the bleeding risk should be assessed in AF patients w ith CMBs.

The Evolution of the Neurosurgical Treatment of Ischemic Stroke

The neurosurgical approach to the management of ischemic stroke has evolved dramatically over the past century with the bulk of these changes occurring over the past 25 years. With recent advances in technology and continued refinements in neurosurgical techniques there has been significant improvement to the safety and efficacy of our treatment options. The focus of this article will be to review the historical and recent reports in the literature related to revascularization techniques.

A Prospective Multicenter Study Evaluating Bleeding Risk after Endoscopic Ultrasound-Guided Fine Needle Aspiration in Patients Prescribed Antithrombotic Agents

BACKGROUND/AIMS: Although the risk of bleeding after endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is low, the safety of EUS-FNA in patients prescribed antithrom-botic agents is unclear. Therefore, this study evaluated the incidence of bleeding after EUS-FNA in those patients. METHODS: Between September 2012 and September 2015, patients who were prescribed antithrombotic agents underwent EUS-FNA at 13 institutions in Japan were prospectively enrolled in the study. The antithrombotic agents were managed according to the guidelines of the Japanese Gastrointestinal Endoscopy Society. The rate of bleeding events, thromboembolic events and other complications within 2 weeks after EUS-FNA were analyzed. RESULTS: Of the 2,629 patients who underwent EUS-FNA during the study period, 85 (62 males; median age, 74 years) patients were included in this stduy. Two patients (2.4%; 95% confidence interval [CI], 0.6% to 8.3%) experienced bleeding events. One patient required surgical intervention for hemothorax 5 hours after EUS-FNA, and the other experienced melena 8 days after EUS-FNA and required red blood cell transfusions. No thromboembolic events occurred (0%; 95% CI, 0.0% to 4.4%). Three patients (3.5%; 95% CI, 1.2% to 10.0%) experienced peri-puncture abscess formation. CONCLUSIONS: The rate of bleeding after EUS-FNA in patients prescribed antithrombotic agents might be considerable.

Cerebral microbleed burden and thrombolytic therapy for acute ischemic stroke / 国际脑血管病杂志

Thrombolytic therapy is one of the standard treatments of acute ischemic stroke.The patients with acute ischemic stroke often complicated with cerebral microbleed.Whether thrombolytic therapy will increase the risks of bleeding and early neurological deterioration in such patients are not conclusive.This article reviews the impact of cerebral microbleed burden on the outcome after thrombolytic therapy in patients with acute ischemic stroke.

The clinical efficacy of recombinant tissue plasminogen activator for the treatment of ischemic cerebrovascular disease caused by cerebral thrombosis / 天津医药

Objective To study the clinical efficacy of intra-arterial thrombolysis with recombinant tissue plasminogen activator (rt-PA) for the treatment of ischemic cerebrovascular disease caused by cerebral thrombosis. Methods A total of 245 patients accepted by our hospital during May 2013 and July 2015 were divided into the observation group (n=148) and the control group (n=97). All patients were given conventional process for controling blood pressure and blood lipids. Patients in observation group received intra-arterial thrombolysis with rt-PA, while patients in control group accepted conventional treatment. At the time of admission, the demographic characteristic, vascular influencing factors, baseline clinical findings, laboratory findings and neurological deficits were collected. The improvement of neurological function was evaluated by the modified Rankin scale 3 months after treatment. The levels of fibrinogen (FIB), D-Dimer, activated partial thromboplastin time (APTT) and thrombin time (PT) were measured before and 24 h after the treatment. Results There were no significant differences in demographic characteristic and general clinical data between the two groups ( P>0.05). The proportion of patients with improved neurological function was significantly higher in observation group than that of the control group (83.11％vs. 53.61％, P0.05). Twenty-four hours after the treatment, the levels of FIB, D-Dimer, APTT and PT were significantly improved in the observation group compared with those before treatment. The level of FIB was significantly decreased, D-Dimer was significantly increased, APTT and PT were significantly prolonged in observation group compared with those of control group (P<0.05). Conclusion The rt-PA can effectively dissolve thrombosis and correct the coagulation system and fibrinolytic system.