Ruptured sinus valsalva aneurysm - an uncommon cause of new onset heart failure onset heart failure / Rotura de aneurisma del seno de valsalva: una causa infrecuente de insuficiencia cardíaca aguda

Abstract: A young man presented to the emergency room with symptoms of recent onset heart failure. On physical examination he showed signs of right heart failure and a continuous murmur. Transesophageal echocardiography an computed tomography confirmed the diagnosis of a ruptured right sinus of Valsalva aneurysm an left to right shunt. After successful surgical repair the patient became asymptomatic, the shunt disappeared and he is well 3 months after surgery.

Resumen: Se presenta el caso clínico de un hombre joven que desarrolla insuficiencia cardíaca de reciente comienzo. Clínicamente lo relevante eran signos de insuficiencia cardíaca derecha y la presencia de un soplo continuo. Por ecocardiografía trans esofágica y Angio TAC, se confirmó la presencia de un aneurisma del seno de Valsalva derecho roto con cortocircuito de izquierda a derecha. Se procedió al cierre del aneurisma, confirmando se buen resultado, acompañado de una evolución asintomática 3 meses después de la intervención.

Acute Prosthetic Aortic Valve Obstruction Leading to Free Aortic Insufficiency Veno-Arterial Extracorporeal Membrane Oxygenation as a bridge to surgery.

INTRODUCTION: Mechanical prosthetic valve thrombosis (PVT) and obstruction is a lifethreatening event. The significant morbidity and mortality associated with this condition warrants rapid diagnostic evaluation and treatment. CASE REPORT: A 66-year-old female patient with a history of aortic valve replacement 13 years before, was admitted to our intensive cardiac care unit with symptoms and signs of prosthetic aortic valve dysfunction. During cardiac angiography, she collapsed and fluoroscopy showed an immobile disc, stopped in an open position and causing free aortic regurgitation. Cardio-pulmonary resuscitation (CPR) was initiated and a VA-ECMO was inserted as a bridge to emergent cardiac surgery. Surgery was then performed and the patient was successfully discharged with no neurological impairment. DISCUSSION: We present a case where Veno-Arterial Extracorporeal Membrane Oxygenation (VA- ECMO) was successfully used as a bridge to emergent surgery in a cardiac arrest patient due to prosthetic valve thrombosis. CONCLUSIONS: This case illustrates how a relative contraindication (severe aortic insufficiency) to VA-ECMO may, in the end, be an indication in a very particular scenario.

Arterial Vascular Complications in Peripheral Venoarterial Extracorporeal Membrane Oxygenation Support.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) has evolved as a life-saving measure for patients requiring emergent support of respiratory and cardiac function. The femoral artery is the standard site for vascular access when initiating adult venoarterial (VA) ECMO. Cannulation-related complications are a known source of morbidity and it has been speculated that patients undergoing ECMO via femoral arterial cannulation are more likely to develop peripheral vascular complications (up to 70%). METHODS: Retrospective institutional review of patients requiring ECMO (January 2011-August 2017). The primary outcome of this study was to investigate the prevalence of cannulation-related complications on VA ECMO and to determine its effect on patient morbimortality. RESULTS: Eighty-two patients underwent ECMO during the period of study, 56,1% were male with a mean age of 55,8 years. The VA mode was used in 61 patients, 56 with peripheral cannulation. Femoral arterial access was established in 52 patients (73% percutaneously). Vascular complications were observed in 28,6% of the VA femoral ECMOs: 12 acute limb ischemias and 3 major hemorrhages. At the time of femoral cannulation, distal peripheral catheter (DPC) was placed in 5 patients and none developed limb ischemia. For those who developed limb ischemia, several interventions were performed: DPC placement in 9 cases, fasciotomy in 4 and 2 major amputations. Thirty patients underwent arterial cannulas open surgical removal: 8 underwent balloon catheter trombectomy and 5 needed femoral reconstruction. There was an association between PAD (p=0,03) and ischemic cardiopathy (p=0,02;OR 4,5) with the present of vascular complications after ECMO implantation. CONCLUSIONS: Cannulation of femoral vessels remains associated with considerable rates of vascular events (28.6%). PAD and ischemic cardiopathy are associated with vascular complications in this form of cannulation.

Right single coronary artery as an incidental finding in Takotsubo syndrome and acute heart failure: Case report and review of the literature.

INTRODUCTION: Single coronary artery (SCA) with no associated congenital heart disease is a rare congenital anomaly. Most cases are asymptomatic and incidental findings, but SCA can cause ischemia, congestive heart failure, and sudden cardiac death (SCD). CASE REPORT: A 44-year-old woman presented with Takotsubo cardiomyopathy and cardiogenic shock. Selective cannulation of the left coronary artery (LCA) was not possible on coronary angiography (CA); an SCA was revealed arising from the right sinus, continuing distally as the circumflex artery and thereafter as the left anterior descending artery. Coronary computed tomography angiography (CCTA) confirmed left main atresia and no coronary stenosis. Cardiac magnetic resonance imaging (MRI) showed diffuse myocardial edema and no perfusion defects. The patient's clinical course was favorable under conservative management. DISCUSSION: Our paper describes an incidental finding of right SCA. We report a Lipton type R-I, in which a dominant right SCA supplies the entire myocardium. It is the rarest SCA presentation, with an incidence of 0.0008%; only 15 cases have been reported in the literature, all of which were studied by CA. Of these 15, one had SCD, five angina, one ventricular arrhythmia and one complicated acute coronary syndrome. CCTA confirmed the diagnosis in seven patients, MRI in one and transesophageal echocardiography in another. Nine patients had coronary lesions. Two underwent coronary artery bypass grafting, one percutaneous intervention and 11 conservative treatment. CONCLUSION: Right SCA with congenital absence of the LCA is one of the rarest coronary artery anomalies. In a significant percentage of patients it is associated with ischemia and can be life-threatening. CCTA and MRI are the modalities of choice for diagnosis and risk stratification.

Extracorporeal membrane oxygenation in circulatory and respiratory failure - A single-center experience. / Oxigenação por membrana extracorporal na falência circulatória e respiratória ­ experiência de um centro.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) provides mechanical pulmonary and circulatory support for patients with shock refractory to conventional medical therapy. In this study we aim to describe the indications, clinical characteristics, complications and mortality associated with use of ECMO in a single tertiary hospital. METHODS: We conducted a retrospective observational cohort study of all patients supported with ECMO in two different intensive care units (general and cardiac), from the first patient cannulated in April 2011 up to October 2016. RESULTS: Overall, 48 patients underwent ECMO: 29 venoarterial ECMO (VA-ECMO) and 19 venovenous ECMO (VV-ECMO). In VA-ECMO, acute myocardial infarction was the main reason for placement. The most frequent complication was lower limb ischemia and the most common organ dysfunction was acute renal failure. In VV-ECMO, acute respiratory distress syndrome after viral infection was the leading reason for device placement. Access site bleeding and hematologic dysfunction were the most prevalent complication and organ dysfunction, respectively. Almost 70% of ECMO episodes were successfully weaned in each group. Survival to discharge was 37.9% for VA-ECMO and 63.2% for VV-ECMO. In VA-ECMO, the number of inotropic agents was a predictor of mortality. CONCLUSION: Patients with respiratory indications for ECMO experienced better survival than cardiac patients. The need for more inotropic drugs was a predictor of mortality in VA-ECMO. This is the first published record of the overall experience with ECMO in a Portuguese tertiary hospital.

Arterial Vascular Complications in Peripheral Venoarterial Extracorporeal Membrane Oxygenation Support.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) has been evolved as a life-saving measure for patients requiring emergent support of respiratory and cardiac function.The femoral artery is the standard site for vascular access when initiating adult venoarterial (VA) ECMO.Cannulation-related complications are a known source of morbidity and it has been speculated that patients undergoing ECMO via femoral arterial cannulation are more likely to develop peripheral vascular complications (up to 70%). In patients with severe peripheral arterial disease (PAD) these risks are even higher and its presence may be considered a relative contraindication for femoral artery cannulation. METHODS: Retrospective institutional review of patients requiring ECMO (January 2011-August 2017).The primary outcome of this study was to investigate the prevalence of cannulation- -related complications on VA ECMO and to determine its effect on patient morbimortality.We evaluated demographics and co-morbidities data.Patients were divided into two groups (complications present VS not present) and statistic analysis was performed to determine the impact of different variables such as co-morbidities,cannulation strategy and time on ECMO in each group.Operative reports were reviewed to analyze the surgical procedures implied for treating vascular complications. RESULTS: Eighty-two patients underwent ECMO therapy during the period of study, 56,1% were male with a mean age of 55,8 years.The median time on the ECMO device was 5,5 days.The VA mode was used in 61 patients, 56 with peripheral cannulation.Femoral arterial access was established in 52 patients (73% percutaneously).Vascular complications were observed in 28,6% of the VA femoral ECMOs:12 acute limb ischemias and 3 major hemorrhages. At the time of femoral cannulation, distal peripheral catheter (DPC) was placed in 5 patients and none developed subsequent limb ischemia.For those who developed limb ischemia, several interventions were performed: DPC placement in 9 cases, fasciotomy in 4 and 2 major amputations. Thirty patients underwent arterial cannulas open surgical removal:8 underwent balloon catheter trombectomy and 5 needed femoral reconstruction.There was an association between PAD (p=0,03) and ischemic cardiopathy (p=0,02;OR 4,5) with the present of vascular complications after ECMO implantation.VA femoral ECMO mortality was 69,2% (n=36).Vascular complications after ECMO support are not associated with higher mortality rates (p>0,05). CONCLUSION: Cannulation of femoral vessels remains associated with considerable rates of vascular events (28.6%).PAD and ischemic cardiopathy are associated with vascular complications in this form of cannulation.Physical examination and the assessment of ankle-brachial índex before ECMO implantation is therefore recommended.Improved efforts at preventing these complications need to be developed to avoid additional morbidity in an already critical patient population.