Extracorporeal cardiopulmonary resuscitation: is it futile?

PURPOSE OF REVIEW: Extracorporeal cardiopulmonary resuscitation (ECPR) is a treatment modality used to restore end-organ perfusion in the setting of refractory cardiac arrest in patients receiving cardiopulmonary resuscitation (CPR). Despite advances in medicine, survival from cardiac arrest remains low with conventional CPR. The body of literature relating to ECPR is limited to retrospective studies and case series, with data that are inconsistent. Routine use of ECPR is not currently endorsed by the American Heart Association. RECENT FINDINGS: In several single-center retrospective studies, ECPR was associated with a higher level of return of spontaneous circulation and survival to hospital discharge, when compared with conventional CPR. However, data from larger population-based registry studies have not reproduced these findings. Implementation of ECPR is a complex endeavor that requires specialized, multidisciplinary expertise to be successful. SUMMARY: ECPR may be considered as an adjunct to CPR in cases of refractory cardiac arrest. The success of ECPR relies on specialized expertise, thoughtful patient selection, and timely initiation.

Severe tricuspid regurgitation due to interactions with right ventricular permanent pacemaker or defibrillator leads.

Although thought to be a rare event, permanent pacemakers and implantable cardioverter-defibrillators with right ventricular intracardiac leads have the potential to induce tricuspid valve dysfunction. Adverse lead-valve interactions can take place through a variety of mechanisms including damage at the time of implantation, leaflet pinning, or long-term fibrosis encapsulating the leaflet tissue. Clinical manifestations can display a wide range of severity, as well as a highly variable time span between implantation and hemodynamic deterioration. This review aims to describe the potential pathophysiologic effects of intracardiac device leads on the tricuspid valve, with a focus on ideal diagnostic strategies and treatment options once lead-induced valvular dysfunction is suspected.

Measurement of Blood Loss in Cardiac Surgery: Still Too Much.

BACKGROUND: Cardiac surgery is associated with a significant decrease in hematocrit. It is unclear whether that occurs from hemodilution, loss of red cells, or both. Hematocrit is a major determinant of transfusion decisions although transfusion is associated with increased morbidity and mortality. Physicians must determine whether this anemia is the result of hemodilution or red blood cell loss as the former would be treated with packed red blood cell transfusions and the latter by diuresis. We hypothesize that the decrease in hematocrit observed in cardiac surgery is due to hemodilution. METHODS: Blood volume (BV), plasma volume (PV), and red blood cell volume (RBCV) were measured in 54 patients undergoing coronary artery bypass graft surgery, valve surgery, or coronary artery bypass graft/valve surgery. Measurements were made preoperatively, immediately postoperatively, and 2 hours after surgery utilizing a dilution tracer method and hematocrit measurements. RESULTS: Preoperative average BV was 6,094 mL (SD 1,904 mL), RBCV was 2,024 mL (SD 720 mL), and PV was 4,070 mL (SD 1,339 mL). Postoperative average BV was 4,834 mL (SD 1,432 mL), RBCV 1,226 mL (SD 527 mL), and PV 3,607 mL (SD 993 mL). Blood volume decreased 18% (p < 0.0001), RBCV decreased 38% (p < 0.001), and PV decreased 8% (p < 0.012). There were no significant changes between postoperative values and those 2 hours later in the cardiac surgery intensive care unit. CONCLUSIONS: Decreases in hematocrit observed in cardiac surgery patients are due to significant red blood cell losses and not to hemodilution. Red blood cell losses averaged 38%. Plasma volume also decreased.

Immunotherapy for Metastatic Melanoma with Right Atrial Involvement in a Patient with Rheumatoid Arthritis.

Prognosis for metastatic melanoma has improved significantly with the use of immune checkpoint inhibitors. Given improvements in survival, aggressive surgical treatment may be considered in patients with life-threatening complications from their disease that would not otherwise be considered in advanced disease. Patients with preexisting autoimmune diseases or prior immune-related adverse events from therapy are largely excluded from clinical trials. Concerns exist that immunotherapy in these patients could worsen autoimmune disease or increase the risk of developing additional immune-related adverse events on therapy. We present a case of a patient with rheumatoid arthritis that presented with obstructive heart failure secondary to melanoma that had metastasized to the right atrium. After aggressive surgical resection to stabilize him from his life-threatening heart failure, he was treated with ipilimumab, which was stopped due to an immune-related adverse event. He was then started on pembrolizumab and had a durable response to therapy. Aggressive surgical treatment should be considered in patients with a cancer that may respond to immunotherapy. Furthermore, some patients with preexisting autoimmune disease may be safely treated with checkpoint inhibition therapy, and patients with a severe immune toxicity from one class may successfully be treated with an alternate class.

Indicadores multidimensionais de educação e homicídios nos territórios focalizados pelo Pacto Nacional pela Redução de Homicídios

Esta Nota Técnica apresenta um mapeamento das condições educacionais nas escolas e nos bairros em que se observou a incidência de homicídios em 2014, dentre os 81 municípios que são o foco do PNRH e que concentravam 48,6% dos homicídios do país naquele ano. Traz uma breve discussão do efeito da educação sobre crimes. Detalha a metodologia empregada, incluindo as bases de dados e indicadores utilizados, além de uma descrição das dificuldades para fazer o presente mapeamento. Mostra os resultados de nossos cálculos e, além de relatar os indicadores por escola, por bairro e por cada um dos 81 municípios que compõem o foco principal do pacto, aborda a situação relativa de cada dimensão da escola, em relação a todas as escolas situadas na mesma unidade federativa. Por fim, começa uma reflexão sobre o uso desse documento para motivar um debate sobre os possíveis caminhos e tecnologias que venham a ter efeito para aprimorar as condições educacionais em cada uma das dimensões analisadas nos bairros mais violentos do país, que possivelmente estão nas localidades em que as crianças e jovens se encontram expostos a maiores vulnerabilidades socioeconômicas e deficiência em seus processos educacionais.

Atlas da violência 2016

Esta nota possui oito seções centrais. A primeira traz uma análise acerca da evolução dos homicídios nas unidades federativas entre 2004 e 2014. Na segunda seção, produz estimativas para captar a taxa de prevalência de homicídios nas 558 microrregiões do país, em que a correlação espacial é levada em conta de modo a aprimorar a acurácia dos indicadores. Na terceira seção trata de um assunto de crucial importância que versa sobre a letalidade policial e sobre a necessidade de se produzir dados de melhor qualidade pelas organizações. Na quarta, quinta e sexta seções, analisa a evolução da letalidade violenta contra os jovens, negros e mulheres no Brasil, respectivamente. A sétima seção é dedicada à arma de fogo e a sua relação com os homicídios nas unidades federativas. Nessa seção, faz-se um exercício contrafactual para dimensionar a quantidade de homicídios que teríamos hoje, caso o Estatuto do Desarmamento não tivesse sido sancionado em 2003. Na oitava seção, faz algumas considerações sobre a qualidade dos dados sobre agressões (homicídios) do SIM, nas unidades federativas. Para tanto, compara os registros acerca das agressões letais com aqueles das mortes violentas com causa indeterminada e com o total de Crimes Violentos Letais Intencionais, segundo os registros policiais.

An alternative technique of implanting a nontransvenous implantable cardioverter-defibrillator system in adults with no or limited venous access to the heart.

BACKGROUND: In some patients at high risk for sudden cardiac death, a transvenous implantable cardioverter-defibrillator (ICD) cannot be implanted owing to limited vascular access. These patients can benefit from a nontransvenous defibrillation system consisting of a rate-sensing lead attached to the epicardium and a subcutaneous (SQ) array. OBJECTIVE: We examine the feasibility, safety, and clinical circumstances requiring implant of nontransvenous defibrillation system in adults. METHODS: Eight patients received an ICD system composed of an SQ array and either a chronic endocardial rate/sense lead (n = 5) or a new epicardial rate/sense lead (n = 3) for primary (n = 2) or secondary (n = 6) prevention. The obstacles to transvenous ICD implantation included recurrent endovascular lead infections (n = 1), congenital heart disease (n = 4), and superior vena cava occlusion (n = 3). The array was tunneled posteriorly, and the epicardial rate-sensing leads were implanted by left lateral minithoractomy. Four patients also required left ventricular pacing. RESULTS: Successful defibrillation was obtained in all patients at 29 ± 2.6 J. There were no major cardiovascular complications. Over a mean follow-up of 545 ± 204 days there was one appropriate and no inappropriate shocks. None of the patients required system revision. There were no significant changes in impedance, pacing threshold, or ventricular sensing observed with the epicardial leads and no change in high-voltage impedance. CONCLUSIONS: The nontransvenous defibrillation system described is an effective technique in an adult population with acceptable pacing and defibrillation threshold.