Fighting the pandemic with collaboration at heart: Report from cardiologists in a COVID-19-dedicated Portuguese intensive care unit.

INTRODUCTION AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) spread quickly around the world. Although mainly a respiratory illness, there is growing interest in non-respiratory manifestations, particularly cardiovascular ones. At our center, mobilization of cardiologists with intensive care training was needed. Our aim is to describe patients with severe COVID-19 admitted to a Portuguese intensive care unit (ICU), the cardiovascular impact of the disease and the experience of cardiologists working in a COVID-19 ICU. METHODS: Data from adult patients with COVID-19 admitted to the ICU of Centro Hospitalar de Vila Nova de Gaia/Espinho between 16 March 2020 and 21 April 2020 were analyzed retrospectively. RESULTS: Thirty-five patients were admitted. Mean age was 62.6±6.0 years and 23 (65.7%) were male. Dyslipidemia was the most common cardiovascular risk factor (65.7%, n=23), followed by hypertension (57.1%, n=20). Mean ICU stay time was 15.9±10.0 days. Patients had high rates of mechanical ventilation (88.6%, n=31) and vasopressor support (88.6%, n=31). Low rates of new onset left systolic dysfunction were detected (8.5%, n=2). One patient required venoarterial extra-corporeal membrane oxygenation. Mortality was 25% (n=9). Acute myocardial injury and N-terminal pro-B-type natriuretic peptide (NT-proBNP) elevation was detected in 62.9% (n=22). Patients that died had higher NT-proBNP compared to those discharged alive (p<0.05). Care by cardiologists frequently changed decision making. CONCLUSIONS: The cardiovascular impact of COVID-19 seems relevant but is still widely unknown. Studies are needed to clarify the role of cardiac markers in COVID-19 prognosis. Multidisciplinary care most likely results in improved patient care.

Impella support for cardiogenic shock and high-risk percutaneous coronary intervention: A single-center experience.

INTRODUCTION AND OBJECTIVES: The use of mechanical circulatory support is increasing in cases of cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR-PCI). The Impella® is a percutaneous ventricular assist device that unloads the left ventricle by ejecting blood to the ascending aorta. We report our center's experience with the use of the Impella® device in these two clinical settings. METHODS: We performed a single-center retrospective study including all consecutive patients implanted with the Impella® between 2007 and 2019 for CS treatment or prophylactic support of HR-PCI. Data on clinical and safety endpoints were collected and analyzed. RESULTS: Twenty-two patients were included: 12 were treated for CS and 10 underwent an HR-PCI procedure. In the CS-treated population, the main cause of CS was acute myocardial infarction (five patients); hemolysis was the most frequent device-related complication (63.7%). In-hospital, cumulative 30-day and one-year mortality were 58.3%, 66.6% and 83.3%, respectively. In the HR-PCI group, all patients had multivessel disease (mean baseline SYNTAX I score: 44.1±13.7). In-hospital, 30-day and one-year mortality were 10.0%, 10.0% and 20.0%, respectively. There were no device- or procedure-related deaths in either group. CONCLUSION: The short- and long-term results of Impella®-supported HR-PCI were comparable to those in the literature. In the CS group, in-hospital and short-term outcomes were poor, with high mortality and non-negligible complication rates.

Fighting the pandemic with collaboration at heart: Report from cardiologists in a COVID-19-dedicated Portuguese intensive care unit.

INTRODUCTION AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) spread quickly around the world. Although mainly a respiratory illness, there is growing interest in non-respiratory manifestations, particularly cardiovascular ones. At our center, mobilization of cardiologists with intensive care training was needed. Our aim is to describe patients with severe COVID-19 admitted to a Portuguese intensive care unit (ICU), the cardiovascular impact of the disease and the experience of cardiologists working in a COVID-19 ICU. METHODS: Data from adult patients with COVID-19 admitted to the ICU of Centro Hospitalar de Vila Nova de Gaia/Espinho between 16 March 2020 and 21 April 2020 were analyzed retrospectively. RESULTS: Thirty-five patients were admitted. Mean age was 62.6±6.0 years and 23 (65.7%) were male. Dyslipidemia was the most common cardiovascular risk factor (65.7%, n=23), followed by hypertension (57.1%, n=20). Mean ICU stay time was 15.9±10.0 days. Patients had high rates of mechanical ventilation (88.6%, n=31) and vasopressor support (88.6%, n=31). Low rates of new onset left systolic dysfunction were detected (8.5%, n=2). One patient required venoarterial extra-corporeal membrane oxygenation. Mortality was 25% (n=9). Acute myocardial injury and N-terminal pro-B-type natriuretic peptide (NT-proBNP) elevation was detected in 62.9% (n=22). Patients that died had higher NT-proBNP compared to those discharged alive (p<0.05). Care by cardiologists frequently changed decision making. CONCLUSIONS: The cardiovascular impact of COVID-19 seems relevant but is still widely unknown. Studies are needed to clarify the role of cardiac markers in COVID-19 prognosis. Multidisciplinary care most likely results in improved patient care.

INTRODUÇÃO E OBJETIVOS: A doença pelo novo coronavirus (COVID-19) espalhou-se rapidamente pelo globo. Embora tenha atingimento essencialmente respiratório, existe interesse nas manifestações extrarrespiratórias, nomeadamente nas cardiovasculares. No nosso centro, foi necessária a mobilização de cardiologistas com experiência em cuidados intensivos para enfrentar este desafio. O objetivo desta investigação é descrever a população internada com COVID-19 grave numa UCI portuguesa, o impacto cardiovascular desta doença e a nossa experiência enquanto cardiologistas numa UCI COVID-19. MÉTODOS: Dados de adultos com COVID-19 internados na UCI do Centro Hospitalar de Vila Nova de Gaia/Espinho entre 16/03/2020 e 21/04/2020 foram analisados retrospetivamente. RESULTADOS: Foram internados 35 doentes. A média de idade foi 62,6±6,0 anos e 23 (65,7%) doentes eram homens. A dislipidemia foi o fator de risco cardiovascular mais prevalente (65,7%, n=23), seguida pela hipertensão (57,1%, n=20). O tempo médio de internamento em UCI foi 15,9±10,0 dias. A necessidade de ventilação mecânica (88,6%, n=31) e suporte vasopressor (88,6%, n=31) foi alta, mas poucos doentes desenvolveram disfunção sistólica de novo (n=2,85%). A mortalidade foi de 25% (n=9). Foi detetada lesão miocárdica aguda e elevação do NT-proBNP em 62,9% (n=22) dos doentes, sendo os níveis de NT-proBNP mais elevados nos doentes que faleceram (p<0,05). A participação de cardiologistas na UCI alterou frequentemente a decisão clínica. CONCLUSÃO: O impacto cardiovascular da COVID-19 parece relevante mas é parcamente conhecido, sendo necessários mais estudos para clarificar o papel dos marcadores cardíacos no prognóstico da COVID-19. As equipas multidisciplinares provavelmente melhoram os cuidados de saúde prestados a estes doentes.

Balloon Aortic Valvuloplasty in Patients Admitted for Cardiogenic Shock with Severe Aortic Stenosis: A Retrospective Analysis of 14 Cases.

Introduction Balloon aortic valvuloplasty (BAV), introduced in 1986, quickly lost its wide adoption due to the high incidence of restenosis after the procedure and due to improved skills in transcatheter aortic valve implantation (TAVI). It has seen a re-emergence in the last few years as bailout therapy in critical care patients presenting with cardiogenic shock (CS) and severe aortic stenosis (AS), who are temporarily unable to tolerate such a procedure as TAVI or surgery for valve replacement. Methods We did a retrospective analysis of every BAV performed between January 1, 2008, and November 11, 2018, in our hospital and identified those admitted to the cardiac intensive care unit (CICU) due to cardiogenic shock with severe aortic stenosis, as defined in the European Society of Cardiology Guidelines. Procedures were categorized as emergent (within 24h after the decision to intervene) and urgent (24h after the decision was made but before discharge). Results During this period, of 98 BAV performed, 14 were performed on patients with CS with severe AS, nine of them being emergent. The patients' mean age was 76.2±7.2 years, with 6 (43%) of them being female. On the day of BAV, the mean Euroscore II and sequential organ failure (SOFA) were, respectively, 19±7% and 8.0±2.4 in emergent cases and 11±5% and 4.8±2.9 in urgent cases. In patients deemed emergent, there was a tendency for a decrease in SOFA in the days following the procedure, although not statistically significant (p>0.05). Clinically significant aortic regurgitation did not occur in any patient, neither were there any major post-procedure complications. Thirty-day mortality was 33% in emergent cases and 0% in urgent cases. In emergent cases, four were later submitted to TAVI and one had surgery for aortic valve replacement surgery. Only one patient in the urgent group was regarded as a candidate for TAVI. Discussion and conclusion Emergent cases presented with higher scores of severity and procedure risk and had greater mortality. In this group, a greater proportion of survivors was later deemed fit for definite procedures. This highlights that presenting status does not seem to influence the prognosis of those extremely high-risk patients once the acute event is promptly treated. Nevertheless, the low sample size precludes generalization of the findings. BAV as bailout treatment may be safe in patients presenting with CS and severe AS, allowing patient survival for elective definitive treatment.

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.

A rare cause of hoarseness in a young patient.

Syphilis is nowadays a rare cause of aortic aneurysms in developed countries. Commonly saccular, syphilitic aneurysms are frequently single, involving the ascending aorta and arch and are frequently asymptomatic unless large enough to cause symptoms due to compression of surrounding structures or death from rupture. In this paper, the authors present the case of a 32-years old patient presenting with progressive weakness, anorexia, weight loss and hoarseness, who was diagnosed with a multiple saccular aortic aneurysms, which were syphilitic in nature. The patient underwent surgery for a hemiarch replacement after receiving a cycle of antibiotics and had an uneventful recovery. This case illustrates that, although rare, syphilis must be recognized as a potential source of aneurismal disease as it warrants antibiotic therapy and screening of involvement of other organs.

A sífilis é atualmente uma causa rara de aneurisma da aorta em países desenvolvidos. Normalmente saculares, os aneurismas sifilíticos são frequentemente simples, envolvendo a aorta ascendente e arco. São frequentemente assintomáticos a menos que grandes o suficiente para causar sintomas devido à compressão das estruturas vizinhas, ou morte por ruptura. Neste artigo, os autores apresentam o caso de um paciente de 32 anos de idade com queixas de fraqueza progressiva, anorexia, perda de peso e rouquidão, a quem lhe foi diagnosticado múltiplos aneurismas saculares da aorta, de natureza sifilítica. O paciente foi submetido a uma cirurgia de substituição do hemiarco aórtico depois de receber um ciclo de antibióticos e teve uma recuperação sem intercorrências. Este caso ilustra que, embora rara, a sífilis deve ser reconhecida como uma fonte potencial de doença aneurismática, tanto aórtica como também de outros órgãos.

Aortic intramural hematoma: an unpredictable evolution.

Aortic intramural hematoma (IMH) is an acute aortic syndrome characterized by bleeding into the media of the aortic wall without intimal disruption or the classic flap formation. Its natural history is variable and still poorly understood, so strategies for therapeutic management are not fully established. In some cases there is partial or complete regression of the hematoma under medical treatment, but most progress to dissection, aneurysmal dilatation or aortic rupture. The authors present the case of a 44-year-old hypertensive male patient admitted with a diagnosis of IMH of the descending aorta. Despite initial symptom resolution and optimal medical therapy, the IMH evolved to a pseudoaneurysm, which was successfully treated by an endovascular approach.

Anatomical versus functional assessment of coronary artery disease: direct comparison of computed tomography coronary angiography and magnetic resonance myocardial perfusion imaging in patients with intermediate pre-test probability.

Computed tomography coronary angiography (CTA) and cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI) are state-of-the-art tools for noninvasive assessment of coronary artery disease (CAD). We aimed to compare the diagnostic accuracy of CTA and CMR-MPI for the detection of functionally relevant CAD, using invasive coronary angiography (XA) with fractional flow reserve (FFR) as a reference standard, and to evaluate the best protocol integrating these techniques for assessment of patients with suspected CAD. 95 patients (68 % men; 62 ± 8.1 years) with intermediate pre-test probability (PTP) of CAD underwent a sequential protocol of CTA, CMR-MPI and XA. Significant CAD was defined as >90 % coronary stenosis, 40-90 % stenosis with FFR ≤ 0.80 or left main stenosis ≥50 %. Prevalence of significant CAD was 43 %. CTA was more sensitive (100 %) but less specific (59 %) than CMR-MPI (88 and 89 %, respectively) for detection of significant CAD, with a strong trend for higher global diagnostic accuracy of CMR-MPI (88 vs. 77 %, p = 0.05). An integrated approach based on an initial CTA and subsequent referral to CMR-MPI of positive/inconclusive results had the best diagnostic performance (AUC 0.91). The direct referral to XA of patients with positive/inconclusive CTA performed worse than a selective approach based on CMR-MPI results (AUC 0.80 vs. 0.91, p = 0.005). In this intermediate PTP population, CMR-MPI showed a strong trend toward better performance compared to CTA for the assessment of functionally significant CAD. A combined protocol integrating coronary anatomy and function seems to be a very effective approach in the accurate diagnosis of CAD.

Interrupted aortic arch: A misdiagnosed cause of hypertension.

We present the case of a 47-year-old man with hypertension for over 20 years, referred to our hospital due to mild aortic dilatation detected on a transthoracic echocardiogram. On physical examination weak lower limb pulses and a blood pressure differential of >50 mmHg between arms and legs were detected. Complete interruption of the aortic arch below the left subclavian artery was diagnosed by computed tomography angiography. With this case we aim to draw attention to aortic coarctation and interrupted aortic arch as potential causes of hypertension and to highlight the importance of the physical examination in the diagnosis of secondary causes of hypertension.

[Percutaneous rheolytic thrombectomy in the treatment of high-risk acute pulmonary embolism: Initial experience of a single center]. / Trombectomia percutânea reolítica no tratamento de tromboembolismo pulmonar de alto risco: experiência inicial de um centro.

For years, the treatment of high-risk pulmonary embolism (PE) was based on two well-defined strategies: thrombolysis, whose benefits have been documented in randomized trials, and surgical embolectomy. However, mechanical reperfusion by percutaneous techniques is used in an increasing number of patients, and is a valid therapeutic option when there is a formal contraindication to thrombolysis, as rescue therapy when thrombolysis fails to improve hemodynamics, and/or when emergency surgical thrombectomy is unavailable or contraindicated. This article discusses the indications for the use of percutaneous techniques in PE, reports the initial experience of our center with the AngioJet® thrombectomy device (Possis Medical Inc, Minneapolis, MN, USA) and reviews the available evidence, the most recent recommendations and the main complications associated with this procedure.

Diffuse aneurysmal and obstructive coronary artery disease: a do-not-intervene patient.

Coronary artery aneurysms are uncommon but potentially hazardous entities found on a small percentage of coronary angiograms. The best management strategy remains to be determined; the coexistence of obstructive coronary artery disease is the main determinant of prognosis. We report the case of a middle-aged woman with mixed aneurysmal and obstructive coronary artery disease presenting as an acute myocardial infarction, probably due to atherosclerosis. The unusual severity and complexity of the angiographic presentation of this case, with involvement of all major coronary arteries, raises important issues in terms of the patient's treatment options.

Aborted sudden cardiac death as first presentation of Wolff-Parkinson-White syndrome.

Sudden cardiac death (SCD) can be the first clinical manifestation of Wolff-Parkinson-White (WPW) syndrome. Catheter ablation of accessory pathways is now a safe and effective procedure, and is widely recommended in patients with WPW syndrome. However, management of the asymptomatic WPW patient remains controversial. Recent studies have readdressed the issue of risk stratification and prophylactic catheter ablation. We describe a case of malignant arrhythmia and aborted SCD as first presentation of WPW syndrome in a previously asymptomatic 17-year-old patient.

Transcatheter aortic valve implantation: is anatomy still the limiting factor?

INTRODUCTION: Despite rapid advances in transcatheter aortic valve prostheses, anatomical constraints remain that can limit access to this treatment for patients with severe aortic stenosis. The objective of this study was to determine the proportion of patients anatomically suitable for this technique using the different devices and approaches available. METHODS: We retrospectively analyzed 145 consecutive patients referred to our center for transcatheter aortic valve implantation. Aortic annulus diameter was measured by transesophageal echocardiography and minimum iliofemoral diameter was determined by multidetector computed tomography. We determined the proportion of patients anatomically suitable for current devices (26-mm, 29-mm and 31-mm Medtronic CoreValve for transfemoral, transaxillary or transaortic approaches, and 23-mm, 26-mm and 29-mm Edwards Sapien XT for transfemoral or transapical approaches). RESULTS: The Medtronic CoreValve was suitable for 89% of patients via transfemoral access and 93.8% via transaxillary or transaortic approaches, while the Edwards Sapien XT was suitable for 82.1% of patients via transfemoral and 97.2% via transapical approaches. Only 1.4% of patients were anatomically unsuitable for all devices and approaches. CONCLUSIONS: In this population, most patients were anatomically suitable for transcatheter aortic valve implantation if assessed on the basis of multiple devices and multiple access approaches.

[Surgical treatment of a complete aortic arch interruption]. / Tratamento Cirúrgico de um Interrupção Completa do Arco Aórtico.

We describe the clinical case of a 48-year-old woman referred to our centre due to a recently diagnosed severe symptomatic aortic stenosis. Her past medical history included arterial hypertension diagnosed when she was eighteen years old. On preoperative study a complete interruption of the aortic arch was found, distal to the origin of the left subclavian artery. The patient underwent successful two-stage surgical correction by repair of the aortic interruption followed by aortic valve replacement.

A rare cause of acute heart failure.

We describe a rare clinical case of ruptured sinus of Valsalva aneurysm (RSVA) into the right ventricle, complicated with severe aortic regurgitation (AR) and myocardial ischaemia. The AR was caused by a hemodynamic effect solely, in which the shunt of blood flow through the ruptured site pulled the right aortic cusp away from closure. The pathological mechanism of the AR was clearly visualized by transesophageal echocardiography. Early successful primary closure of the RSVA resulted in resolution of the associated AR without any additional procedure.