Membrana de circulación extracorpórea veno-arterial para ablación de tormenta eléctrica en shock cardiogénico: caso clínico / Veno-arterial extracorporeal membrane oxygenation (ECMO) used for support during ablation of ventricular electrical storm: case report

RESUMEN: Se presenta el caso clínico de un paciente que presenta un infarto del miocardio con trombolisis no exitosa y posterior implantación de 2 stents coronarios quien desarrolla, algunos días después, una tormenta eléctrica ventricular. Una ablación de la taquicardia se realizó bajo ECMO, con buen resultado. Se detalla la descripción del caso, revisa y discute el tema.

ABSTRAC: A patient with a myocardial infarction whom, following a failed thrombolisis and implantion of 2 stents developed a ventricular electrical storm and hemodynamic instability. A successful ablation of the tachycardia with the use of ECMO was performed. A full description is included, along with a discussion of the subject.

Tratamiento con radiofrecuencia de la tormenta eléctrica: evolución y seguimiento / Radiofrequency treatment for electrical storm: evolution and monitoring

Resumen Introducción y objetivos: La tormenta eléctrica (TE) se caracteriza por episodios repetidos de taquicardia ventricular o fibrilación ventricular relacionados con mal pronóstico a corto y largo plazos. El objetivo fue evaluar la prevalencia, resultados y supervivencia de los pacientes sometidos a tratamiento intervencionista por TE en un centro de referencia. Métodos: Estudio unicéntrico, observacional y retrospectivo. Se revisaron los procedimientos de ablación por TE y se evaluaron las características basales de los pacientes, tipo de procedimiento, mortalidad total, recurrencia de arritmia, mortalidad cardiovascular y necesidad de trasplante. Resultados: Desde enero de 2009 hasta diciembre de 2016 se realizaron 67 procedimientos (38% de complejos: 19% de ablación endoepicárdica, 7.5% de crioablación epicárdica quirúrgica, 3% de simpatectomía, 3% de inyección coronaria con alcohol; 6% de apoyo con oxigenación con membrana extracorpórea) en 41 pacientes (61% de causa isquémica) por TE. La mortalidad intraprocedimiento fue del 1.5%. La mediana de seguimiento fue de 23.5 meses (RIQ, 14.2-52.7). Tras el primer ingreso por TE (uno o varios procedimientos), la mortalidad a un año fue de 9.8%. La incidencia acumulada de trasplante cardiaco por TE fue de 2.4%. En el análisis multivariado, el riesgo de recurrencias arrítmicas o muerte por cualquier causa fue significativamente mayor en pacientes con arritmias clínicas inducibles (HR, 9.03; p = 0.017). Conclusiones: El tratamiento de pacientes con TE, instituido en un centro de referencia y con experiencia, se relacionó con una tasa baja de recurrencia y supervivencia elevada, con una tasa de trasplante cardiaco por TE muy baja. Ante una recurrencia temprana es recomendable practicar un nuevo procedimiento durante el ingreso.

Abstract Introduction and objective: Electrical storm (ES) is characterized by repeated episodes of ventricular tachycardia or ventricular fibrillation, with poor short and long term prognosis. Our objective was to evaluate the prevalence, results of interventional treatment and survival of patients undergoing interventional treatment for ES in our center. Methods: Retrospective, unicentric and observational study. ES ablation procedures were revised and data regarding baseline characteristics of the patients, type of procedure, total mortality, recurrence of arrhythmia, cardiovascular mortality and the need for transplantation were evaluated. Results: From January 2009 to December 2016, 67 procedures (38% complex procedures: 19% epicardial ablation, 7.5% surgical epicardial crioablation, 3% simpatectomy, 3% coronary alcohol injection, 6% extracorporeal membrane oxygenation support) were performed in 41 patients (61% Ischemic etiology) due to ES. Intraprocedural mortality was 1.5%. The median follow-up was 23.5 months (IQR [14.2-52.7]). After the first admission for ES (one or several procedures), 1-year mortality was 9.8%. The cumulative incidence of cardiac transplantation was 2.4%. The risk of arrhythmic recurrences or death was significantly higher in patients with inducible clinical arrhythmias after ablation (HR: 9.03, p = 0.017). Conclusions: The treatment of patients with ES, performed in a reference center, allows obtaining good rates of recurrence and survival, with very low rates of cardiac transplantation for ES. In the presence of an early recurrence, it is advisable to perform a new procedure during admission.

Muerte súbita intrahospitalaria luego de infarto agudo de miocardio en Cuba en los últimos tres años. Análisis de registros institucionales / Sudden intra-hospital death after acute myocardial infarction in Cuba in the last three years. Analysis of institutional records

Resumen Objetivo: Analizar el comportamiento de posibles causas predisponentes de muerte súbita (MS) intrahospitalaria luego de un infarto agudo de miocardio (IMA) en registros cubanos. Material y método: Se realizó una búsqueda de registros clínicos de pacientes con IMA en Cuba en las bases de datos de revistas nacionales, Scientific Library On-line (ScieLO) y Medline. Se priorizaron los artículos publicados desde 2016 para ser incluidos. Se definió como muerte súbita aquélla secundaria a arritmias ventriculares malignas (TV y FV), así como los pacientes con rotura cardíaca y actividad eléctrica sin pulso o asistolia como forma de presentación. Con posterioridad se evaluó la relación de este parámetro con la aparición de muerte súbita en 710 pacientes del Registro de Síndromes Coronarios Agudos (RESCUE). Resultados: En el contexto extrahospitalario, más de la mitad de las muertes súbitas cardíacas son secundarias a un infarto agudo de miocardio. En el hospital, la mortalidad en Cuba por IMA es homogénea. Sólo los centros con intervencionismo coronario escapan a este fenómeno. Aunque no del todo letales, las arritmias ventriculares malignas se relacionan con un peor pronóstico y su prevalencia no es homogénea en los registros revisados. Conclusiones: La muerte súbita luego de infarto agudo de miocardio será aún en Cuba una de las principales causas de muerte en los pacientes de fase aguda.

Abstract Objective: To analyze possible predisposing causes of in hospital sudden cardiac death (SCD) after an acute myocardial infarction (IMA) in Cuban registries. Material and methods: A search of clinical records of patients with IMA in Cuba was performed in the databases of national journals, Scientific Library On-line and Medline. Those articles published since 2016 were prioritized for inclusion. Sudden death is defined as that secondary to malignant ventricular arrhythmias (ventricular tachycardia, ventricular fibrillation) as well as patients with cardiac rupture with pulseless electrical activity or asystole as a form of presentation. Subsequently, the relationship of this parameter with the occurrence of sudden death was evaluated in 710 patients from the Registry of Acute Coronary Syndromes (RESCUE). Results: In the out-of-hospital setting, more than half of SCD are secondary to an IMA. Once in the hospital, mortality in Cuba from IMA is homogeneous. Only centers with coronary interventionism escape this phenomenon. Although not totally lethal, the presence of malignant ventricular arrhythmias is associated with a worse prognosis and its prevalence is not homogeneous in the reviewed records. Conclusions: Sudden death after IMA will continue to be one of the main causes of death of patients in the acute phase in Cuba.

Prognostic Factors in Severe Chagasic Heart Failure / Fatores Prognósticos na Insuficiência Cardíaca Grave de Etiologia Chagásica

Abstract Background: Prognostic factors are extensively studied in heart failure; however, their role in severe Chagasic heart failure have not been established. Objectives: To identify the association of clinical and laboratory factors with the prognosis of severe Chagasic heart failure, as well as the association of these factors with mortality and survival in a 7.5-year follow-up. Methods: 60 patients with severe Chagasic heart failure were evaluated regarding the following variables: age, blood pressure, ejection fraction, serum sodium, creatinine, 6-minute walk test, non-sustained ventricular tachycardia, QRS width, indexed left atrial volume, and functional class. Results: 53 (88.3%) patients died during follow-up, and 7 (11.7%) remained alive. Cumulative overall survival probability was approximately 11%. Non-sustained ventricular tachycardia (HR = 2.11; 95% CI: 1.04 - 4.31; p<0.05) and indexed left atrial volume ≥ 72 mL/m2 (HR = 3.51; 95% CI: 1.63 - 7.52; p<0.05) were the only variables that remained as independent predictors of mortality. Conclusions: The presence of non-sustained ventricular tachycardia on Holter and indexed left atrial volume > 72 mL/m2 are independent predictors of mortality in severe Chagasic heart failure, with cumulative survival probability of only 11% in 7.5 years.

Resumo Fundamento: Fatores prognósticos são bastante estudados na insuficiência cardíaca (IC), mas ainda não possuem um papel estabelecido na IC grave de etiologia chagásica. Objetivo: Identificar a associação de fatores clínicos e laboratoriais com o prognóstico da IC grave de etiologia chagásica, bem como a associação desses fatores com a taxa de mortalidade e a sobrevida em um seguimento de 7,5 anos. Métodos: 60 pacientes portadores de IC grave de etiologia chagásica foram avaliados com relação às seguintes variáveis: idade, pressão arterial, fração de ejeção, sódio plasmático, creatinina, teste de caminhada de 6 minutos, taquicardia ventricular não sustentada, largura do QRS, volume do átrio esquerdo indexado e classe funcional. Resultados: 53 (88,3%) pacientes foram a óbito durante o período de seguimento e 7 (11,7%) permaneceram vivos. A probabilidade de sobrevida geral acumulada foi de aproximadamente 11%. Taquicardia ventricular não sustentada (HR = 2,11; IC 95%: 1,04 - 4,31; p<0,05) e volume do átrio esquerdo indexado ≥ 72 ml/m2 (HR = 3,51; IC 95%: 1,63 - 7,52; p<0,05) foram as únicas variáveis que permaneceram como preditores independentes de mortalidade. Conclusão: A presença de taquicardia ventricular não sustentada ao Holter e o volume do átrio esquerdo indexado > 72 ml/m2 são preditores independentes de mortalidade na IC chagásica grave, com probabilidade de sobrevida acumulada de apenas 11% em 7,5 anos.

Time-dependent expression of vascular endothelial growth factor after acute myocardial ischemia in rats / 法医学杂志

OBJECTIVE@#To investigate the immunohistochemical distributions and expressions of vascular endothelial growth factor (VEGF) in the model of rat myocardial ischemia.@*METHODS@#The model of myocardial ischemia was established by ligating the left anterior descending (LAD) coronary artery of rats. The changes of VEGF expression were detected by immunohistochemistry and Western blot at time points after myocardial ischemia. The electrocardiographic changes were evaluated uninterruptedly.@*RESULTS@#The expression of VEGF was not be found in control group. Fifteen minutes after LAD ligation, weak positive expression of VEGF were found in the ischemic myocardium. The expression of VEGF reached the peak at 3 hours after ligation. The VEGF distribution was mainly localized in the ischemic and peri-ischemic regions. Six hours after LAD ligation, the expression of VEGF decreased comparing with 3 hours and showed a relatively higher level. Fatal arrhythmia was found in nine rats by the electrocardiograph.@*CONCLUSION@#The immunohistochemical staining of VEGF could be helpful for investigating the location and severity of acute myocardial ischemia. Fatal arrhythmia may be secondary to myocardial ischemia.

Abordagem e investigação clínica em pacientes com taquicardia ventricular sustentada / Approach and clinical research in patients with sustained ventricular tachycardia

A taquicardia ventricular sustentada (TVS) é uma emergência clínica em que há risco de mortalidade súbita cardíaca, daí a necessidade de ser abordada de modo objetivo e sistemático. História clínica, exame físico e ECG são fundamentais na abordagem do paciente com taquicardia de QRS largo. Devem ser pesquisados ativamente os preditores clínicos, sinais clínicos e critérios eletrocardiográficos capazes de diagnosticar com grande probabilidade de acerto a TVS. Após a abordagem de emergência, o paciente deve ser encaminhado para avaliação da cardiopatia. Os testes diagnósticos incluem métodos gráficos (ECG basal, teste de esforço, ECGAR e eletrocardiografia dinâmica) e de imagem (ecocardiograma, ressonância magnética e tomografia computadorizada). Há ainda a possibilidade de avaliação invasiva (estudo eletrofisiológico). Apresenta-se uma revisão das estretégicas de abordagem de pacientes com taquicardia ventricular e dos métodos diagnósticos que auxiliam a busca da cardiopatia subjacente.

Utilidad del desfibrilador automático implantable en la prevención de muerte súbita: resultados de la medicina basada en evidencia / Usefulness of the implantable cardiodefibrillator (ICD) in the prevention of sudden death: results of evidence based medicine

A great percentage of patients who have suffered a myocardial infarction have ventricular left dysfunction. In agreement with the different prospective studies, many of these patients will have an event of ventricular arrhythmias that does them candidates for receiving a strategy of primary or secondary prevention with an ICD. The same studies have showed a significant reduction in mortality with the therapy of the ICD compared with the conventional therapy what demonstrates the balance cost - benefit in favor of the use of these devices in long periods of follow-up. The benefits of mortality with the use of the therapy with ICD at the primary prevention are at least so good as those of the secondary prevention of agreement to the results of different prospective studies.

Muerte súbita ambulatoria / Ambulatory sudden death

Se seleccionaron en forma retrospectiva 12 registros de muerte súbita ambulatoria. Se analizaron las arritmias causantes de la muerte súbita, las alteraciones del ritmo y del electrocardioograma que la precedieron y las circunstancias en las que ocurrió. En diez pacientes (83,33 por ciento) la muerte súbita se debió a fibrilación ventricular, precedida en 6 por taquicardia ventricular sostenida, en 2 por torsades de pointes y en los otros 2 pacientes la fibrilación ventricular fue la única arritmia. Dos pacientes fallecieron en bradiarritmia (16,66 por ciento), uno en asistolia y el otro en disociación electromecánica. Las taquiarritmias ventriculares son la causa más común de muerte súbita ambulatoria

Cardioversor-desfibrilador implantável: conceitos básicos relacionados ao seu funcionamento e impacto na sobrevida de pacientes portadores de taquiarritmias ventriculares / Implantable cardioverter-defibrillator: basic concepts related to its operation and impact in survival of ventricular tachycardia carrier inpatients

O tratamento farmacológico dos pacientes que sobreviveram a um episódio de morte súbita é muitas vezes frustrante. Mesmo com o mais moderno esquema terapêutico, a mortalidade deste subgrupo de pacientes continua elevada, em torno de 30 por cento ao ano. O cardioversor-desfibrilador implantável modificou este sombrio panorama ao praticamente eliminar a ocorrência de morte súbita relacionada a recorrência das taquiarritmias ventriculares. Esta revisao focaliza conceitos básicos relacionados ao funcionamento dos cardioversores-desfibriladores implantáveis e seu impacto na sobrevida de pacientes portadores de taquiarritmias ventriculares.