ABSTRACT
OBJECTIVES: To determine the presenting features, prognostic factors, course, and outcome of critically ill patients with systemic lupus erythematosus admitted to the intensive care unit (ICU). DESIGN: Retrospective patient record review. SETTING: Two academic teaching hospitals. PATIENTS: All patients with systemic lupus erythematosus admitted to the ICUs between January 1982 and July 1993. MEASUREMENTS AND MAIN RESULTS: There were 28 female and two male patients. Fifteen patients were white, 11 patients were black, and four patients were Asian. The median age was 29 yrs. The reasons for admission to the ICU were multifactorial. However, most patients were admitted for infective, renal, cardiac, or coagulation complications. Despite aggressive management, 16 (53%) patients died in the ICU or shortly after discharge. The median ICU survival rate (admission to death) was 22 days. The only pretreatment factor that predicted a poor outcome was the presence of renal involvement due to systemic lupus erythematosus. CONCLUSIONS: Our study suggests that patients with systemic lupus erythematosus admitted to an ICU often have florid disease manifestations with multifactorial reasons precipitating the admission. The prognosis for such patients is poor, particularly in the presence of renal involvement.
Subject(s)
Lupus Erythematosus, Systemic/mortality , APACHE , Adolescent , Adult , Critical Illness , Female , Humans , Intensive Care Units , Lupus Erythematosus, Systemic/complications , Lupus Erythematosus, Systemic/physiopathology , Male , Middle Aged , Outcome Assessment, Health Care , Prognosis , Retrospective Studies , Survival RateABSTRACT
Our data indicate that MVR, with or without chordal preservation, for pure severe MR in symptomatic younger rheumatic patients with a good preoperative ejection fraction results in normalization of LV size and performance by 1 year. Normalization of LV performance was only achieved at 1 year after surgery, and it is therefore essential to extend the assessment of LV function to at least 1 year postoperatively.
Subject(s)
Heart Valve Prosthesis , Mitral Valve Insufficiency/surgery , Rheumatic Heart Disease/surgery , Ventricular Function, Left/physiology , Adolescent , Adult , Age Factors , Case-Control Studies , Female , Follow-Up Studies , Humans , Male , Mitral Valve , Mitral Valve Insufficiency/etiology , Mitral Valve Insufficiency/physiopathology , Registries , Regression Analysis , Rheumatic Heart Disease/physiopathology , Stroke Volume/physiology , Time Factors , Treatment OutcomeABSTRACT
A patient with rheumatic mitral and aortic stenosis is described in whom balloon dilatation of the mitral valve was complicated by an iatrogenic atrial septal defect with a small left to right shunt. Over the course of 4 years, the patient became progressively cyanosed and clubbed and was found to have reversed the shunt across the atrial septal defect due to the occurrence of severe tricuspid stenosis. The tricuspid valve was successfully dilated with re-establishment of a net left to right shunt. This syndrome, the first of its kind, should be appropriately termed the reversed Lutembacher syndrome.
Subject(s)
Cyanosis/etiology , Lutembacher Syndrome/complications , Osteoarthropathy, Secondary Hypertrophic/etiology , Adolescent , Aortic Valve Stenosis/therapy , Catheterization , Echocardiography , Hemodynamics/physiology , Humans , Lutembacher Syndrome/diagnosis , Lutembacher Syndrome/therapy , Male , Mitral Valve Stenosis/therapy , Rheumatic Heart Disease/complications , Rheumatic Heart Disease/diagnosis , Rheumatic Heart Disease/therapy , Tricuspid Valve Stenosis/complications , Tricuspid Valve Stenosis/diagnosis , Tricuspid Valve Stenosis/therapyABSTRACT
The safety of a very low level of anticoagulation combined with dipyridamole in a rheumatic population (mean age 31 +/- 13 years) with the St. Jude Medical (SJM) prosthesis has not yet been tested. Furthermore, no data are available on the safety of relatively infrequent monitoring of anticoagulation levels and of the necessity for different therapeutic targets according to valve position, number of risk factors, and other baseline risk factors for thromboembolism. In this study, the performance of the SJM prosthesis was tested using a target international normalized ratio (INR) of 2.0 to 2.5 combined with dipyridamole 300 mg/day applied uniformly to all patients. Clinical, biochemical, and echocardiographic data were acquired prospectively in 200 consecutive patients at 3-month intervals. Follow-up (mean 27 +/- 13 months) was complete in 95% of patients. Thirteen patients died (2.9%/patient year). Severe left ventricular dysfunction was the cause of death in 10 of 13 patients. Probability of survival (Kaplan-Meier) was 0.92 at 36 months and of event-free survival 0.84 at 36 months. The median INR was 2.0 +/- 0.9. Valve obstruction did not occur, and there were 3 thromboembolic events (0.6%/patient year). Incidence of bleeding was 1.6%/patient year (n = 7) and was major (hemorrhagic stroke) in 1 (0.2%/patient year). Thus, the SJM prosthesis performs very well despite the use of very low level warfarin anticoagulation combined with dipyridamole. A 3-month assessment of the anticoagulation level is safe. Left ventricular dysfunction rather than valve-related complications is the leading cause of mortality in this population.
