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Introduction: An electrical storm is a condition of cardiac electrical instability characterized by several episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) within 24 hours, requiring medication and/or defibrillation, with a death rate ranging from 22 to 82%.1 The treatment of an electrical storm is determined by the etiology; therefore, for acute coronary syndrome, percutaneous coronary intervention is the method of choice, whereas radiofrequency catheter ablation is the method of choice for VT. Hemodynamically unstable patients frequently require mechanical circulatory support, such as extracorporeal membrane oxygenation (ECMO). This paper describes the case of a younger patient presenting with an ST-segment elevation myocardial infarction, which was complicated by cardiorespiratory arrest, refractory VF, and cardiogenic shock, and who required ECMO to stabilize the condition. Case report: This is a 42-year-old male who presented to the Bjelovar General Hospital on September 9, 2023, with acute chest pains, tingling in both limbs, and short-term dizziness. The patient is admitted with no electrocardiographic symptoms of a myocardial infarction and normal laboratory values; therefore, nitrite treatment is administered. After 2 hours, the patient complains of pain again, which he rates at 10/10 on the visual analogue scale, as well as indicators of an acute myocardial infarction, prompting the transfer to the University Hospital Centre Zagreb. During the patient’s transport, a cardiorespiratory arrest occurs due VF, and defibrillation is performed four times with the use of adrenaline. On arrival, the patient is somnolent, hypotensive, tachydyspnoic, and has audible rales, for which he is sedated, intubated, and mechanically ventilated. Following intubation, the patient becomes rhythmically unstable and falls into cardiac arrest, at which point resuscitation is initiated in accordance with the ALS protocol. Because of the electrical storm, which is caused by refractory VF, the resuscitation method requires the insertion of a peripheral veno-arterial ECMO. The period between the beginning of CPR and the initiation of the ECMO system was 20 minutes. Following the condition’s stabilization, an urgent coronary angiography was performed to identify a thrombotic obstruction of the LAD, followed by percutaneous intervention with aspiration thrombectomy and placement of a drug-eluting stent. A favorable clinical response is observed following the intervention, with inotropic support of dobutamine, with an improvement in hemodynamic status, recovery of pulsatility, reduction of flow on the ECMO system, normalization of acid-base status and lactate values, and recovery of hourly diuresis. The initial ultrasound of the heart revealed severely impaired left ventricular systolic function (LVEF 25%) with preserved right ventricular function, whereas the control ultrasound on September 11 revealed recovery of systolic function (LVEF 50%), and the patient was successfully weaned from the ECMO system. After the sedation is removed, the patient’s neurological recovery is evaluated, and the patient is transferred to the Department. On the ninth day of hospitalization, the patient is discharged home with a recommendation for cardiac rehabilitation. Conclusion: An electrical storm is a potentially lethal situation that requires rapid reaction and multidisciplinary patient treatment. In this case, prompt defibrillation and insertion of the ECMO systems supported urgent coronary angiography, resulted in optimum flow through the coronary arteries, and saved the patient’s life. [ABSTRACT FROM AUTHOR]

Introduction: Virus associated hemophagocytic syndrome (VAHS) is severe complication of numerous viral infections that is associated with “cytokine storm” and the accumulation of activated T-lymphocytes and macrophages in various organs, frequently resulting in multiorgan failure and death1,2. We present a case report of VAHS caused by Influenza A infection. Case report: 50-years old, previously healthy male presented to Emergency Department with fever and respiratory failure. Initial arterial blood gases showed global respiratory failure with acidosis (pH < 6.8, pCO2 9.3 kPa, pO2 8.7 kPa, lactates 13.5 mmol/L, HCO3- unmeasurable). Computed tomography showed left sided pneumonia, and initial laboratory workup showed severe leukopenia, elevated C-reactive protein, and mild renal lesion (Table 1). Polymerase Chain Reaction (PCR) was positive for Influenza A, and Streptococcus Pyogenes was isolated from bronchoalveolar lavage. After initial workup patient arrested and cardiopulmonary reanimation (CPR) with intubation was performed. Post-CPR echocardiography showed severely reduced left ventricular systolic function (LVEF <15%) with suspected thrombus in left ventricle (Figure 1). Patient was hemodynamically unstable despite massive volume resuscitation, vasopressors, and inotropes so under ultrasound guidance veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was placed. Hemodialysis with Oxyris filter was initiated. Because of severe pancytopenia bone marrow biopsy was performed which confirmed VAHS. Treatment included Pentaglobin and intravenous immunoglobulins supplementation, high doses of glucocorticoids and cyclosporin A. After 5 days ECMO configuration was changed to VAV ECMO because of suboptimal peripheral oxygenation. Bedside echocardiography was performed every day and gradual recovery of LVEF was verified and because of that, seven days after admission ECMO configuration was changed to VV ECMO. Total ECMO support time was 20 days. Because of prolonged mechanical ventilation percutaneous tracheotomy was performed. Treatment complications included multiple hospital acquired infections, cytomegalovirus reactivation, necrosis of all toes and two fingers, severe critical illness polyneuropathy, cachexia, acalculous cholecystitis. After 3 month of treatment patient is in process of weaning from mechanical ventilation. Conclusion: VAHS is one of rare and potentially lethal complications of Influenza A which can lead to multiorgan failure that can require mechanical circulatory support. Echocardiography plays crucial role in diagnostics and management of critical ill patients. [ABSTRACT FROM AUTHOR]

Introduction: Influenza affects millions worldwide every year. Although most cases are mild, severe complications can occur, including myocarditis1. Extracorporeal membrane oxygenation (ECMO) is a treatment option for patients with severe respiratory and/or cardiac failure. We present a case report of a patient with influenza-induced myocarditis and subsequent heart failure treated successfully with ECMO. Case report: 21-years-old male with no known history of medical illness presented to the Emergency Department at University Hospital Centre with fever, cough, and shortness of breath starting three weeks earlier. Chest X-ray showed pneumonia, PCR was COVID-19 negative but influenza positive. 12- lead electrocardiogram showed diffuse ST-segment elevation, cardiac biomarkers were elevated, and echocardiography verified reduced left ventricular ejection fraction (LVEF) of 44% with pericardial effusion. Patient was diagnosed with acute myopericarditis and pneumonia, admitted to hospital and started on broad-spectrum antibiotics. Four days later patient’s respiratory distress worsened requiring intubation and mechanical ventilation. Hemodynamic status deteriorated requiring noradrenaline and dobutamine support. Bedside echocardiogram showed akinesia of inferolateral and anterolateral wall with severely reduced LVEF. Due to escalation of support and hemodynamic instability, decision was made to initiate veno-arterial (V-A) ECMO support. During the procedure patient had cardiac arrest and was successfully resuscitated two times. Two days later, patient was transported to University Hospital Centre Zagreb. Echocardiography showed LVEF of 20% while the chest X-ray showed signs of severe congestion interpreted as ECMO lung oedema. Due to that, an immediate implantation of Impella was performed. However, as soon as Impella established adequate cardiac output, a severe case of Harlequin syndrome developed which required conversion of ECMO configuration to V-A-V that stabilized the situation and enabled conversion into V-V ECMO two days later. Following further stabilization, VV ECMO was removed two days later, Impella the following day, and patient was extubated. Cardiac recuperation was dramatic and cardiac MRI showed an LVEF of 57%. Patient was discharged home after 24 days. Conclusion: This case highlights the appropriate use of different mechanical circulatory support modalities guided by different imaging modalities for bridging a case of severe influenza-induced myocarditis from a cardiac arrest situation to successful hospital discharge. [ABSTRACT FROM AUTHOR]

Introduction: Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary support system. It has advanced significantly in recent years and has become a therapeutic option for patients with cardiorespiratory failure. ECMO support is established by cannulation of the patient’s circulatory system. There are two basic types of ECMO systems, veno-arterial and veno-venous modality. The VA-ECMO modality is most often used in cardiothoracic surgery, because unlike VV-ECMO support, it also provides respiratory support to the cardiovascular system. Neurological complications after ECMO occur frequently, and the prevalence and types of neurological complications vary depending on the patient population1 . A patient with a brachial plexus injury associated with VA-ECMO immediately after heart transplantation is presented. Weakness of the right arm was noted after cannulation of the axillary artery to place the ECMO device. Application of the ECMO procedure is associated with multiple risks (eg. bleeding, formation of blood clots). He was diagnosed with a peripheral nerve injury through a neurological and electrodiagnostic examination (multi slice computer tomography of the brain and electromyoneurography of the right hand), which revealed a lesion of the right brachial plexus. Doppler sonography was performed to determine the compressive risk of a blood clot. Early physiotherapy procedures for such neurological complications aim to restore the function of the injured nerves and muscles to their previous level and prevent potential disability. Methods and Results: The patient was selected from the register of the Institute for Cardiac and Transplantation Medicine from patients treated with ECMO from January 2013 to September 2022. One patient had unilateral arm weakness after starting ECMO therapy. The data from the neurological examination and electrophysiological examination for this patient proved the diagnosis of brachial plexus injury, dominantly the upper part of the plexus. Conclusion: Axillary artery cannulation resulting in hematoma formation was identified as a probable risk factor for brachial plexus injury in our patient. Physiotherapists are crucial in the early rehabilitation phase after such neurological injuries in re-establishing functions through strength, coordination, flexibility and preventing disability. [ABSTRACT FROM AUTHOR]

Introduction: Acute myocardial ischemia is a well-known cause of ventricular arrhythmias, often fatal. Polymorphic ventricular tachycardia (PVT) and ventricular fibrillation (VF) are mostly seen during ongoing myocardial ischemia and within first 72 hours of a myocardial infarction which often results in hemodynamic instability with significant risk of mortality1,2. This is a case report of a 42-year-old male presenting with a hemodynamically unstable electrical storm following an acute in-stent thrombosis. Case report: 43-year-old man presented to the Emergency Department (ED) with retrosternal chest pain. His initial electrocardiogram (ECG) showed an ST elevation in anteroseptolateral leads. In the ED he suffered a cardiac arrest due to VF. On successful cardiopulmonary resuscitation with defibrillation, urgent coronarography was performed with the placement of one drug-eluting (DE) stent in the proximal left anterior descending artery. Postprocedural, in the Coronary Care Unit an electrical storm with incessant and recurring PVT and VF refractory to medical treatment and requiring multiple direct- current shocks (in total over 60 times). An indication was made for re-evaluation by coronary angiography. Prior to the procedure in the Catheterization Laboratory a peripheral veno-arterial (VA) femoro-femoral extracorporeal membrane oxygenation (ECMO) was placed. Repeated angiography showed an acute in-stent thrombosis and reperfusion was successfully performed with placement of a second DE stent. After the intervention the patient was rhythmically stable with no recurrence of ventricular arrhythmias. He was successfully weaned off VA-ECMO 8 days later and discharged 55 days later with optimized medical therapy, no clinical signs of heart failure and with no neurological deficits. On follow-up, echocardiography showed hypokinesia of anterolateral wall with left ventricular ejection function 45 % and he had no signs of heart failure and no anginal symptoms. Conclusion: In the setting of an acute myocardial infarction, an electrical storm following a percutaneous revascularization, especially one refractory to medication and with no evident metabolic cause, should raise suspicion of acute in-stent thrombosis. A low threshold for reintervention should be set in such situations. Temporary mechanical circulatory support, if available, provides a good hemodynamic stabilization for the procedure and for later rhythm and circulatory management. [ABSTRACT FROM AUTHOR]