Influence of Microcirculatory Dysfunction on Myocardial Injury after Cardiopulmonary Resuscitation / 生物医学与环境科学（英文）

Objective@#This study aimed to examine the effects of microcirculatory dysfunction and 654-1 intervention after cardiopulmonary resuscitation on myocardial injury.@*Methods@#Landrace pigs were divided into a sham operation group (S group, n= 6), ventricular fibrillation control group (VF-C group, n= 8) and 654-1 intervention group (VF-I group, n= 8). Hemodynamics was recorded at baseline, at recovery of spontaneous circulation (ROSC), and 1 h, 2 h, 4 h and 6 h thereafter. Sidestream dark field (SDF) technology was used to evaluate and monitor the microcirculation flow index, total vessel density, perfusion vessel ratio, De-Backer score, and perfusion vessel density in animal viscera at various time points.@*Results@#After administration of 654-1 at 1.5 h post-ROSC, the hemodynamics in the VF-I group, as compared with the VF-C group, was significantly improved. The visceral microcirculation detected by SDF was also significantly improved in the VF-I group. As observed through electron microscopy, significantly less myocardial tissue injury was present in the VF-I group than the VF-C group.@*Conclusion@#Administration of 654-1 inhibited excessive inflammatory by improving the state of visceral microcirculation.

Ablación y neuromodulación en tormenta arrítmica: serie de 4 casos y revisión de la literatura / Ablation and neuromodulation in arrhythmic storm: a report of 4 cases and literature review

Resumen: Se presenta una serie de 4 casos clínicos de pacientes con y sin cardiopatía estructural, que tuvieron uno o más episodios de tormenta arrítmica. Se describen los tratamientos con sus resultados y una revisión bibliográfica con los avances en el tema más allá de la ablación con catéter.

Abstract: We present 4 clinical cases of patients with and without structural heart disease, who had one or more episodes of arrhythmic storm. Treatments, results and a bibliographic review with advances beyond catheter ablation are described.

Muerte súbita cardíaca por fibrilación ventricular asociada a isquemia miocárdica, tratada por desfibrilador automático implantable / Sudden cardiac death due to ventricular fibrillation associated with myocardial ischemia, treated by implantable cardioverter defibrillator

Resumen: Reportamos el caso de un hombre de 67 años, con múltiples factores de riesgo cardiovascular, quien en el año 2015 presentó muerte súbita por fibrilación ventricular sin lesiones coronarias significativas, tras lo cual se implantó un desfibrilador automático. En el año 2019 presentó un nuevo episodio de fibrilación ventricular en relación con síndrome coronario agudo con supradesnivel del ST localizado en pared anterior, registrado y adecuadamente resuelto por el dispositivo. Se demostró una oclusión aterotrombótica en la porción proximal de la arteria descendente anterior. Fue precoz y exitosamente manejado con angioplastía coronaria percutánea e implante de stent fármaco activo, guiado por tomografía por coherencia óptica intracoronaria. A las 48 horas post angioplastía, presentó episodio de taquicardia ventricular polimorfa reconocido y tratado por el cardiodesfibrilador, sin consecuencias. Electivamente se efectuó angioplastía e implante de stent metálico en arteria coronaria derecha distal, con buen resultado angiográfico. La posterior evolución del paciente fue satisfactoria, sin manifestaciones de insuficiencia cardíaca, angina ni arritmias.

Abstract: A 67-year-old man, with multiple cardiovascular risk factors who in 2015 presented sudden death due to ventricular fibrillation without significant coronary lesions, after which an implantable automatic defibrillator (ICD) was implanted. In 2019, he presented a new episode of ventricular fibrillation adequately resolved by the device, in relation to an acute coronary syndrome with ST elevation in the anterior wall of the left ventricle, due to atherothrombotic occlusion in the proximal portion of the anterior descending artery. He was early and successfully managed with percutaneous coronary angioplasty by the insertion of a drug eluting stent, implanted guided by intracoronary optical coherence tomography. Forty eight hours later, he presented an episode polymorphic ventricular tachycardia recognized and treated by the ICD. Angioplasty with a bare metal stent implantation were performed in the distal right coronary artery, with good angiographic results. The subsequent course was satisfactory, with no manifestations of heart failure, angina or arrhythmias.

Recent advances in external cardiac defibrillation techniques / 生物医学工程学杂志

As an important medical electronic equipment for the cardioversion of malignant arrhythmia such as ventricular fibrillation and ventricular tachycardia, cardiac external defibrillators have been widely used in the clinics. However, the resuscitation success rate for these patients is still unsatisfied. In this paper, the recent advances of cardiac external defibrillation technologies is reviewed. The potential mechanism of defibrillation, the development of novel defibrillation waveform, the factors that may affect defibrillation outcome, the interaction between defibrillation waveform and ventricular fibrillation waveform, and the individualized patient-specific external defibrillation protocol are analyzed and summarized. We hope that this review can provide helpful reference for the optimization of external defibrillator design and the individualization of clinical application.

Ressuscitação cardíaca pré-hospitalar. Do pré-hospitalar à sala de emergência: minutos que salvam uma vida - suporte básico / Prehospital cardiac ressuscitation. From prehospital to the emergency room: minutes that save a life - basic support

A incidência exata de parada cardiorrespiratória (PCR) mesmo em países com registros clínicos bem estruturados ainda é desconhecida, mas as estimativas variam de 180.000 a mais de 450.000 mortes anuais. A etiologia mais comum da PCR é a doença cardiovascular isquêmica que ocasiona no desenvolvimento de arritmias letais. A sobrevivência decorrente da PCR apresenta desfechos divergentes. No cenário extra-hospitalar, os estudos relataram taxas de sobrevida de 1% a 6%. Três revisões sistemáticas de alta hospitalar sobre a PCR extra-hospitalar mostraram 5% a 10% de sobrevida entre aqueles tratados através de serviços médicos de emergência e 15% quando o distúrbio do ritmo era a fibrilação ventricular (FV). O suporte básico de vida consiste em ressuscitação cardiopulmonar (RCP) e, quando disponível, desfibrilação com desfibrilador externo automático (DEA). As chaves para a sobrevivência após a PCR são reconhecimento e tratamento precoces, especificamente, início imediato de excelente RCP e desfibrilação precoce. O presente artigo discutirá os princípios do suporte básico de vida em adultos do pré-hospitalar à sala de emergência, conforme descritos nas Diretrizes de Ressuscitação Cardiopulmonar e Atendimento Cardiovascular de Emergência do ILCOR e AHA, atualizadas em novembro de 2017

The exact incidence of cardiorespiratory arrest (CRA) even in countries with well-structured clinical records is still unknown, but estimates range from 180,000 to over 450,000 annual deaths. The most common etiology of CRA is ischemic cardiovascular disease, resulting in the development of lethal arrhythmias. Survival of CRA shows divergent outcomes. In the out-of-hospital setting, studies have reported survival rates of 1% to 6%. Three systematic reviews of hospital discharge on extra-hospital CRA showed 5% to 10% survival between those treated by emergency medical services and 15% when the rhythm disorder was ventricular fibrillation (VF). Basic life support consists of cardiopulmonary resuscitation (CPR) and, when available, defibrillation with an automatic external defibrillator (AED). The keys to survival of CRA are early recognition and treatment, specifically, immediate onset of excellent CPR and early defibrillation. This article will discuss the basics of adult life support from prehospital to emergency room, as outlined in the ILCOR and AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, updated in November 2017

Subcutaneous implantable cardioverter defibrillator: early experience

Abstract Introduction: The implantable cardioverter defibrillator had been increasing the survival of patients at high risk for sudden cardiac death. The subcutaneous implantable cardioverter defibrillator was developed to mitigate the complications inherent to lead placement into cardiovascular system. Objective: To report the initial experience of 18 consecutive cases of subcutaneous implantable cardioverter defibrillator implantation showing the indications, potential pitfalls and perioperative complications. Methods: Between September 2016 and March 2017, 18 patients with indication for primary and secondary prevention of sudden cardiac death, with no concomitant indication for artificial cardiac pacing, were included. Results: The implantation of the subcutaneous implantable cardioverter defibrillator successfully performed in 18 patients. It was difficult to place the subcutaneous lead at the parasternal line in two patients. One patient returned a week after the procedure complaining about an increase in pain intensity at pulse generator pocket site, which was associated with edema, temperature rising and hyperemia. Two patients took antialgic medication for five days after surgery. A reintervention was necessary in one patient to replace the lead in order to correct inappropriate shocks caused by myopotential oversensing. Conclusion: In our initial experience, although the subcutaneous implantable cardioverter defibrillator implantation is a less-invasive, simple-accomplishment procedure, it resulted in a bloodier surgery perhaps requiring an operative care different from the conventional. Inappropriate shock by oversensing is a reality in this system, which should be overcame in order not to become a limiting issue for its indication.

Tempestade elétrica em portadores de cardiodesfibriladores automáticos implantáveis / Electrical storm in patients with automatic implantable cardioverter defibrillators

A tempestade elétrica em portadores de cardiodesfibriladores implantáveis é a ocorrência de pelo menos três intervenções apropriadas, resultante de taquicardia ventricular ou fibrilação ventricular, em 24 horas. É preditor de mau prognóstico e a terapia varia de medicamentos até transplante cardíaco. Este estudo teve por objetivo revisar orientações de diagnóstico e prevenção, visando ao tratamento (farmacológico, intervencionista e cirúrgico) da tempestade elétrica em portadores desses dispositivos. Compilamos publicações no Medline/PubMed e em revistas nacionais. O tratamento das condições basais e desencadeantes, como insuficiência cardíaca e insuficiência coronária, reduziu a morte súbita. A miodarona, betabloqueadores, lidocaína e magnésio são a base terapêutica. A ablação por cateter reduz arritmias e choques, estabiliza o ritmo e melhora o prognóstico. A taquicardia ventricular com substrato permite a abordagem de um circuito estável. A compreensão dos mecanismos e as melhorias no mapeamento eletrofisiológico possibilitam seu uso na fibrilação ventricular. Diferentes condições necessitam de abordagem cirúrgica, eliminando focos arritmogênicos e/ou permitindo o remodelamento,utilizando ressincronização, tratamentos para coronariopatia, valvopatias e cardiopatias congênitas, ressecção endocárdica guiada por eletrofisiologia e transplante em pacientes refratários. Atuando no sistema nervoso, aneuromodulação é alternativa. Durante anestesia peridural torácica, a denervação simpática cardíaca tem efeitos consistentes e persistentes. De modo semelhante à denervação simpática renal, pode ser um novo horizonte. Concluímos que identificar a causa é fundamental. O tratamento dos fatores causais melhora o controle e o prognóstico. Amiodarona, bloqueadores beta-adrenérgicos, lidocaína e magnésio são opções. Procedimento ablativo deve ser ponderado para taquicardia e fibrilação ventricular. Abordagem cirúrgica e neuromodulação...

Electrical storm in patients with implantable cardioverter defibrillator is the occurrence of at least three appropriate interventions resulting from tachycardia or ventricular fibrillation within 24 hours. It a predictor of poor prognosis and its treatment may vary from drug therapy to heart transplantation. Our objectivewas to review diagnostic and prevention guidelines aiming at the treatment (drug therapy, interventional and surgical treatment) of electrical storm in patients using these devices. We analyzed publications from Medline/PubMed and Brazilian medical journals. The treatment of baseline conditions and triggers, such as heart failure and coronary insufficiency, reduced sudden death. Amiodarone, betablockers, lidocaine and magnesium are the therapeutic basis. Catheter ablation reduces shock and arrhythmia, stabilizes rhythm and improves prognosis. Ventricular tachycardia with substratum allows the approach of a stable circuit. Understanding the mechanismsand improvements in electrophysiological mapping enables the use of catheter ablation in ventricular fibrillation.Different conditions require a surgical approach, eliminating arrhythmogenic cores and/or allowing cardiac remodeling, using cardiac resynchronization therapy, treatment for coronary artery disease, valve disease,congenital heart disease, electrophysiology-guided endocardial resection and heart transplantation in refractory patients. Neuromodulation is an alternative that acts on the nervous system. During thoracic epidural anesthesia, cardiac sympathetic denervation has consistent and persisting effects. Similarly, renal denervation may be anotherfuture possibility. In conclusion, identifying the cause is essential. Treatment of baseline factors improves control and prognosis. Amiodarone, betablockers, lidocaine and magnesium are pharmacological options. Catheterablation may be considered for tachycardia and ventricular fibrillation. Surgical approach and neuromodulation...

Como identificar e enfrentar a tempestade elétrica na prática clínica? / How to identify and manage electrical storm in clinical practice

O uso na prática clínica de novas formas de terapia dos portadores de cardiopatia vem aumentando a sobrevida e melhorando sua qualidade de vida ao longo dos anos. O advento dos cardioversores-defibriladores implantáveis foi um marco no tratamento dos pacientes com cardiopatias graves e mais propensos a morte súbita, com redução da taxa de mortalidade nesses pacientes. Porém, surgiram novas questões no manejo desses pacientes, especialmente no que concerne o seguimento dos portadores desses dispositivos em relação à sua otimização para redução de terapias inapropriadas, melhora de qualidade psicossocial e a conduta frente a situações emergenciais representadas por arritmias frequentes, repetitivas erefratárias, como no caso da Tempestade Elétrica. O objetivo do presente trabalho é revisar as definições, epidemiologia e especialmente a conduta frente a esse grupo de pacientes, que deve aumentar nos próximos anos, com a maior prevalência das cardiopatias, especialmente a isquêmica, e o maior número de implantes de dispositivos cardíacos eletrônicos...

The use of new forms of therapy in patients with heart disease has increased the survival and quality of life of these patients in recent years. The advent of implantable cardioverter- defibrillators was a landmark in the treatment of patients with severe heart disease, who were more prone to sudden death, and led to a reduction in mortality rates among these patients. However, new issues emerged in the management of these patients, especially concerning the follow-up of cardioverter-defibrillator patients in terms of reducing inappropriate therapies, improving their quality of life, and managing emergency situations represented by frequent, repetitive and refractory arrhythmias, such as Electrical Storm. The purpose of this paper is to revise the definitions, epidemiology, and above all, the management of this group of patients, which is expected to grow in the coming years, with the greater prevalence of heart disease, especially ischemic heart disease, and thein creased use of electronic heart implants...

Aparente amenaza para la vida por el síndrome de QT prolongado / An apparent life threatening secondary to long Qt syndrome

Se presenta el caso de un lactante con un episodio de pérdida de conocimiento, en quien se diagnosticó fibrilación ventricular. Se realizó desfibrilación externa con éxito, permitiendo luego arribar al diagnóstico etiológico de síndrome de QT prolongado, constituyendo un ejemplo documentado de esta entidad como causa del síndrome de muerte súbita del lactante.

We report the case of an infant with an episode of loss of consciousness, in whom ventricular fibrillation was diagnosed. He was successfully defibrillated and long QT syndrome was diagnosed as his baseline disease. This case constitutes a documented example of this entity as a cause of the sudden infant death syndrome.

I diretriz de ressuscitação cardiopulmonar e cuidados cardiovasculares de emergência da Sociedade Brasileira de Cardiologia: resumo executivo / I guideline for cardiopulmonary resuscitation and emergency cardiovascular care - Brazilian Society of Cardiology: executive summary

Apesar de avanços nos últimos anos relacionados à prevenção e a tratamento, muitas são as vidas perdidas anualmente no Brasil relacionado à parada cardíaca e a eventos cardiovasculares em geral. O Suporte Básico de Vida envolve o atendimento às emergências cardiovasculares principalmente em ambiente pré-hospitalar, enfatizando reconhecimento e realização precoces das manobras de ressuscitação cardiopulmonar com foco na realização de compressões torácicas de boa qualidade, assim como na rápida desfibrilação, por meio da implementação dos programas de acesso público à desfibrilação. Esses aspectos são de fundamental importância e podem fazer diferença no desfecho dos casos como sobrevida hospitalar sem sequelas neurológicas. O início precoce do Suporte Avançado de Vida em Cardiologia também possui papel essencial, mantendo, durante todo o atendimento, a qualidade das compressões torácicas, adequado manejo da via aérea, tratamento específico dos diferentes ritmos de parada, desfibrilação, avaliação e tratamento das possíveis causas. Mais recentemente dá-se ênfase a cuidados pós-ressuscitação, visando reduzir a mortalidade por meio do reconhecimento precoce e tratamento da síndrome pós-parada cardíaca. A hipotermia terapêutica tem demonstrado melhora significativa da lesão neurológica e deve ser realizada em indivíduos comatosos pós-parada cardíaca. Para os médicos que trabalham na emergência ou unidade de terapia intensiva é de grande importância o aperfeiçoamento no tratamento desses pacientes por meio de treinamentos específicos, possibilitando maiores chances de sucesso e maior sobrevida.

Despite advances related to the prevention and treatment in the past few years, many lives are lost to cardiac arrest and cardiovascular events in general in Brazil every year. Basic Life Support involves cardiovascular emergency treatment mainly in the pre-hospital environment, with emphasis on the early recognition and delivery of cardiopulmonary resuscitation maneuvers focused on high-quality thoracic compressions and rapid defibrillation by means of the implementation of public access-to-defibrillation programs. These aspects are of the utmost importance and may make the difference on the patient's outcomes, such as on hospital survival with no permanent neurological damage. Early initiation of the Advanced Cardiology Life Support also plays an essential role by keeping the quality of thoracic compressions; adequate airway management; specific treatment for the different arrest rhythms; defibrillation; and assessment and treatment of the possible causes during all the assistance. More recently, emphasis has been given to post-resuscitation care, with the purpose of reducing mortality by means of early recognition and treatment of the post-cardiac arrest syndrome. Therapeutic hypothermia has provided significant improvement of neurological damage and should be performed in comatose individuals post-cardiac arrest. For physicians working in the emergency department or intensive care unit, it is extremely important to improve the treatment given to these patients by means of specific training, thus giving them the chance of higher success and of better survival rates.

Magnets and implantable cardioverter defibrillators: What's the problem.

A growing number of surgical patients present to the operating room with implantable cardioverter defibrillators (ICD). Peri-operative care of these patients dictates that ICD function be suspended for many surgical procedures to avoid inappropriate, and possibly harmful, ICD therapy triggered by electromagnetic interference (EMI). An alternative to reprogramming the ICD is the use of a magnet to temporarily suspend its function. However, this approach is not without complications. We report a case where magnet use failed to inhibit ICD sensing of EMI, and a shock was delivered to the patient. Measures to decrease EMI, controversies regarding magnet use, and expert recommendations are discussed.

A eficácia da terlipressina versus adrenalina na ressuscitação cardiopulmonar em suínos / The efficacy of terlipressin versus adrenaline in swine cardiopulmonary resuscitation / La eficacia de la terlipresina versus adrenalina en la resucitación cardiopulmonar en cerdos

JUSTIFICATIVA E OBJETIVOS: O objetivo deste estudo foi avaliar a eficácia da terlipressina (TP) versus adrenalina (ADR) em aumentar a pressão de perfusão coronariana (PPC) e o retorno da circulação espontânea (RCE) na RCP em suínos. MÉTODOS: Sob anestesia cetamina/tiopental, induziu-se fibrilação ventricular em 44 porcos fêmeas imaturos, permanecendo não assistida por 10 min, seguidos de 2 min de RCP-manual (100 compressões/10 ventilações/min com ar). Os animais foram então alocados em quatro grupos, recebendo: 1) ADR (45 µg.kg-1); 2) salina-placebo (10 mL); 3) TP (20 µg.kg-1); 4) TP (20 µg.kg-1) + ADR (45 µg.kg-1). Desfibrilação foi realizada 2 min após, observando-se os animais sobreviventes por um período de 30 min. ECG, PA sistêmica, PAD e PetCO2 foram monitorados continuamente. RESULTADOS: A TP não diferiu do placebo quanto aos efeitos na PPC, com baixas taxas de RCE em ambos os grupos (1/11 vs.2/11; p = NS). A ADR aumentou a PPC de 13 ± 12 para 54 ± 15 mmHg (p < 0,0001), efeito similar a TP + ADR (de 21 ± 10 para 45 ± 13 mmHg; p < 0,0001), com altas taxas de RCE/sobreviventes em ambos os grupos (10/11 vs.9/11, respectivamente). Entre os sobreviventes, maior PAM foi observada no grupo TP + ADR vs.ADR (105 ± 19 mmHg vs.76 ± 21 mmHg; p = 0,0157). CONCLUSÕES: ADR e TP + ADR foram efetivas para aumentar a PPC/RCE neste modelo experimental, mas a TP, isolada, não foi diferente do placebo. Contudo, nos animais sobreviventes do grupo TP + ADR observou-se maior estabilidade hemodinâmica após a RCE, sugerindo que a TP possa ser uma medicação útil no manuseio da hipotensão pós-RCP.

BACKGROUND AND OBJECTIVES: The objective of the present study was to evaluate the efficacy of terlipressin (TP) vs.adrenaline (ADR) in increasing coronary perfusion pressure (CPP) and return of spontaneous circulation (ROSC) in swine CPR. METHODS: Under anesthesia with ketamine/thiopental, ventricular fibrillation was induced in 44 female immature pigs, remaining unassisted for 10 minutes, followed by 2 minutes of manual CPR (100 compression/10 ventilations/min with air). Animals were, then, divided into four groups: 1) ADR (45 µg.kg-1); 2) saline-placebo (10 mL); 3) TP 20 µg.kg-1); and TP (20 µg.kg-1) + ADR (45 µg.kg-1). Defibrillation was performed after 2 minutes, observing surviving animals for a 30-minute period. Electrocardiogram, systemic BP, DBP, and PetCO2 were monitored continuously. RESULTS: Terlipressin did not differ from placebo regarding the effects on CPP, with low rates of ROSC in both groups (1/11 vs.2/11; p = NS). Adrenaline increased CPP from 13 ± 12 to 54 ± 15 mmHg (p < 0.0001), similar effect to TP + ADR (from 21 ± 10 to 45 ± 13 mmHg; p < 0.0001), with high rates of ROSC/survivors in both groups (10/11 vs.9/11, respectively). Among survivors, greater MAP was observed in the TP + ADR group vs.ADR (105 ± 19 mmHg vs.76 ± 21 mmHg; p = 0.0157) groups. CONCLUSIONS: Adrenaline and TP + ADR were effective on maintaining CPP/ROSC in this experimental model, but isolated TP did not differ from placebo. However, in surviving animals in the TP + ADR group, greater hemodynamic stability was observed after ROSC, suggesting that TP can be a useful medication in the management of post-CPR hypotension.

JUSTIFICATIVA Y OBJETIVOS: El objetivo de este estudio fue evaluar la eficacia de la terlipresina (TP) versus adrenalina (ADR) en aumentar la presión de perfusión coronaria (PPC) y el retorno de la circulación espontánea (RCE) en la RCP en cerdos. MÉTODOS: Bajo la anestesia ketamina/tiopental, se indujo la fibrilación ventricular en 44 cerdos hembras no adultos, permaneciendo no asistida por 10 min, seguidos de 2 min de RCP-manual (100 compresiones/10 ventilaciones/min con aire). Los animales se ubicaron entonces en cuatro grupos, recibiendo: 1) ADR (45 µg.kg-1); 2) salina-placebo (10 mL); 3) TP (20 µg.kg-1); 4) TP (20 µg.kg-1) + ADR (45 µg.kg-1). La desfibrilación fue realizada 2 min después, haciendo el seguimiento de los animales sobrevivientes por un período de 30 min. ECG, PA sistémica, PAD y PetCO2 fueron monitorizados continuamente. RESULTADOS: La TP no fue diferente del placebo en cuanto a los efectos en la PPC, con bajas tasas de RCE en ambos grupos (1/11 vs.2/11; p = NS). La ADR aumentó la PPC de 13 ± 12 para 54 ± 15 mmHg (p < 0,0001), efecto similar a TP + ADR (de 21 ± 10 para 45 ± 13 mmHg; p < 0,0001), con altas tasas de RCE/supervivientes en ambos grupos (10/11 vs.9/11, respectivamente). Entre los supervivientes, se observó una mayor PAM en el grupo TP + ADR vs.ADR (105 ± 19 mmHg vs.76 ± 21 mmHg; p = 0,0157). CONCLUSIONES: La ADR y TP + ADR fueron efectivas para aumentar la PPC/RCE en este modelo experimental, pero la TP aislada, no fue diferente del placebo. Sin embargo, en los animales supervivientes del grupo TP + ADR, vimos una mayor estabilidad hemodinámica después de la RCE, lo que nos indica que la TP puede ser una medicación útil en el manejo de la hipotensión post-RCP.

Panorama del desfibrilador externo automático en el mundo / The automated external defibrillator in the world panorama

El desfibrilador externo automático es un recurso considerado Clase I para el manejo de la fibrilación ventricular a nivel prehospitalario. En este artículo se revisa la normatividad y recomendaciones que han hecho algunos países del mundo para su implementación.

Trombosis venosa mayor asociada a catéter de hipotermia terapéutica en un paciente con paro cardiorrespiratorio recuperado: comunicación de un caso y revisión de la literatura / Venous thrombosis secondary to catheter insertion for hypothermia after cardiac arrest: Report of one case

To improve survival and reduce neurological injury, the use of mild hypothermia following cardiac arrest has been recommended. We report a 65 years old woman who presented an out-of-hospital ventricular fibrillation and cardiac arrest. The patient was comatose following initial resuscitation and was admitted into the ICU, where cooling was initiated using an intravascular catheter. After 48 hours, rewarming was initiated. Although no neurological impairment was observed, physical examination of the right inguinal area and echo-Doppler examination revealed an extensive catheter-related thrombophlebitis with right ileocaval vein occlusion., with high risk of masive and life threatening pulmonary embolism. We report a clinical case and review the literature to point out the need for a high index of diagnostic suspicion of deep venous thrombosis in these specific setting.

Cardiac herniation following completion pneumonectomy for bronchiectasis.

Sporadic reports on cardiac herniation are available in the literature; most of them had followed intrapericardial pneumonectomies for malignant pulmonary tumors. We present an uncommon event of heart herniation after a completion pneumonectomy indicated for chronic bronchiectasis. A 35-year-old male patient was operated for left completion pneumonectomy. A 6 cm Χ 4 cm area of adherent pericardium near the obtuse margin of heart was removed during surgery. During head-end elevation of the bed in postoperative intensive care unit, patient got accidentally tilted to the left side, which resulted in ventricular fibrillation. Chest cavity was re-opened for cardiopulmonary resuscitation. Left ventricle was found herniating through the pericardial deficiency into the left-thoracic cavity with the cardiac apex touching chest wall. During surgical re-exploration, the pericardial deficiency was closed with a synthetic Dacron patch. Hemodynamic condition remained stable in the immediate postoperative period. Patients had infection of the left thoracic cavity after 5 weeks, for which he was subjected to thoracoplasty and omentopexy. Prompt recognition with timely intervention is life saving from cardiac herniation. Strategy of closing the pericardial defect after pneumonectomy should be followed routinely, irrespective of the indication for pneumonectomy.

Fibrilação ventricular durante atividade esportiva tratada com sucesso / Fibrilación ventricular durante actividad deportiva tratada con êxito / Ventricular fibrillation during sport activity successfully treated

A sobrevida após parada cardio-respiratória extra-hospitalar é estimada em menos de 5 por cento. Apresentamos um caso de fibrilação ventricular, durante atividade esportiva. Ressuscitação cardio-pulmonar foi iniciada precocemente por pessoa leiga, e desfibrilação foi realizada em menos de três minutos, com desfibrilador externo automático, com sucesso. O programa de acesso público à desfibrilação tem aumentado a sobrevida após fibrilação ventricular extra-hospitalar. Devemos estimular o treinamento de pessoas leigas com relação ao uso de desfibriladores externos automáticos e o programa Suporte Básico de Vida, incentivando a implementação deste em locais com grande afluxo de pessoas e locais com risco elevado de ocorrer morte súbita, a exemplo de centros esportivos.

Survival after out-of-hospital cardiopulmonary arrest is estimated at less than 5 percent. We report a case of ventricular fibrillation during sports activity. Cardiopulmonary resuscitation was initiated early by a layperson, and defibrillation was successfully performed within less than three minutes, with an automated external defibrillator. The public access to defibrillation programs has increased the survival after out-of-hospital ventricular fibrillation. We should encourage the training of laypeople in relation to the use of automated external defibrillators and the Basic Life Support program by stimulating their implementation in places where large numbers of people gather or where people are at a high risk of sudden death, as is the case of sports centers.

La sobrevida tras una parada cardiorrespiratoria extrahospitalaria se estima en menos del 5 por ciento. Presentamos un caso de fibrilación ventricular durante actividad deportiva La resucitación cardiopulmonar fue iniciada precozmente por personal no técnico, y la desfibrilación se realizó en menos de tres minutos, con desfibrilador externo automático, con éxito. El programa de acceso público a la desfibrilación aumentó la sobrevida después de la fibrilación ventricular extrahospitalaria. Debemos estimular la capacitación de personas no técnicas con relación al uso de desfibriladores externos automáticos y el programa Soporte Básico de Vida, incentivando la implementación del mismo en locales con gran afluencia de personas y locales con riesgo elevado de ocurrencia de muerte súbita, como es el caso de los centros deportivos.

Paro cardiorrespiratorio extra-hospitalario de causa cardiaca en Santiago de Chile: experiencia del equipo medicalizado del SAMU Metropolitano / Out-of-hospital cardiac arrest (OHCA) in Santiago de Chile: experience of a physician-staffed ambulance team

Introducción: Existe poca información publicada sobre el Paro Cardiorrespiratorio Extra-Hospitalario (PCR-EH) en Chile y Latinoamérica; su manejo se basa en información extranjera. Nuestro objetivo fue describir un grupo de pacientes que sufrieron un PCR-EH de causa cardiaca y que recibieron maniobras de reanimación por parte de un equipo medicalizado, en Santiago de Chile. Metodología: Estudio descriptivo, de acuerdo a las recomendaciones Utstein. Se incluyó a todos los pacientes que sufrieron un PCR-EH de causa cardiaca, en quienes el equipo de la ambulancia medicalizada del Sistema de Atención Médica de Urgencias (SAMU) de Santiago intentó maniobras de reanimación, entre 2000 y 2005. Resultados: Se incluyó a 221 pacientes. En 58,1 por ciento el PCREH ocurrió en el domicilio y en 53,2 por ciento fue presenciado por testigos. El 44,4 por ciento estaban recibiendo reanimación cardiopulmonar básica (RCPB) al llegar la ambulancia. El intervalo llamada-respuesta fue 13,5 minutos (información disponible en el 18,9 por ciento de los pacientes). El primer ritmo monitorizado fue asistolía en 52,2 por ciento, fibrilación ventricular en 32,4 por ciento, y actividad eléctrica sin pulso en 14,0 por ciento. Un 28,1 por ciento retornó a circulación espontánea durante las maniobras. El 16,4 por ciento fue hospitalizado y 3,3 por ciento fue dado de alta vivo. Conclusiones: El grupo estudiado tiene características similares a otros reportes; sin embargo, la RCPB al llegar la ambulancia fue más frecuente y el intervalo llamada respuesta fue más largo que otros estudios. La sobrevida es baja, pero comparable con otras ciudades. Son necesarios mejores registros y más investigación local para mejorar el tratamiento de estos pacientes.

Introduction: Little is known about out-of-hospital cardiac arrest (OHCA) in Chile and Latin America; decisions are often taken using other countries information. The aim of this study was to describe the characteristics and survival of patients who suffered OHCA of cardiac aetiology in whom resuscitation was attempted by a physician-staffed ambulance team in Santiago, Chile. Methods: Descriptive study, according to the Utstein guidelines. We included all patients suffering OHCA of cardiac aetiology in whom resuscitation was attempted by the physician-staffed ambulance team of the Sistema de Atención Médica de Urgencias (SAMU) in Santiago, between 2000 and 2005. Results: 221 patients were included. 58.1 percent suffered OHCA at home and 53.2 percent were witnessed by bystanders. 44.4 percent were receiving bystander basic cardio-pulmonary resuscitation (CPR) at ambulance arrival. Call response interval was 13.5 minutes (information available in 18.9 percent of patients). The first monitored rhythm was asystole in 52.2 percent, ventricular fibrillation in 32.4 percent and pulsless electrical activity in 14.0 percent. 28.1 percent returned to spontaneous circulation during resuscitation. 16.4 percent were admitted to hospital and 3.3 percent were discharged alive. Conclusions: Patients in our study have similar characteristics than those reported elsewhere; however, bystander CPR maneuvers were more frequent and call-response interval was longer than other reports. Survival was low, but comparable with other urban settings. More research is needed to improve the results on the management of these patients.

Portadores de CDI com limiar de desfibrilação elevado: evolução clínica e alternativas terapêuticas / ICD patients with elevated defibrillation threshold: clinical behavior and therapeutic alternatives

FUNDAMENTO: A programação ideal da energia de choque do CDI deve ser pelo menos 10 J acima do limiar de desfibrilação (LDF), necessitando de técnicas alternativas quando o LDF é elevado. OBJETIVO: Avaliar o comportamento clínico dos portadores de CDI com LDF>25 J e a eficácia da terapêutica escolhida. MÉTODOS: Foram selecionados portadores de CDI, entre janeiro de 2000 e agosto de 2004 (banco de dados prospectivo), com LDF>25 J intra-operatório, e analisaram-se: características clínicas, FEVE, resgate de eventos arrítmicos pelo CDI e óbitos. RESULTADOS: dentre 476 pacientes, 16 (3,36 por cento) apresentaram LDF>25J. Idade média de 56,5 anos, sendo 13 pacientes (81 por cento) do sexo masculino. Quanto à cardiopatia de base 09 eram chagásicos, 04 isquêmicos e 03 com etiologia idiopática. A FEVE média dos pacientes foi 37 por cento e 94 por cento utilizavam amiodarona. O seguimento médio foi de 25,3 meses. Em 02 pacientes com LDF > Choque Máximo (CM), foi necessário implante de eletrodo de choque adicional (array), sendo mantido programação com CM em zona de FV (>182bpm) nos demais. Durante o seguimento 03 pacientes apresentaram 67 terapias de choque apropriadas (TCA) com sucesso. Ocorreram 07 óbitos sendo 5 por causas não cardíacas e 2 por insuficiência cardíaca avançada. Os pacientes que foram a óbito apresentaram níveis de LDF maiores (p=0,0446), entretanto sem relação com a causa dos mesmos tendo em vista que não ocorreram TCA sem sucesso. CONCLUSÃO: Nessa coorte de pacientes com CDI, a ocorrência de LDF elevado foi baixa, implicando terapêuticas alternativas. Houve associação com disfunção ventricular grave, entretanto sem correlação com as causas de óbito.

BACKGROUND: The ideal programming of the implantable cardioverter defibrillator (ICD) shock energy should be at least 10J above the defibrillation threshold (DFT), requiring alternative techniques when the DFT is elevated. OBJECTIVE: To assess the clinical behavior of ICD patients with DFT>25J and the efficacy of the chosen therapy. METHODS: Patients who had undergone ICD implantation between Jan/00 and Aug/04 (prospective database) and presented intraoperative DFT>25J were selected. The analyzed variables were: clinical characteristics, LVEF, rescue of arrhythmic events from ICD and causes of deaths. RESULTS: among 476 patients, 16 (3.36 percent) presented DFT>25J. The mean age was 56.5 years, and 13 patients (81 percent) were men. According to the baseline cardiomyopathy, 09 patients had Chagas' disease, 04 had ischemic cardiomyopathy and 03 had idiopathic cardiomyopathy. Mean LVEF was 0.37 and amiodarone was used by 94 percent of the patients. Mean follow-up (FU) period was 25.3 months. DFT was higher than maximum energy shock (MES) in 2 patients and it was necessary to implant an additional shock electrode (array). It was programmed MES in ventricular fibrillation zone of ICD therapy in the other patients. In the FU, 03 patients had 67 successful appropriate shock therapies (AST). There were 05 noncardiac and 02 heart failure deaths. The patients who died showed higher DFT levels (p=0.044) without correlation with death because there wasn't unsuccessful AST. CONCLUSION: In this cohort of ICD patients, the occurrence of elevated DFT (>25J) was low, leading to alternative therapies. There was an association with severe ventricular dysfunction, although without correlation to the causes of death.