RESUMO
Venous thromboembolism (VTE) represents a major health problem, especially in cancer patients, who experience a significantly higher incidence of both deep vein thrombosis and pulmonary embolism compared to the general population. Indeed, patients with cancer have a prothrombotic state resulting in both increased expression of procoagulants and suppression of fibrinolytic activity. In addition, VTE increases the morbidity and mortality of these patients. For all these reasons, the prevention and treatment of VTE in cancer setting represent major challenges in daily practice. In general, low-molecular-weight heparin monotherapy is the standard of care for the management of cancer-associated VTE, as Vitamin K antagonists are less effective in this setting. Direct oral anticoagulants offer a potentially promising treatment option for cancer patients with VTE, since recent studies demonstrated their efficacy and safety also in this peculiar setting.
Assuntos
Aspirina/administração & dosagem , Doença da Artéria Coronariana/cirurgia , Trombose Coronária/prevenção & controle , Stents Farmacológicos , Intervenção Coronária Percutânea/instrumentação , Inibidores da Agregação Plaquetária/administração & dosagem , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Aspirina/efeitos adversos , Tomada de Decisão Clínica , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico , Trombose Coronária/etiologia , Esquema de Medicação , Quimioterapia Combinada , Hemorragia/induzido quimicamente , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação Plaquetária/efeitos adversos , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
We present the case of a 69-year-old patient who was referred to the Department of Echocardiography for surgical treatment of severe tricuspid valve regurgitation (TVR) with advanced congestive heart failure. In 2013 the patient underwent unsuccessful percutaneous ablation for permanent atrial fibrillation. In 2015, following numerous episodes of atrial fibrillation and congestive heart failure with left pleural effusion, the patient was admitted to another center. A transthoracic echocardiogram showed severe TVR and moderate precapillary pulmonary hypertension, confirmed at right cardiac catheterization. He showed bilateral ankle swelling, mild systolic cardiac murmur and localized leftmost decreased breath sounds. Chest X-ray revealed left-sided pulmonary edema and ipsilateral large pleural effusion. Following percutaneous drainage of the left pulmonary effusion, the patient underwent transthoracic and transesophageal echocardiography (TEE), confirming severe TVR due to annular dilation, severe pulmonary hypertension (60 mmHg) and right ventricular overload. At TEE, we found a narrowed single left pulmonary vein. Coronary artery angiography showed no critical stenosis. The patient underwent cardiac magnetic resonance and Angiography that confirmed ostial stenosis of a single left pulmonary vein. We performed successful bare-metal stent implantation. After the procedure, we observed progressive improvement in the patient's clinical condition, concomitant with reverse pulmonary hypertension, significant TVR reduction and chest X-ray normalization. This is a rare case of unilateral pulmonary edema following percutaneous ablation of atrial fibrillation.
RESUMO
The objective of this study was to investigate the prognostic significance of 12-lead electrocardiogram (ECG) patterns in a large multicenter cohort of patients with hypertrophic cardiomyopathy; 1,004 consecutive patients with hypertrophic cardiomyopathy and a recorded standard ECG (64% men, mean age 50 ± 16 years) were evaluated at 4 Italian centers. The study end points were sudden cardiac death (SCD) or surrogates, including appropriate implanted cardiac defibrillator discharge and resuscitated cardiac arrest and major cardiovascular events (including SCD or surrogates and death due to heart failure, cardioembolic stroke, or heart transplantation). Prevalence of baseline electrocardiographic characteristics was: normal ECG 4%, ST-segment depression 56%, pseudonecrosis waves 33%, "pseudo-ST-segment elevation myocardial infarction (STEMI)" pattern 17%, QRS duration ≥120 ms 17%, giant inverted T waves 6%, and low QRS voltages 3%. During a mean follow-up of 7.4 ± 6.8 years, 77 patients experienced SCD or surrogates and 154 patients experienced major cardiovascular events. Independent predictors of SCD or surrogates were unexplained syncope (hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.4 to 4.5, p = 0.003), left ventricular ejection fraction <50% (HR 3.5, 95% CI 1.9 to 6.7, p = 0.0001), nonsustained ventricular tachycardia (HR 1.7, 95% CI 1.1 to 2.6, p = 0.027), pseudo-STEMI pattern (HR 2.3, 95% CI 1.4 to 3.8, p = 0.001), QRS duration ≥120 ms (HR 1.8, 95% CI 1.1 to 3.0, p = 0.033), and low QRS voltages (HR 2.3, 95% CI 1.01 to 5.1, p = 0.048). Independent predictors of major cardiovascular events were age (HR 1.02, 95% CI 1.01 to 1.03, p = 0.0001), LV ejection fraction <50% (HR 3.73, 95% CI 2.39 to 5.83, p = 0.0001), pseudo-STEMI pattern (HR 1.66, 95% CI 1.13 to 2.45, p = 0.010), QRS duration ≥120 ms (HR 1.69, 95% CI 1.16 to 2.47, p = 0.007), and prolonged QTc interval (HR 1.68, 95% CI 1.21 to 2.34, p = 0.002). In conclusion, a detailed qualitative and quantitative electrocardiographic analyses provide independent predictors of prognosis that could be integrated with the available score systems to improve the power of the current model.
Assuntos
Cardiomiopatia Hipertrófica/fisiopatologia , Morte Súbita Cardíaca/epidemiologia , Insuficiência Cardíaca/mortalidade , Acidente Vascular Cerebral/mortalidade , Adolescente , Adulto , Fatores Etários , Idoso , Cardiomiopatia Hipertrófica/mortalidade , Eletrocardiografia , Feminino , Transplante de Coração , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Volume Sistólico , Síncope/epidemiologia , Taquicardia Ventricular/epidemiologia , Taquicardia Ventricular/fisiopatologia , Adulto JovemRESUMO
OBJECTIVE: The modified Fontan procedure represents the final stage for the palliation of hearts with single-ventricle physiology. Different opinions exist regarding the optimal timing of the operation, with most centres advocating early intervention. By contrast, over the past decade, we have progressively increased the age at Fontan operation with the aim to potentially delay the onset of late Fontan failure, and to possibly use larger extracardiac conduits. We retrospectively reviewed our surgical experience with Fontan operation, to understand the impact of this strategy on morbidity and mortality. METHODS: Between 1990 and 2008, 65 patients underwent a modified Fontan operation at our institution (extracardiac conduit in 52 and lateral tunnel in 13). The median age at operation in our series was 7.3 years (range: 2.2-15.8 years) and this value was used to divide the study cohort into two groups. Group A (n=28) included patients with an age at Fontan operation