Risk factors for delayed extubation after ventricular septal defect closure: a prospective observational study

Objective: The objective of our study was to determine the feasibility of early extubation and to identify the risk factors for delayed extubation in pediatric patients operated for ventricular septal defect closure. Methods: A prospective, observational study was carried out at our Institute. This study involved consecutive 135 patients undergoing ventricular septal defect closure. Patients were extubated if feasible within six hours after surgery. Based on duration of extubation, patients were divided two groups: Group 1= extubation time ≤ 6 hours, Group 2= extubation time >6 hours. Results: A total of 99 patients were in Group 1 and 36 patients in Group 2. Duration of ventilation was 4.4±0.9 hours in Group 1 and 25.9±24.9 hours in Group 2 (P<0.001). Univariate analysis showed that young age, low weight, low partial pressure of oxygen, trisomy 21, multiple ventricular septal defect, high vasoactive inotropic score, transient heart block and low cardiac output syndrome were associated with delayed extubation. However, regression analysis revealed that only trisomy 21 (OR: 0.248; 95%CI: 0.176-0.701; P=0.001), low cardiac output syndrome (OR: 0.291; 95%CI: 0.267-0.979; P=0.001), multiple ventricular septal defect (OR: 0.243; 95%CI: 0.147-0.606; P=0.002) and vasoactive inotropic score (OR: 0.174 95%CI: 0.002-0.062; P=0.039) are strongest predictors for delayed extubation. Conclusion: Trisomy 21, low cardiac output syndrome, multiple ventricular septal defect and high vasoactive inotropic score are significant risk factors for delay in extubation. Age, weight, pulmonary artery hypertension, size of ventricular septal defect, aortic cross-clamp and cardiopulmonary bypass time did not affect early extubation.

Levosimendan in a neonate with severe coarctation of aorta and low cardiac output syndrome.

We report successful use of levosimendan after failed balloon angioplasty in a critically ill neonate with coarctation of aorta (CoA) and severe low cardiac output syndrome (LCOS). Treatment with levosimendan improved left heart function, and decreased lactate and brain natriuretic peptide levels. To our knowledge, this is the first report on the safe and successful use of levosimendan in the management of LCOS due to severe CoA in a neonate awaiting surgical repair.

É necessário suspender o betabloqueador na insuficiência cardíaca descompensada com baixo débito? / Is it necessary to suspend betablockers in decompensated heart failure with low output? / ¿Es necesario suspender el betabloqueante en la insuficiencia cardíaca descompensada con bajo débito?

FUNDAMENTO: Há evidências de que a suspensão do betabloqueador (BB) na descompensação cardíaca pode aumentar mortalidade. A dobutamina (dobuta) é o inotrópico mais utilizado na descompensação, no entanto, BB e dobuta atuam no mesmo receptor com ações antagônicas, e o uso concomitante dos dois fármacos poderia dificultar a compensação. OBJETIVO: Avaliar se a manutenção do BB associado à dobuta dificulta a compensação cardíaca. MÉTODOS: Estudados 44 pacientes com FEVE < 45 por cento e necessidade de inotrópico. Divididos em três grupos de acordo com o uso de BB. Grupo A (n=8): os que não usavam BB na admissão; Grupo B (n=25): os que usavam BB, porém foi suspenso para iniciar a dobuta; Grupo C (n=11): os que usaram BB concomitante à dobuta. Para comparação dos grupos, foram utilizados os testes t de Student, exato de Fisher e qui-quadrado. Considerado significante p < 0,05. RESULTADOS: FEVE média de 23,8 ± 6,6 por cento. O tempo médio do uso de dobuta foi semelhante nos três grupos (p=0,35), e o uso concomitante da dobuta com o BB não aumentou o tempo de internação (com BB 20,36 ± 11,04 dias vs sem BB 28,37 ± 12,76 dias, p=NS). Na alta, a dose do BB foi superior nos pacientes em que a medicação não foi suspensa (35,8 ± 16,8 mg/dia vs 23,0 ± 16,7 mg/dia, p=0,004). CONCLUSÃO: A manutenção do BB associado à dobuta não aumentou o tempo de internação e não foi acompanhada de pior evolução. Os pacientes que não suspenderam o BB tiveram alta com doses mais elevadas do medicamento.

BACKGROUND: There is evidence that the suspension of betablockers (BB) in decompensated heart failure may increase mortality. Dobutamine (dobuta) is the most commonly used inotrope in decompensation, however, BB and dobuta act with the same receptor with antagonist actions, and concurrent use of both drugs could hinder compensation. OBJECTIVE: To evaluate whether the maintenance of BB associated with dobuta difficults cardiac compensation. METHODS: We studied 44 patients with LVEF < 45 percent and the need for inotropics. Divided into three groups according to the use of BB. Group A (n=8): those who were not using BB at baseline; Group B (n=25): those who used BB, but was suspended to start dobuta; Group C (n = 11): those who used BB concomitant to dobuta. To compare groups, we used the Student t, Fisher exact and chi-square tests. Considered significant if p < 0.05. RESULTS: Mean LVEF 23.8 ± 6.6 percent. The average use of dobuta use was similar in all groups (p = 0.35), and concomitant use of dobutamine with BB did not increase the length of stay (BB 20.36 ± 11.04 days vs without BB 28.37 ± 12.76 days, p = NS). In the high dose, BB was higher in patients whose medication was not suspended (35.8 ± 16.8 mg/day vs 23.0 ± 16.7 mg/day, p = 0.004). CONCLUSION: Maintaining BB associated with dobutamine did not increase the length of hospitalization and was not associated with the worst outcome. Patients who did not suspend BB were discharged with higher doses of the drug.

FUNDAMENTO: Hay evidencias de que la suspensión del betabloqueante (BB) en la descompensación cardíaca puede aumentar la mortalidad. La dobutamina (dobuta) es el inotrópico más utilizado en la descompensación, mientras tanto, BB y dobuta actúan en el mismo receptor con acciones antagónicas, y el uso concomitante de los dos fármacos podría dificultar la compensación. OBJETIVO: Evaluar si la manutención del BB asociado a la dobuta dificulta la compensación cardíaca. MÉTODOS: Estudiados 44 pacientes con FEVI < 45 por ciento y necesidad de inotrópico. Divididos en tres grupos de acuerdo con el uso de BB. Grupo A (n=8): los que no usaban BB en la admisión; Grupo B (n=25): los que usaban BB, sin embargo fue suspendido para iniciar la dobuta; Grupo C (n=11): los que usaron BB concomitantemente a la dobuta. Para comparación de los grupos, fueron utilizados los test t de Student, exacto de Fisher y qui-cuadrado. Considerado significante P < 0,05. RESULTADOS: FEVI media de 23,8±6,6 por ciento. El tiempo medio de uso de dobuta fue semejante en los tres grupos (p=0,35), y el uso concomitante de la dobuta con el BB no aumentó el tiempo de internación (con BB 20,36 ± 11,04 días vs sin BB 28,37 ± 12,76 días, p=NS). En el alta, la dosis del BB fue superior en los pacientes en que la medicación no fue suspendida (35,8 ± 16,8 mg/día vs 23,0 ± 16,7 mg/día, p=0,004). CONCLUSIÓN: La manutención del BB asociado a la dobuta no aumentó el tiempo de internación y no fue acompañada de peor evolución. Los pacientes que no suspendieron el BB tuvieron alta con dosis más elevadas del medicamento.

Causas incomuns de instabilidade hemodinâmica durante revascularização miocárdica sem circulação extracorpórea / Uncommon causes of hemodynamic instability during myocardial revascularization without cardiopulmonary bypass / Causas poco comunes de inestabilidad hemodinámica durante la revascularización miocárdica sin circulación extracorpórea

Justificativa e objetivos: A revascularização miocárdica (RM) em pacientes com hipertrofia e/ou disfunção ventricular é frequentemente realizada sem utilização de circulação extracorpórea (CEC) porque o desmame da CEC pode ser difícil nesses casos. O controle intraoperatório exige ajuste hemodinâmico estrito, bem como uso de pinçamento aórtico parcial para minimizar alterações hemodinâmicas é efetivo. O objetivo foi relatar dois casos de instabilidade hemodinâmica durante RM sem CEC, após pinçamento parcial da aorta. Relato dos casos: No primeiro caso, a paciente do sexo feminino apresentava diâmetro aórtico ligeiramente reduzido (2,8 cm) e o segundo paciente apresentava fração de ejeção ventricular esquerda (FEVE) de 24 por cento à ecocardiografia. Em ambos os casos, observou-se importante hipotensão arterial e elevação da pressão arterial pulmonar imediatamente após pinçamento aórtico. As equipes cirúrgicas foram avisadas e a instabilidade hemodinâmica de cada caso resolvida após a liberação do pinçamento parcial da aorta. Os pinçamentos posteriores foram realizados em menor área aórtica e as anastomoses proximais realizadas sem intercorrências. Conclusões: Embora as causas mais comuns de instabilidade hemodinâmica durante a RM sem CEC refiram-se à manipulação da posição cardíaca e a alterações da pré-carga ventricular, nesses casos, hipotensão arterial e hipertensão pulmonar deveram-se, provavelmente, à diminuição do débito cardíaco secundário ao aumento da pós-carga em pacientes com pequeno diâmetro relativo da aorta ou disfunção ventricular ocorridos mesmo com pinçamento parcial. A adequada monitoração intraoperatória e a correção imediata de alterações hemodinâmicas podem minimizar a morbimortalidade cirúrgica.

Background and objectives: Myocardial revascularization (MR) in patients with ventricular hypertrophy and/or dysfunction is frequently performed without cardiopulmonary bypass (CB), since it can be difficult to wean those patients off CB. Intraoperative control demands strict hemodynamic adjustment, as well as partial clamping of the aorta to minimize hemodynamic changes. The objective of this study was to report two cases of hemodynamic instability during MR without CB after partial clamping of the aorta. Case report: The first case is a female patient, whose aortic diameter was slightly reduced (2.8 cm); the second case refers to a patient with left ventricular ejection fraction (LVEF) of 24 percent on the echocardiogram. In both cases, significant hypotension and increase in pulmonary blood pressure were observed immediately after clamping of the aorta. The surgical teams were informed of the problem, and in both cases the hemodynamic instability was reverted after unclamping of the aorta. Afterwards, smaller areas of the aorta were clamped and proximal anastomoses were performed without intercurrence. Conclusions: Although cardiac manipulation and changes in ventricular preload represent the most common causes of hemodynamic instability during MR without CB, in the cases presented here, hypotension and pulmonary hypertension were most likely secondary to a reduction in cardiac output due to the increase in afterload in patients with a relatively small aortic diameter or ventricular dysfunction even with partial clamping. Adequate intraoperative monitoring and immediate correction of the hemodynamic changes can minimize surgical morbidity and mortality.

Justificativa y objetivos: La revascularización miocárdica (RM) en pacientes con hipertrofia y/o disfunción ventricular, es a menudo realizada sin la utilización de la circulación extracorpórea (CEC), porque el destete de la CEC puede ser difícil en esos casos. El control intraoperatorio exige un ajuste hemodinámico estricto, y también puede ser eficaz, el uso del pinzamiento aórtico parcial para minimizar las alteraciones hemodinámicas. El objetivo fue relatar dos casos de inestabilidad hemodinámica durante la RM sin CEC, después del pinzamiento parcial de la aorta. Relato de los casos: En el primer caso, la paciente del sexo femenino presentaba un diámetro aórtico ligeramente reducido (2,8 cm), y el segundo paciente presentaba una fracción de eyección ventricular izquierda (FEVI) de un 24 por ciento a la ecocardiografía. En los dos casos, observamos una importante hipotensión arterial y una elevación de la presión arterial pulmonar inmediatamente después del pinzamiento aórtico. Los equipos de cirugía recibieron el aviso y la inestabilidad hemodinámica de cada caso se resolvió después de la liberación del pinzamiento parcial de la aorta. Los pinzamientos posteriores se realizaron en una menor área aórtica y las anastomosis proximales se hicieron sin intercurrencias. Conclusiones: Aunque las causas más frecuentes de la inestabilidad hemodinámica durante la RM sin CEC se refieran a la manipulación de la posición cardiaca y a las alteraciones de la precarga ventricular, en esos casos, la hipotensión arterial y la hipertensión pulmonar se debieron probablemente, a la reducción del débito cardíaco secundario, al aumento de la poscarga en pacientes con un diámetro reducido relativo de la aorta, o a la disfunción ventricular todos inclusive con pinzamiento parcial. El adecuado monitoreo intraoperatorio y la inmediata corrección de las alteraciones hemodinámicas, pueden minimizar la morbimortalidad quirúrgica.

Doenças associadas à resistência à insulina/hiperinsulinemia, não incluídas na síndrome metabólica / Insulin resistance/hyperinsulinemia associated diseases not included in the metabolic syndrome

Nos últimos anos, no Brasil e em países do mundo desenvolvido, a obesidade se tornou um problema de saúde pública mais importante que a desnutrição. Com o aumento de prevalência de obesidade, identificou-se que, além do DM2 e da síndrome metabólica, outras entidades clínicas também estavam associadas à resistência à insulina. Nesta revisão, abordaremos algumas destas alterações, com destaque para a doença hepática gordurosa não alcoólica, mas incluindo também a SOP, a hiperuricemia, a doença renal crônica, a insuficiência cardíaca, alterações cognitivas e câncer.

In the past years, in Brazil and in developed countries, obesity has become a major public health problem. It was identified that besides DM2 and metabolic syndrome other clinical entities were associated with insulin resistance. In this review we describe some of these alterations emphasizing nonalcoholic fatty liver disease, but also including polycistic ovary disease, hyperuricemia, chronic renal failure, heart failure, cognitive decline and cancer.

Predicted outcome after repair of tetralogy of Fallot by postoperative pressure ratio between right and left ventricle.

BACKGROUND: The surgical management of tetralogy of Fallot (TOF) has continued to evolve and there are now generally excellent early and long-term results following complete repair. OBJECTIVE: To investigate the early results of the authors' current surgical management of TOF by assessing the perioperative and early to intermediate follow-up period. The authors paid particular attention to the post-operative ratio of right ventricular to left ventricular systolic pressure (RVSP/LVSP), focusing on the presence of low cardiac output, intensive care unit (ICU) stay, prolonged of inotropic support and ventilation support time. STUDY DESIGN: Retrospective study. MATERIAL AND METHOD: Between June 2002 and August 2004, 31 consecutive patients underwent complete repair of TOF. Their mean age was 7.7 +/- 5.1 years (range, 2.9 to 25.3). A previous palliative shunt had been performed in 14 (45.2%) patients. Twenty-three patients (74.2%) were in NYHA FC II. Mean hematocrit and oxygen saturation were 50.9 +/- 10.25% and 80.5 +/- 8.6%, respectively. Mean preoperative ratio of RVSP/LVSP was 1.1 +/- 0.15. The operative approach was transatrial/transpulmonary, and 17 (54.8%) patients required a transannular patch. An extracardiac valve conduit was necessary in 3 (9.7%) patients with pulmonary atresia. RESULTS: There were no operative or late deaths. Two cases were reoperated from cardiac tamponade. Mean postoperative ratio of RVSP/LVSP was 0.53 +/- 0.16. Median ICU and hospital stays were 2.2 and 11 days, respectively. Presence of low cardiac output and prolonged inotropic support were significantly (P < 0.05) related to a RVSP/LVSP ratio of more than 0.5. At median follow-up of 6 months, 29 (93.5%) patients were asymptomatic and all patients were free of significant residual lesion. CONCLUSION: The authors' early results in complete repair of TOF patients are acceptable with a low incidence of morbidity. A postoperative RVSP/LVSP ratio of more than 0.5 was significantly associated to adverse outcome. Late complications may, however, develop, and long term follow-up for early detection of any such complications is essential.

Late-life depression, heart failure and frontal white matter hyperintensity: a structural magnetic resonance imaging study

The relevance of the relationship between cardiac disease and depressive symptoms is well established. White matter hyperintensity, a bright signal area in the brain on T2-weighted magnetic resonance imaging scans, has been separately associated with cardiovascular risk factors, cardiac disease and late-life depression. However, no study has directly investigated the association between heart failure, major depressive symptoms and the presence of hyperintensities. Using a visual assessment scale, we have investigated the frequency and severity of white matter hyperintensities identified by magnetic resonance imaging in eight patients with late-life depression and heart failure, ten patients with heart failure without depression, and fourteen healthy elderly volunteers. Since the frontal lobe has been the proposed site for the preferential location of white matter hyperintensities in patients with late-life depression, we focused our investigation specifically on this brain region. Although there were no significant group differences in white matter hyperintensities in the frontal region, a significant direct correlation emerged between the severity of frontal periventricular white matter hyperintensity and scores on the Hamilton scale for depression in the group with heart failure and depression (P = 0.016, controlled for the confounding influence of age). There were no significant findings in any other areas of the brain. This pattern of results adds support to a relationship between cardiovascular risk factors and depressive symptoms, and provides preliminary evidence that the presence of white matter hyperintensities specifically in frontal regions may contribute to the severity of depressive symptoms in cardiac disease.

General physicians and the management of heart failure in an Argentine population

Los m¨¦dicos generales y el tratamiento de la insuficiencia card¨ªaca en una muestra de la poblaci¨®n argentina. El objetivo de este estudio fue evaluar c¨®mo los m¨¦dicos generales (MG) piensan que debe tratarse la insuficiencia card¨ªaca (IC) y c¨®mo ponen en pr¨¢ctica su conocimiento. Se realiz¨® en la ciudad de Buenos Aires y su ¨¢rea suburbana, con la colaboraci¨®n de 5 cardi¨®logos, y de 29 MG que fueron seleccionados al azar, a los cuales se les solicit¨® que guardasen las historias cl¨ªnicas de todos los pacientes que ellos hab¨ªan atendido con IC. Se obtuvieron los datos de 220 pacientes. La metodolog¨ªa fue similar a la utilizada en una iniciativa internacional llamada Improvement realizada en Europa. Se evalu¨® el conocimiento de los MG y su percepci¨®n sobre el manejo de la IC mediante una ¡°encuesta de percepci¨®n¡±, y c¨®mo una muestra representativa de pacientes fue tratada, a trav¨¦s de una ¡°encuesta sobre la pr¨¢ctica¡±. El lectrocardiograma y la radiograf¨ªa de t¨®rax se le pidieron a la mayor¨ªa de los pacientes (≅90%), pero el ecocardiograma se pidi¨® s¨®lo en el 67% de casos. Cuarenta por ciento de los pacientes ten¨ªan historia de infarto de miocardio y de angina de pecho, pero la ergometr¨ªa no fue considerada como una prueba de diagn¨®stico importante y s¨®lo se asent¨® en el 16% de las HC. Igualmente la cinecoronariograf¨ªa se realiz¨® en el 7% de pacientes. S¨®lo el 23% de los pacientes ten¨ªan una fracci¨®n de eyecci¨®n del ventr¨ªculo izquierdo documentada en sus HC. En la pr¨¢ctica, el 43% de pacientes estaban recibiendo un inhibidor de la ECA y una tercera parte betabloqueantes. S¨®lo 9% recibieron estas drogas combinadas. En la ¨²ltima entrevista, 50% ten¨ªan hipertensi¨®n arterial (¡Ý 140/ 90 mmHg) y en 15% no se hab¨ªa consignado este dato en las HC de los pacientes. Este estudio mostr¨® que el conocimiento y tratamiento de la IC en una muestra de MG, era menor que el ¨®ptimo.

Herpes simplex type 2 pneumonia

Extensive reviews of pulmonary infections in AIDS have reported few herpetic infections. Generally these infections are due to Herpes simplex type 1. Pneumonia due to herpes type 2 is extremely rare. We describe a 40 year-old HIV positive woman who complained of fever, cough and dyspnea for seven years. She had signs of heart failure and the appearance of her genital vesicles was highly suggestive of genital herpes. Echocardiography showed marked pulmonary hypertension, right ventricular hypertrophy and tricuspid insufficiency. After a few days of hospitalization she was treated with Aciclovir and later with Ganciclovir. An open pulmonary biopsy revealed an interstitial inflammation, localized in the alveolar walls. Some pulmonary arteries had widened walls and focal hyaline degeneration. Immunohistochemistry indicated that the nuclei had herpes simplex virus type 2 in many endothelial cells (including vessels with widened walls), macrophages in the alveolar septa and pneumocytes. There was clinical improvement after treatment for herpes. We concluded that as a consequence of herpes infection, endothelial involvement and interstitial inflammation supervene, with thickening of vascular walls and partial obliteration of the vessel lumen. A direct consequence of these changes in pulmonary vasculature was pulmonary hypertension followed by heart failure.

Tratamento da insuficiência cardíaca terminal através da correçäo da insuficiência mitral secundária e remodelaçäo ventricular / Treatment of terminal cardic insufficiency by means of correction of secondary insufficiency and ventricular remodelling

INTRODUÇÄO: A sobrevida de pacientes com miocardiopatia e insuficiência mitral secundária em classe funcional IV é muito pequena em curtos períodos de observaçäo, apesar dos progressos consideráveis obtidos com o tratamento médico. Tem sido demonstrado que o aparecimento de insuficiência mitral secundária piora o prognóstico e a qualidade de vida e que a correçäo da insuficiência mitral permite melhor controle do paciente. OBJETIVO: O presente trabalho propöe o implante de uma prótese em posiçäo mitral que elimina a insuficiência mitral e remodela a base do ventrículo esquerdo e o seu eixo longitudinal. CASUíSTICA E MÉTODOS: Analisamos 33 pacientes com insuficiência cardíaca refratária sob terapêutica máxima operados entre dezembro/95 e setembro/99. O grupo etário variou de 25 a 78 anos (mediana 58) sendo 57,7 por cento do sexo masculino. O período de observaçäo variou de 4 meses a 4 anos (mediana 22 meses). Quanto à etiologia, em 15 pacientes era isquêmica, em 13 dilatada, em 3 chagásica, em 1 pós-parto e em 1 viral. RESULTADOS: Ocorreram 3 óbitos na fase hospitalar (3/33) e 2 na tardia (2/30), estando 28 pacientes em observaçäo. Neste intervalo de seguimento, 88 por cento dos pacientes melhoraram 1 ou 2 classes funcionais, a fraçäo de ejeçäo subiu de 20 a 36 por cento, apesar da eliminaçäo da fraçäo regurgitante, o volume efetivo melhorou consideravelmente (58 para 80 ml) entre a aferiçäo pré-operatória e a última evoluçäo. CONCLUSÄO: A insuficiência cardíaca refratária com insuficiência secundária moderada a severa pode sofrer efetiva paliaçäo com a eliminaçäo de regurgitaçäo e remodelaçäo do ventrículo esquerdo, implantando-se prótese valvar no anel atrioventricular esquerdo

Fatores prognósticos dos resultados de ressuscitaçäo cardiopulmonar em um hospital de cardiologia / Prognostic factors of the results of cardiopulmonary resuscitation in a cardiology hospital

OBJECTIVE: To analyze the early and late results of cardiopulmonary resuscitation in a cardiology hospital and to try to detect prognostic determinants of both short- and long-term survival. METHODS: A series of 557 patients who suffered cardiorespiratory arrest (CRA) at the Dante Pazzanese Cardiology Institute over a period of 5 years was analyzed to examine factors predicting successful resuscitation and long-term survival. RESULTS: Ressuscitation maneuvers were tried in 536 patients; 281 patients (52.4 percent) died immediately, and 164 patients (30.6 percent) survived for than 24 hours. The 87 patients who survived for more than 1 month after CRA were compared with nonsurvivors. Coronary disease, cardiomyopathy, and valvular disease had a better prognosis. Primary arrhythmia occurred in 73.5 percent of the >1-month survivor group and heart failure occurred in 12.6 percent of this group. In those patients in whom the initial mechanism of CRA was ventricular fibrillation, 33.3 percent survived for more than 1 month, but of those with ventricular asystole only 4.3 percent survived. None of the 10 patients with electromechanical dissociation survived. There was worse prognosis in patients included in the extreme age groups (zero to 10 years and 70 years or more). The best results occurred when the cardiac arrest took place in the catheterization laboratories. The worst results occurred in the intensive care unit and the hemodialysis room. CONCLUSION: The results in our series may serve as a helpful guide to physicians with the difficult task of deciding when not to resuscitate or when to stop resuscitation efforts

Pseudo-infarto do miocárdio durante episódio de Herpes Zoster / Pseudo-myocardial infarction during an episode of herpes zoster

The patient arrived at the emergency unit with a history of acute myocardial infarction, for which she was treated. Without improvement in the pain, the patient developed heart failure and underwent a hemodynamic study, which showed normal coronary arteries and extensive ventricular impairment. During evolution, the clinical findings improved and herpes zoster appeared on the right shoulder. In a few months the clinical findings subsided, and the findings of the electrocardiogram, chest X-ray, and ventricular function were normal. The patient is currently asymptomatic

Falla hepatica fulminante: forma atipica de presentacion de insuficiencia cardiaca / Fulminant hepatic failure: atypical form of cardiac failure presentation

La insuficiencia cardíaca puede presentar como manifestación clínica la enfermedad hepática congestiva. En el shock cardiogénico puede aparecer falla hepática aguda por isquemia hepática. Presentamos una paciente que con antecedentes de insuficiencia cardíaca crónica ingresa a nuestro servicio por presentar mal estado general asociado a deterioro progresivo del hepatograma, del tiempo de protrombina y de la función renal. Las serologías virales y los autoanticuerpos fueron negativos. No tenía antecedentes de contacto con hepatotóxicos. En su evolución presentó encefalopatía sin evidencias iniciales de shock. Al cuarto día de internación presenta shock cardiogénico, con manifestaciones del laboratorio compatibles con isquemia y congestión hepáticas. La paciente fallece 24 horas después. La histología demostró cambios compatibles con isquemia hepática. Se han descripto varios casos de hepatopatías crónicas sin causa evidente que resultaron ser manifestaciones secundarias a enfermedades cardiológicas, especialmente pericarditis constrictiva o miocarditis restrictivas. En este caso la paciente presentó falla hepática aguda sin evidencia inicial de mayor deterioro de su cardiopatía previa. Con este caso queremos destacar la importancia de las causas cardiológicas como probables etiologías de hepatopatías sin causa aparente.

Mortalidad por infarto agudo del miocardio en una unidad de cuidados intermedios / Mortality rate due to acute myocardial infarction in an Intermediated Care Unit

Se realizó un estudio descriptivo y transversal de 86 pacientes ingresados en la Unidad de Cuidados Intermedios del Hospital Provincial "Dr. Ambrosio Grillo" de Santiago de Cuba durante el bienio 1990-1991, por presentar infarto agudo del miocardio, diagnosticado según criterios clínicos, enzimáticos y electrocardiográficos establecidos por la Organización Mundial de la Salud. La mayor parte de los enfermos tenía 70 años o más, que fue también el grupo prevaleciente entre los fallecidos. El dolor anginoso resultó ser la forma clínica de presentación más frecuente, pero en los que comenzó con insuficiencia cardíaca grados II, III y IV hubo mayor mortalidad. Casi todos los complicados acudieron tardíamente en busca de atención médica. La letalidad representó el 19,77 porciento. Las arritmias e insuficiencia cardíaca prevalecieron entre las complicaciones

Reanimación cardiopulmonar cerebral / Cerebral cardiopulmonary resuscitation

The guidelines, recomendations and complications of cardiopulmonary and brain resuscitation are analized

Informe del primer trasplante de bloque cardiopulmonar realizado en México / Report of the first cardiopulmonar block transplantation performed in Mexico

Objetivo: Informar sobre el primer trasplante cardiopulmonar que se realiza en México. Diseño: Informe de caso clínico. Se trató de paciente femenino de 47 años de edad, con hipertensión pulmonar severa y defecto septal auricular en clase funcional III. El día 4 de junio de 1995, en el Hospital de Cardiología del Centro Médico Nacional Siglo XXI se obtuvo bloque cardiopulmonar a partir de donación múltiple y se traspantó a la paciente. Resultados: El tiempo de hipotermia isquémica fue de 3 horas. La actividad cardíaca reinició a los 14 segundos de reperfusión. El destete de la derivación cardiopulmonar se efectuó sin problemas. A las 36 horas presentó abdomen agudo por hemoperitoneo, se requirió laparotomía por hemostasia, además de detectarse pancreatitis. El bloque cardiopulmonar funcionó adecuadamente por 5 días al cabo de los cuales presentó aumento de cortocorcuitos, hipoxemia, bajo gasto cardíaco y falleció al sexto día. El informe de la autopsia fue: pancreatitis edematosa, rechazo de corazón y pulmón, cambios isquémicos del miocardio y edema pulmonar. Conclusión: Es factible realizar trasplante cardiopulmonar en nuestro país. Las complicaciones coinciden con las descritas en la literatura mundial

Agenesia da artéria pulmonar direita com acentuada hipertensão pulmonar, atenuada por correção cirúrgica / Agenesis of Right Pulmonary Artery with Severe Pulmonary Hypertension Attenuceted by Surgical Correction

A 22 months old infant with agenesis of right pulmonary artery, without other associated congenital heart defects, is reported. Reconstruction of pulmonary arteries by connecting them through a 7mm Goretex tube was performed, with clear clinical improvement in view of disappearance of signs of cardiac insufficiency and of hypoxemia. Contralateral pulmonary hypertension, at systemic level, decreased to 77 in the immediate postoperative period. So, this technique becomes the first option, before considering these cases for cardiopulmonary transplantation.

Tumor evanescente de pulmäo: relato de 6 casos / Evanescent tumor of lung: report of 6 cases

Os autores apresentam seis casos de "tumor evanescente de pulmao"(TEP), diagnosticados em parâmetros clínico-radiológicos, de 1988 a 1993, no Hospital Universitário Lauro Wanderley - UFPB, simulando nódulos pulmonares neoplásicos e que apresentam resposta favorável à conduta instituída para insuficiência cardíaca. Ilustram o tema em pauta com imagens de radiologia simples, tomografia computadorizada, cintilografia e ecocardiografia, enfatizando os aspectos pulmonares exuberantes, e apresentam revisao bibliográfica acerca do assunto.