RESUMEN
OBJECTIVE: The 'Detroit Cardiogenic Shock Initiative' is a single-arm, multicenter study to assess the feasibility of early mechanical circulatory support (MCS) in patients who present with acute myocardial infarction complicated by cardiogenic shock (AMICS) who undergo percutaneous coronary intervention. METHODS: Between July 2016 and February 2017, 4 metro Detroit sites participated in the study. The centers agreed to treat patients with AMICS using a mutually agreed-upon protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those from the 'SHOCK' trial with an additional exclusion criteria being use of intra-aortic balloon pump counter pulsation prior to MCS. RESULTS: A total of 41 consecutive patients were included. Patients had an average age of 65 ± 14 years, 71% were male and 59% of patients were admitted to the hospital in cardiogenic shock. Prior to receiving MCS, 93% of patients were on vasopressors or inotropes, 15% of patients had a witnessed out of hospital cardiac arrest, 27% of patients had an in-hospital cardiac arrest, and 17% were under active cardiopulmonary resuscitation while MCS was being implanted. In accordance to the protocol recommendation, 66% of patients had a MCS device inserted prior to PCI. Right heart catheterization and hemodynamic monitoring was performed in 83% of patients. Door to support times averaged 83 ± 58 minutes and 71% of patients were able to reduce the levels of inotropes and vasopressors within the first 24-hours of their index procedure. Pre-procedure cardiac power output (CPO) was 0.57 W and post-procedure CPO was 0.95 W, a 67% increase (p < 0.001). Survival to explant for the entire cohort was 85% a significant improvement from institutional historical controls (85% vs 51% p < 0.001) and survival to discharge was 76%. CONCLUSION: Centers who adopted a regional shock protocol emphasizing the delivery of early MCS with invasive hemodynamic monitoring can achieve rapid door to support times and can improve survival in patients who present with AMICS. Larger national studies will be needed to further validate this pilot feasibility study.
Asunto(s)
Oxigenación por Membrana Extracorpórea/instrumentación , Corazón Auxiliar , Contrapulsador Intraaórtico/instrumentación , Infarto del Miocardio/cirugía , Intervención Coronaria Percutánea , Choque Cardiogénico/terapia , Anciano , Remoción de Dispositivos , Oxigenación por Membrana Extracorpórea/efectos adversos , Oxigenación por Membrana Extracorpórea/mortalidad , Estudios de Factibilidad , Femenino , Hemodinámica , Humanos , Contrapulsador Intraaórtico/efectos adversos , Contrapulsador Intraaórtico/mortalidad , Masculino , Michigan , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/mortalidad , Infarto del Miocardio/fisiopatología , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Proyectos Piloto , Diseño de Prótesis , Recuperación de la Función , Factores de Riesgo , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/mortalidad , Choque Cardiogénico/fisiopatología , Factores de Tiempo , Tiempo de Tratamiento , Resultado del TratamientoAsunto(s)
Electrocardiografía , Migración de Cuerpo Extraño/diagnóstico por imagen , Encefalopatía Hepática/diagnóstico por imagen , Derivación Portosistémica Intrahepática Transyugular , Complicaciones Posoperatorias/diagnóstico por imagen , Stents/efectos adversos , Migración de Cuerpo Extraño/complicaciones , Encefalopatía Hepática/etiología , Humanos , Persona de Mediana Edad , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Espera VigilanteAsunto(s)
Fibrilación Atrial/tratamiento farmacológico , Ecocardiografía Doppler , Embolectomía , Extremidad Inferior/diagnóstico por imagen , Dolor/diagnóstico por imagen , Tromboembolia Venosa/diagnóstico por imagen , Anticoagulantes/uso terapéutico , Fibrilación Atrial/fisiopatología , Humanos , Extremidad Inferior/fisiopatología , Masculino , Estenosis de la Válvula Mitral/tratamiento farmacológico , Estenosis de la Válvula Mitral/fisiopatología , Enfermedades Reumáticas/tratamiento farmacológico , Enfermedades Reumáticas/fisiopatología , Resultado del Tratamiento , Tromboembolia Venosa/terapia , Warfarina/uso terapéuticoRESUMEN
We present a case of 72-year-old male with reported past medical history of recurrent transient ischemic attacks (TIAs) presenting with myriad of neurological symptoms. Patient was transferred from outlying hospital with complaints of right sided facial droop and dysarthria. Computed tomography angiography (CTA) showed high grade proximal left internal carotid artery (ICA) stenosis along with interesting finding of a free floating thrombus (FFT) in the left ICA. After discussion with the neurosurgical team, our case was treated conservatively with combination of antiplatelet therapy with Aspirin and anticoagulation with Warfarin without recurrence of TIAs or strokes on six-month follow-up.
RESUMEN
Partial anomalous pulmonary venous return (PAPVR) is a rare congenital malformation. The infracardiac variant with the right lobe of the lung draining to the inferior vena cava (IVC) is called Scimitar syndrome. The infantile subtype presents before one year of age and the adult variant is also usually diagnosed in childhood. A 70-year-old woman presented with worsening shortness of breath. An echocardiogram suggested severe pulmonary hypertension that was confirmed by right heart catheterization. A computed tomography (CT) without contrast revealed an anomalous vein from the right upper lobe suggestive of Scimitar syndrome. The patient did not have any other associated congenital heart defects (CHD) (incomplete Scimitar syndrome). A surgical treatment approach was avoided due to the incomplete nature of the Scimitar syndrome. Incomplete Scimitar syndrome may present later and with less severity than the typical Scimitar syndrome with left to right shunting occurring only in the lung and may be managed nonsurgically.
RESUMEN
Cardiogenic shock due to ST elevation myocardial infarction in a patient with a single coronary artery involving the sole vessel is a rare presentation. This can be clinically and angiographically challenging. Proper recognition of the topography of diseased vessels and a systematic guarded approach can lead to procedural success. We report a case of an 81-year-old woman who presented with chest pain followed by a near syncope associated with an acute myocardial infarction. Coronary angiography revealed a single proximally occluded right coronary artery and an anomalous left main coronary artery (originating from the proximal right coronary artery) and occluded distal left circumflex artery. The right coronary artery was successfully stented following predilation without compromising the anomalous left main origin. The flow in the chronically occluded left circumflex artery (originating from the anomalous left main) which was depended on the retrograde supply from right coronary artery through collaterals, was also re-established.
Asunto(s)
Anomalías de los Vasos Coronarios/cirugía , Infarto del Miocardio/cirugía , Choque Cardiogénico/cirugía , Anciano de 80 o más Años , Dolor en el Pecho/diagnóstico , Angiografía Coronaria , Anomalías de los Vasos Coronarios/diagnóstico , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Femenino , Humanos , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/fisiopatología , Intervención Coronaria Percutánea , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/fisiopatologíaRESUMEN
OBJECTIVES: Cardiac ischaemic marker release is associated with adverse clinical outcomes after cardiac surgery. We sought to compare the release of cardiac troponin I (cTnI) after hybrid coronary revascularization (HCR) with off-pump coronary artery bypass surgery (OPCAB). METHODS: Using data from a prospective single-centre registry, we compared cTnI measured at postoperative day 1 following one-stage HCR and OPCAB among patients with normal baseline cTnI. Multivariable linear regression analysis was used to adjust for variables that may have influenced cardiac marker release other than the used revascularization strategy. RESULTS: Sixty-five consecutive patients underwent elective HCR (n = 33) or OPCAB (n = 32). Overall, no differences were seen in comorbidities, CABG risk scores and the lesion-specific SYNTAX score. Procedural complications were lower (15.2 vs 34.4%, P = 0.072), but 30-day and 1-year clinical outcomes (death, myocardial infarction, and repeat revascularization) were similar between the two groups (3.0 vs 3.1% and 9.1 vs 6.2%, respectively). Post-procedural cTnI release measured at 24 h after surgery was significantly lower following HCR compared with OPCAB [ratio of upper reference level URL: median: 3.5, interquartile range (IQR): 0.8-9.1 vs 12.8, IQR: 6.9-21.8, P = 0.001]. After adjusting for potential confounders, HCR was associated, on average, with cTnI less than half (46%) compared with CABG (P <0.0001). CONCLUSIONS: HCR is associated with lower postoperative cTn release, compared with OPCAB. Further research into the clinical implications of this finding is warranted.
Asunto(s)
Puente de Arteria Coronaria Off-Pump/efectos adversos , Enfermedad de la Arteria Coronaria/terapia , Intervención Coronaria Percutánea/efectos adversos , Troponina I/sangre , Anciano , Biomarcadores/sangre , Distribución de Chi-Cuadrado , Puente de Arteria Coronaria Off-Pump/mortalidad , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/sangre , Infarto del Miocardio/etiología , Intervención Coronaria Percutánea/mortalidad , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Aneurisma/cirugía , Procedimientos Endovasculares/métodos , Arteria Subclavia/anomalías , Malformaciones Vasculares/diagnóstico , Aneurisma/complicaciones , Aneurisma/diagnóstico , Angiografía , Afasia/diagnóstico , Afasia/etiología , Afasia/cirugía , Broncoscopía , Diagnóstico Diferencial , Femenino , Humanos , Persona de Mediana Edad , Arteria Subclavia/cirugía , Tomografía Computarizada por Rayos X , Malformaciones Vasculares/complicaciones , Malformaciones Vasculares/cirugíaAsunto(s)
Rotura de la Aorta , Seno Aórtico , Adulto , Rotura de la Aorta/complicaciones , Rotura de la Aorta/diagnóstico , Rotura de la Aorta/cirugía , Aortografía , Implantación de Prótesis Vascular , Procedimientos Quirúrgicos Cardíacos , Anuloplastia de la Válvula Cardíaca , Ecocardiografía Doppler en Color , Ecocardiografía Transesofágica , Endocarditis/etiología , Endocarditis/cirugía , Atrios Cardíacos/cirugía , Humanos , Masculino , Seno Aórtico/diagnóstico por imagen , Seno Aórtico/cirugía , Resultado del Tratamiento , Insuficiencia de la Válvula Tricúspide/etiología , Insuficiencia de la Válvula Tricúspide/cirugíaRESUMEN
Paradoxical hemodynamic instability is defined as unexpected hemodynamic compromise that develops in a patient after pericardial fluid drainage. The overall incidence of the condition is about 5%, and it has a high in-hospital mortality rate. The condition has been reported to occur regardless of the approach that is used to drain the fluid or the underlying cause of the disease. The pathophysiology of paradoxical hemodynamic instability and the appropriate intervention are not very clear, and further studies are needed to identify appropriate preventive measures.We report a rare manifestation of paradoxical hemodynamic instability in a 65-year-old woman who had a history of stage IV lung cancer. She presented with a one-week history of pleuritic chest pain and shortness of breath on exertion. Echocardiography revealed a large circumferential pericardial effusion with right atrial and ventricular collapse during diastole, suggesting a compressive effect of the pericardial fluid; however, left ventricular systolic function was well preserved. The patient underwent the scheduled creation of a subxiphoid pericardial window. Immediately after the pericardial fluid was evacuated, her heart began to beat more vigorously, but this was abruptly followed by an episode of asystole. Pacing and medical therapy were unsuccessful in preventing repeated episodes of asystole, and the patient died.To our knowledge, this is the 2nd report of unexpected asystole after the creation of a subxiphoid pericardial window, and it is the first report of a takotsubo-like contractile pattern associated with paradoxical hemodynamic instability.
Asunto(s)
Arritmias Cardíacas/etiología , Carcinoma de Pulmón de Células no Pequeñas/complicaciones , Taponamiento Cardíaco/cirugía , Hemodinámica , Neoplasias Pulmonares/complicaciones , Técnicas de Ventana Pericárdica/efectos adversos , Derrame Pleural Maligno/cirugía , Anciano , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatología , Arritmias Cardíacas/terapia , Carcinoma de Pulmón de Células no Pequeñas/secundario , Carcinoma de Pulmón de Células no Pequeñas/terapia , Taponamiento Cardíaco/diagnóstico , Taponamiento Cardíaco/etiología , Taponamiento Cardíaco/fisiopatología , Ecocardiografía , Resultado Fatal , Femenino , Paro Cardíaco/etiología , Paro Cardíaco/fisiopatología , Frecuencia Cardíaca , Humanos , Neoplasias Pulmonares/patología , Neoplasias Pulmonares/terapia , Estadificación de Neoplasias , Derrame Pleural Maligno/diagnóstico , Derrame Pleural Maligno/etiología , Derrame Pleural Maligno/fisiopatologíaAsunto(s)
Neoplasias Cardíacas/diagnóstico por imagen , Mixoma/diagnóstico por imagen , Complicaciones Posoperatorias/diagnóstico por imagen , Ecocardiografía Transesofágica , Procedimientos Endovasculares , Foramen Oval Permeable/terapia , Humanos , Hallazgos Incidentales , Masculino , Persona de Mediana Edad , Dispositivo Oclusor Septal/efectos adversos , TrombosisRESUMEN
OBJECTIVE: We compared the outcomes of same sitting robotic-assisted hybrid coronary artery revascularization (HCR) with off-pump coronary artery bypass grafting (OPCABG) in similar patients with multivessel coronary artery disease. BACKGROUND: HCR is a novel procedure in selected patients with multivessel coronary artery disease (CAD). Although there are some data on staged HCR, the data on same sitting HCR are limited. METHODS: We conducted a prospective study comparing same sitting robotic-assisted HCR patients (n = 25) to a group of consecutive low to moderate risk OPCABG patients (n = 27) during the study period. HCR patients underwent robotic internal mammary artery takedown followed by OPCABG via minithoracotomy. After confirming graft patency, immediate percutaneous coronary intervention on the nonbypass arteries was performed. Comparative analyses were performed on in-hospital and 30 day outcomes. RESULTS: The baseline characteristics were similar for both groups including the severity of CAD (Syntax score 33.5+/-8.2 vs. 34.9+/-8.2, P = 0.556). Overall MACE was similar between both groups; however, the HCR group showed improved hospital outcomes with lower need for postoperative transfusions (12% vs. 67%, P < 0.001), and shorter length of hospital stay (5.1+/-2.8 vs. 8.2+/-5.4 days, P < 0.01). Despite lower postoperative costs, the HCR group had higher overall hospital costs due to higher procedural costs ($33,984 +/-$4,806 vs. $27,816+/-$11,172, P < 0.0001). Propensity model analysis showed similar findings. The HCR group showed improved quality of life measures with shorter time to return to work (5.3+/-3.0 vs. 8.2+/- 4.6 weeks, P = 0.01). CONCLUSIONS: Same sitting HCR appears to be feasible and may offer superior outcomes to standard OPCABG, further studies are warranted.