New strategies for the management of acute decompensated heart failure.

Acute heart failure in adults is the unfolding of heart failure in minutes, hours or a few days. Low output heart failure describes a form of heart failure in which the heart pumps blood at a rate at rest or with exertion that is below the physiological range and the metabolizing tissues extract their required oxygen from blood at a lower rate, causing a proportionately smaller oxygen amount remaining in the blood. Therefore, a widened arterial-venous oxygen difference occurs. High output heart failure is characterized by pumping blood with a rate above the physiological range at rest or during exertion, resulting in an arterial-venous oxygen difference, which is normal or low. This may be caused by peripheral vasodilatation during sepsis or thyrotoxicosis, blood shunting, or reduced blood oxygen content/viscosity (Fig. 1). The differentiation between low output heart failure versus high output heart failure is of highest importance for the choice of therapy and therefore the information and the monitoring of the systemic vascular resistance. Patients who present with acute heart failure suffer from a severe complication of different cardiac disorders. Most often they have an acute injury that affects their myocardial performance (eg, myocardial infarction) or valvular/chamber integrity (mitral regurgitation, ventricular septal rupture), which leads to an acute rise in left-ventricular filling pressures resulting in pulmonary edema.

Síntomas psiquiátricos en la demencia frontal. A propósito de un caso / Psychiatric symptoms in frontal dementia. A case report

Entender la demencia como una alteración cognitiva difusa como se hizo clásicamente (centrándose en los aspectos cognitivos y restando interés a sus componentes psiquiátricos y conductuales) dificulta el diagnóstico de los síndromes degenerativos focales. La demencia frontotemporal suele iniciarse con sintomatología psiquiátrica diversa, por lo que a menudo en sus fases iniciales es tratada con exclusividad por el psiquiatra. En la mayoría de las ocasiones se retrasa así su correcto diagnóstico y manejo terapéutico, tanto psicofarmacológico como psicosocial. Un paciente que en la edad adulta muestra cambios progresivos en la personalidad, con trastornos de conducta y pérdida en la capacidad de juicio asociados, debe hacer sospechar la posibilidad de este diagnóstico. Se presenta el caso de una paciente de 42 años de edad que en los 5 años previos recibió diversos diagnósticos psiquiátricos: trastorno mixto ansioso-depresivo, síndrome maníaco, trastorno disociativo y trastorno dependiente de la personalidad; finalmente, se trató del inicio de una demencia de tipo frontal. Se pone en evidencia la necesidad de prestar atención a los componentes psiquiátricos y conductuales de esta entidad (AU)

Cardiac transplantation: the final therapeutic option for the treatment of heart failure.

End-stage heart failure is still associated with a decrease in quality and prognosis of life. Cardiac transplantation remains the final extraordinary therapeutic option for the treatment of truly irreversible end-stage heart failure in all age groups. The selection process of candidates and the acceptance of patients with relative contra-indications is characterized by the experience and skills of an interdisciplinary transplant team, which should have access to different mechanical circulatory support systems for short-term or long-term use: bridging to transplant as well as for recovery.

Acute and temporary ventricular support with BioMedicus centrifugal pump.

BACKGROUND: Short-term ventricular and pulmonary support can be provided by the Medtronic BioMedicus (Eden Prairie, MN) centrifugal pump, which is available in most cardiovascular surgery centers. This versatile pump can provide support during cardiopulmonary resuscitation, cardiopulmonary bypass, extracorporeal membrane oxygenation, and ventricular assistance. A common use of the pump is to provide ventricular assistance for patients after cardiotomy or cardiogenic shock. METHODS: From January 1986 to September 1995, 141 patients at The Methodist Hospital in Houston, Texas were placed on the BioMedicus centrifugal pump after postcardiotomy cardiac failure. Patient treatment and postimplant complications are discussed. RESULTS: Fifty-four percent of the patients were weaned; however, only 22% survived to discharge. There was a very high mortality rate in the early stage after support was discontinued, after weaning, and after device removal. CONCLUSIONS: A high incidence of complications and death is likely related to the period of attempted weaning from cardiopulmonary bypass before the initiation of ventricular support. When weaning a patient from the pump during cardiopulmonary bypass or during ventricular assistance, it is important to optimize preload, after-load, ventricular function, and cardiac rhythm. In patients who have had postcardiotomy support, avoiding fluid overload, low colloid oncotic pressure, hypoperfusion, and use of excessive inotropic and vasoactive medications improve results.

Rewarming: comparison of contemporary heat-exchangers.

Heat exchange methods must be efficient in order to minimize the patient's pump time. However, comparisons of heat exchangers have been rare. Therefore, the in vivo functions of the most popular, currently available heat exchangers, Sarns, Cobe, Medtronics Maxima, and an experimental model manufactured by Haemonetics were compared. Thirty-two pigs weighing between 63-74 kg were placed on cardiopulmonary bypass with right atrial and ascending aorta cannulation through a right thoracotomy. Thermocouples were placed in the pump tubing before and after the heat exchangers, in the water line before and after the heat exchangers, in the inlet and outlet line of the pump, and the esophagus, brain, bladder, rectum, liver, myocardium, and tympanic membranes of the pigs. They were cooled until the bladder temperature was reduced to 14 degrees C, and maintained at that temperature for 10 minutes. Rewarming was begun until the bladder temperature became 37 degrees C. The pump flow was maintained between 50-60 ml/kg/min with standard ventilation. Cobe, Sarns, Maxima, and Haemonetics heat exchangers were tested and their function determined by comparing the time necessary for rewarming. The Haemonetics heat exchanger required a significant shorter time than the others to rewarm the pigs to normal bladder temperature (Cobe 82.0 +/- 12.0, Sarns 80.3 +/- 15.4, Maxima 89.0 +/- 13.9 Haemonetics 68.7 +/- 13.4, p < 0.05). The principal advantage was seen at the lowest temperatures between the Haemonetics experimental heat exchanger and the other heat exchangers. No statistically significant superiority was seen at higher temperatures. The current heat exchangers are relatively comparable but improved performance is possible with available technology.