Ductular cholestasis, an unusual form of intrahepatic cholestasis, associated with cardiogenic shock and ventricular assist device.

Ventricular assist devices have been shown to be effective in advanced heart failure selected patients. They often have borderline end-organ function, what facilitates organ dysfunction. Liver failure is difficult to manage and leads to increased morbidity and mortality. We report a case of ductular cholestasis, an unusual cholestatic hepatic failure with untractable coagulopathy, developed during the use of a magnetic levitation centrifugal pump, implanted as a bridge to heart transplantation, in a patient with cardiogenic shock (as an end-stage disease of idiopathic dilated cardiomyopathy). We discussed the pathophysiology of this entity and the possible related factors, including the assist device. Preemptive interventions have been advocated as the primary way of treatment. Preoperative optimization of heart function and avoidance of visceral hypoperfusion and sepsis may play a major role.

Respuesta comunitaria a la muerte súbita: resucitación cardiopulmonar con desfibrilación temprana / Responding to sudden death in the community: cardiopulmonary resuscitation with prompt defibrillation

La respuesta a la parada cardiaca extrahospitalaria debe ser una prioridad para todos los sistemas sanitarios por su elevada incidencia y sus dramáticas consecuencias. Es la tercera causa de mortalidad en las sociedades avanzadas. La estrategia asistencial descansa en los cuatro eslabones de la «cadena de supervivencia»: la alerta inmediata, el soporte vital básico realizado por los testigos, la desfibrilación temprana y, por último, el soporte vital avanzado precoz, seguido de los cuidados intensivos tras la resucitación. La efectividad de esta cadena está condicionada por su eslabón más débil; los elementos clave para la supervivencia son las compresiones torácicas precoces, realizadas con mínimas interrupciones, y la desfibrilación temprana. La introducción del desfibrilador externo semiautomático ha hecho posible que se plantee como objetivo realista lograr un tiempo de desfibrilación < 5 min. Su utilización por los servicios de emergencias sanitarios y cuerpos de seguridad es efectiva y eficiente, como también lo es su introducción en espacios públicos adecuadamente seleccionados, aunque en este caso su eficiencia puede variar significativamente según las características y el nivel de riesgo del espacio donde se ubiquen (AU)

Responding to an out-of-hospital cardiac arrest should be a priority for all health-care systems because of the high incidence and dramatic consequences of such events. Cardiac arrest is the third leading cause of mortality in developed countries. The strategy for providing emergency assistance is based on the four links of the «chain of survival»: rapid notification of the emergency services, the provision of basic life support by bystanders, prompt defibrillation and, finally, prompt provision of advanced life support, followed by post-resuscitation intensive care. The effectiveness of this chain of events depends on its weakest link and the key elements for survival are prompt chest compression, carried out with minimal interruption, and prompt defibrillation. The development of semiautomated external defibrillators has made it possible to regard carrying out defibrillation within 5 minutes as a realistic objective. Their use by emergency health services and by first-aid facilities is effective and efficient, as is their introduction into properly selected public areas. However, in public areas, their efficiency could be significantly affected by the nature of the area in which they are located and by the level of risk at that location (AU)

[Levosimendan for postoperative ventricular dysfunction following heart transplantation]. / Utilidad de levosimendán en la disfunción ventricular postoperatoria del injerto en el trasplante cardiaco.

The development of postoperative ventricular dysfunction immediately after heart transplantation is a serious complication that leads to low-output syndrome and which necessitates circulatory support. It is one of the most common causes of early morbidity and mortality. We present our experience with 6 heart transplant patients who were treated with intravenous levosimendan, a calcium sensitizer with inodilator properties, after regular hemodynamic therapy with sympathomimetic amines failed to result in a satisfactory hemodynamic status. Use of this drug was well tolerated and brought about hemodynamic improvements that were sufficient to enable patients to be weaned from inotropic support with amines and which led to clinical recovery, with 5 of the 6 patients being discharged from the intensive care unit.

[Neurologic complications in the immediate postoperative period after cardiac surgery. Role of brain magnetic resonance imaging]. / Complicaciones neurológicas en el postoperatorio inmediato de la cirugía cardíaca. Aportación de la resonancia magnética cerebral.

INTRODUCTION AND OBJECTIVES: Neurologic complications still cause significant morbidity and mortality in the immediate postoperative period following cardiac surgery. Our understanding of the pathogenesis, prevention, and management of these lesions is constantly developing. MATERIAL AND METHOD: We describe neurologic complications and their course in a cardiac surgery cohort and analyze the value of brain magnetic resonance imaging (MRI), using T1-weighted, T2-weighted, and FLAIR sequences, in patients with postoperative stroke or encephalopathy in whom CT scanning revealed no abnormalities explaining their clinical condition. RESULTS: In 688 patients studied postoperatively, we observed 57 neurologic complications (8.3%): 25 strokes, 24 encephalopathies, 5 seizure disorders, 2 brain deaths, and 1 intracranial hemorrhage. Initial CT scanning failed to show significant findings in 70%. 18 patients underwent brain MRI. In all but 1 of the 11 with stroke, MRI showed areas of acute or subacute infarction (i.e., hyperintensity in FLAIR or T2-weighted sequences) in different locations, mainly in a watershed distribution. In 3 of the 4 patients with mild-to-moderate encephalopathy, MRI showed lesions similar to those previously described for stroke. In the remaining 3 patients, who had severe encephalopathy, MRI showed diffuse cortical necrosis. CONCLUSIONS: The incidence of neurologic complications in the postoperative period following cardiac surgery is significant. In a high percentage of patients, brain CT scanning may not show pathologic findings. In selected patients, MRI could help identify areas of infarction not detected by CT. These images could improve clinicians' understanding of the pathogenic, pathophysiologic, clinical, and prognostic characteristics of such neurologic complications.

Complicaciones neurológicas en el postoperatorio inmediato de la cirugía cardíaca. Aportación de la resonancia magnética cerebral / Neurologic complications in the immediate postoperative period after cardiac surgery. Role of brain magnetic resonance imaging

Introducción y objetivos. Las complicaciones neurológicas (CN) causan una importante morbimortalidad en el postoperatorio inmediato de la cirugía cardíaca. La comprensión de la etiopatogenia, la prevención y el tratamiento de éstas están en constante evolución. Material y método. Se describen las CN y su evolución en una serie quirúrgica, y se analizan las aportaciones de la resonancia magnética cerebral (RMC) con secuencias T1, T2 y la supresión de líquido cefalorraquídeo, en los pacientes que presentan ictus o encefalopatía poscirugía y tomografía computarizada (TC) craneal sin hallazgos que justifiquen la situación clínica. Resultados. Se estudió a 688 postoperados; se observaron 57 CN (8,3%): 25 ictus, 24 encefalopatías, 5 pacientes con crisis convulsivas, 2 muertes cerebrales y una hemorragia intracerebral. La TC craneal inicial no mostró hallazgos relevantes en el 70% de las ocasiones. Se realizó RMC en 18 pacientes, 11 de ellos con ictus: excepto en un estudio, en la RMC encontramos áreas de infarto agudo o subagudo (hiperintensas en la secuencia T2 y FLAIR) en diferentes localizaciones. También se realizó en 4 pacientes con encefalopatía leve-moderada y mostró en 3 de ellos lesiones similares a las descritas en los ictus. En los restantes 3 casos con encefalopatía severa, la RMC mostró áreas con múltiples infartos corticales. Conclusiones. Las CN tras cirugía cardíaca se presentan con una incidencia no despreciable. La TC craneal puede no presentar hallazgos patológicos en un alto porcentaje. En pacientes seleccionados, la RMC puede presentar lesiones, y demostrar áreas isquémicas no detectadas en la TC que ayudan a comprender a los clínicos la etiopatogenia, la fisiopatología, la clínica y la evolución de estas complicaciones (AU)

Introduction and objectives. Neurologic complications still cause significant morbidity and mortality in the immediate postoperative period following cardiac surgery. Our understanding of the pathogenesis, prevention, and management of these lesions is constantly developing. Matherial and method. We describe neurologic complications and their course in a cardiac surgery cohort and analyze the value of brain magnetic resonance imaging (MRI), using T1-weighted, T2-weighted, and FLAIR sequences, in patients with postoperative stroke or encephalopathy in whom CT scanning revealed no abnormalities explaining their clinical condition. Results. In 688 patients studied postoperatively, we observed 57 neurologic complications (8.3%): 25 strokes, 24 encephalopathies, 5 seizure disorders, 2 brain deaths, and 1 intracranial hemorrhage. Initial CT scanning failed to show significant findings in 70%. 18 patients underwent brain MRI. In all but 1 of the 11 with stroke, MRI showed areas of acute or subacute infarction (i.e., hyperintensity in FLAIR or T2-weighted sequences) in different locations, mainly in a watershed distribution. In 3 of the 4 patients with mild-to-moderate encephalopathy, MRI showed lesions similar to those previously described for stroke. In the remaining 3 patients, who had severe encephalopathy, MRI showed diffuse cortical necrosis. Conclusions. The incidence of neurologic complications in the postoperative period following cardiac surgery is significant. In a high percentage of patients, brain CT scanning may not show pathologic findings. In selected patients, MRI could help identify areas of infarction not detected by CT. These images could improve clinicians' understanding of the pathogenic, pathophysiologic, clinical, and prognostic characteristics of such neurologic complications (AU)