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Resumo Fundamento O choque cardiogênico (CC) refratário está associado com altas taxas de mortalidade, e o uso de oxigenação por membrana extracorpórea venoarterial (VA-ECMO, do inglês venoarterial extracorporeal membrane oxygenation) como uma opção terapêutica tem gerado discussões. Nesse sentido, sua custo-efetividade, principalmente em países de baixa e média renda como o Brasil, continua incerto.Objetivos: Conduzir uma análise de custo-efetividade na perspectiva do Sistema Único de Saúde (SUS) para avaliar a custo-efetividade de VA-ECMO combinado com o tratamento padrão em comparação ao tratamento padrão isolado em pacientes adultos com CC refratário. Métodos Acompanhamos uma coorte de pacientes com CC refratário tratados com VA-ECMO em centros de assistência terciária do sul brasileiro. Coletamos dados de desfechos e custos hospitalares. Realizamos uma revisão sistemática para complementar nossos dados e usamos o modelo de Markov para estimar a razão de custo-efetividade incremental (RCEI) por ano de vida ajustado pela qualidade (QALY) e por ano de vida ganho. Resultados Na análise do caso-base, a VA-ECMO gerou uma RCEI de Int$ 37 491 por QALY. Análises de sensibilidade identificaram o custo de internação, o risco relativo de sobrevida, e a sobrevida do grupo submetido à VA-ECMO como principais variáveis influenciando os resultados. A análise de sensibilidade probabilística mostrou um benefício do uso de VA-ECMO, com uma probabilidade de 78% de custo-efetividade no limiar recomendado de disposição a pagar. Conclusões Nosso estudo sugere que, dentro do SUS, VA-ECMO pode ser uma terapia custo-efetiva para o CC refratário. Contudo, a escassez de dados sobre a eficácia e de ensaios clínicos recentes que abordem seus benefícios em subgrupos específicos de pacientes destaca a necessidade de mais pesquisas. Ensaios clínicos rigorosos, incluindo perfis diversos de pacientes, são essenciais para confirmar a custo-efetividade com uso de VA-ECMO e assegurar acesso igualitário a intervenções médicas avançadas dentro dos sistemas de saúde, especialmente em países com desigualdades socioeconômicas como o Brasil.

Copyright of Revista Médica Clínica Las Condes is the property of Editorial Sanchez y Barcelo and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Revista de la Facultad de Medicina Humana is the property of Instituto de Investigaciones en Ciencias Biomedicas de la Universidad Ricardo Palma and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: initially, it was believed that, in pediatrics, SARS-CoV-2 infection would be mild or asymptomatic. However, it is now known that children can present a very symptomatic condition, such as Pediatric Multisystem Inflammatory Syndrome (SIM-P). Objective: to report the case of a seven-year-old child with SIM-P post-infection with SARS-CoV-2 progressing to cardiogenic shock. Method: qualitative descriptive case report research. Data collection was done from authorized copies of the medical records made available by the child's guardian, made official by signing the consent terms, TALE/TCLE. Case Report: girl, seven years old, presents to emergency care presenting persistent fever, vomiting, prostration and report of recent contact with an individual with flu-like symptoms. Upon admission, fever, diffuse and intense pain on abdominal palpation, coated tongue, fissures on the lip and hyperemic tonsils. This condition, associated with laboratory tests (increase in inflammatory markers, coagulopathy, myocardial injury and contact with SARS-CoV-2), defined a diagnosis of SIM-P, according to WHO criteria. A place in the Pediatric ICU was requested and Human Immunoglobulin was prescribed. Upon admission, it progressed to cardiogenic shock, using vasoactive drugs. After eight days in hospital, her condition improved. Conclusion: despite being multisymptomatic, gastrointestinal symptoms predominate in SIM-P. However, cardiovascular involvement is concerned due to the risk of unfavorable outcomes, requiring early recognition and treatment. [ABSTRACT FROM AUTHOR]

The right ventricle is susceptible to changes in preload, afterload, and contractility. The answer is its dilation with dysfunction/ acute failure; filling is limited to the left ventricle and cardiac output. Systemic venous congestion is retrograde to the right heart, it is involved in the genesis of cardiogenic shock due to right ventricle involvement. This form of shock is less well known than that which occurs due to left ventricular failure, therefore, treatment may differ. Once the primary treatment has been carried out, since no response is obtained, supportive treatment aimed at ventricular pathophysiology will be the next option. It is suggested to evaluate the preload for the reasoned indication of liquids, diuretics or even ultrafiltration. Restore or maintain heart rate and sinus rhythm, treat symptomatic bradycardia, arrhythmias that make patients unstable, use of temporary pacing or cardioversion procedures. Improving contractility and vasomotility, using vasopressors and inotropes, alone or in combination, the objective will be to improve right coronary perfusion pressure. Balance the effect of drugs and maneuvers on preload and/or afterload, such as mechanical ventilation, atrial septostomy and pulmonary vasodilators. And the increasing utility of mechanical support of the circulation that has become a useful tool to preserve/restore right heart function. [ABSTRACT FROM AUTHOR]

Resumo O presente relato de caso descreve o programa de exercícios aplicado a um paciente do sexo masculino, de 54 anos, internado com choque cardiogênico, aguardando transplante cardíaco e assistido por balão intra-aórtico, um dispositivo de suporte circulatório mecânico temporário. O dispositivo de suporte circulatório mecânico temporário, um balão intra-aórtico, foi colocado na artéria subclávia esquerda, possibilitando o protocolo de exercícios. Antes e após um protocolo de exercícios, foram obtidos dados a partir de cateter de Swan-Ganz, amostra de sangue, peptídeo natriurético cerebral (NT-proBNP), proteína C reativa de alta sensibilidade (PCR-as), teste de caminhada de seis minutos (TC6min) e medição da saturação venosa de oxigênio (SvO2). O protocolo de treinamento físico envolveu a utilização de um cicloergômetro adaptado ao leito, sem carga, uma vez ao dia, por no máximo 30 minutos, até o limite da tolerância. Não foram observados eventos adversos tampouco relacionados ao deslocamento do balão intra-aórtico durante o protocolo de exercícios. O programa de exercícios resultou em maior SvO2 com aumento do TC6min e menores escores de dispneia de Borg (312 metros vs. 488 metros e cinco pontos vs. três pontos, respectivamente). Após completar o protocolo de exercícios de dez dias, o paciente foi submetido a uma cirurgia de transplante cardíaco sem complicações e recuperação total na UTI. O presente estudo demonstrou que o exercício é uma opção viável para pacientes com choque cardiogênico em uso de balão intra-aórtico e que é bem tolerado, além de não haver relatos de eventos adversos.

Resumo Fundamento A infecção concomitante por coronavírus 2019 (COVID-19) e o infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST) estão associados ao aumento de desfechos adversos hospitalares. Objetivos O estudo teve como objetivo avaliar as diferenças angiográficas, de procedimentos, laboratoriais e prognósticas em pacientes positivos e negativos para COVID-19 com IAMCSST submetidos à intervenção coronária percutânea primária (ICP). Métodos Realizamos um estudo observacional retrospectivo e unicêntrico entre novembro de 2020 e agosto de 2022 em um hospital de nível terciário. De acordo com o seu estado, os pacientes foram divididos em dois grupos (positivo ou negativo para COVID-19). Todos os pacientes foram internados por IAMCSST confirmado e foram tratados com ICP primária. Os desfechos hospitalares e angiográficos foram comparados entre os dois grupos. P-valores bilaterais

Introduction and objectives: Cardiogenic shock (CS) complicates 5–10% of cases of myocardial infarction (MI). Whether glycoprotein IIb/IIIa inhibitors (GPIs) are beneficial in these patients is controversial. Our aim is to assess the prognostic impact of GPI use on in-hospital mortality and outcomes in patients with MI and CS undergoing percutaneous coronary intervention (PCI). Methods: Between October 2010 and December 2019, 27 578 acute coronary syndrome (ACS) patients were included in the multicenter Portuguese Registry of Acute Coronary Syndromes. Of these, 357 with an MI complicated by CS were included in the analysis and grouped based on whether they received GPI therapy (with GPI, n=107 and without GPI, n=250). The primary endpoint was in-hospital mortality. Secondary endpoints included successful PCI and in-hospital reinfarction and major bleeding. Results: Demographics and cardiovascular risk factors did not differ between groups. ST-elevation MI patients were more likely to receive GPIs (95% vs. 83%, p=0.002). In-hospital mortality was similar between groups (OR 1.80, 95% CI 0.96–3.37). Only age and the use of inotropes or intra-aortic balloon pump were predictors of mortality. Also, no differences between groups were noted for successful PCI (OR 0.33, 95% CI 0.62–4.06), reinfarction (OR 0.77, 95% CI 0.15–3.90), or major bleeding (OR 1.68, 95% CI 0.75–3.74). Conclusion: The use of GPIs in the context of MI with CS did not significantly impact in-hospital outcomes. Resumo: Introdução e objetivos: O choque cardiogénico (CC) complica 5-10% dos enfartes agudos do miocárdio (EAM). O benefício do uso de inibidores da glicoproteína IIb/IIIa (GPI) nestes doentes é controverso. O nosso objetivo é avaliar o impacto prognóstico do uso de GPI nos outcomes intra-hospitalares em doentes com EAM e CC submetidos a intervenção coronária percutânea (ICP). Métodos: Entre outubro de 2010 e dezembro de 2019, 27 578 doentes com síndrome coronária aguda (SCA) foram incluídos no Registo Português de SCA. Destes, 357 com EAM complicado por CC foram incluídos. Dois grupos foram criados, baseados no facto de terem recebido terapêutica com GPI (GPI, N=107 e sem tratamento com GPI, N=250). O endpoint primário foi a mortalidade intra-hospitalar. Endpoints secundários incluíram sucesso de ICP, re-enfarte e hemorragia major. Resultados: As características demográficas e os fatores de risco cardiovasculares não diferiram entre grupos. Doentes com EAM com supra-ST receberam mais terapêutica com GPI (95% versus 83%, P=0,002). A mortalidade intra-hospitalar foi similar entre grupos (OR 1,80, 95% CI 0,96-3,37, P=0,068). Apenas a idade, uso de inotrópicos ou balão intra-aórtico foram preditores de mortalidade. Não houve diferenças para sucesso de ICP (OR 0,33, 95% CI 0,62-4,06); re-enfarte (OR 0,77, 95% CI 0,15-3,90) ou hemorragia major (OR 1,68, 95% CI 0,75-3,74). Conclusão: O uso de GPI no contexto de EAM com CC não teve impacto significativo nos outcomes intra-hospitalares.

The Swan-Ganz (SG) catheter is an indispensable tool for invasive hemodynamic monitoring but is underused due to controversy for misunderstandings after several confounding studies. The Mexican College of Interventional Cardiology and Endovascular Therapy (COMEOTE) invited a select group of international specialists in interventional cardiology, critical cardiology care, and general intensive care for a consensus statement on SG catheter use, endorsed by COMEOTE and the Mexican College of Critical Care (COMMEC). The consensus recommends the SG as a diagnostic tool in cardiogenic shock from any etiology and at any class and level, involving one ventricle or both; during worsening heart failure/hemodynamic instability, despite adequate treatment; for differential diagnosis during failed treatment for respiratory distress, hypotension, and or progressive renal failure; for simultaneous monitoring of the pulmonary artery and right atrial pressures during severe right heart-related shock. The consensus encourages centers with low SG utilization to include and master its hemodynamic monitoring benefits. [ABSTRACT FROM AUTHOR]

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. Resumo: Introdução e objetivos: O uso de suporte mecânico no choque cardiogénico (CS) e intervenção coronária percutânea de alto risco (HR-PCI) tem aumentado. O Impella® é um sistema de suporte ventricular percutâneo que ejeta sangue do ventrículo esquerdo para a aorta ascendente. Reportamos a experiência do nosso centro com o Impella® nestes dois cenários clínicos. Métodos: Estudo retrospetivo unicêntrico incluindo todos os doentes consecutivos submetidos a implantação de Impella® entre 2007 e 2019, para tratamento de CS ou suporte profilático para HR-PCI. Dados sobre endpoints clínicos e de segurança foram analisados. Resultados: Foram incluídos 22 doentes: 12 tratados por CS e 10 submetidos a HR-PCI. Na população de CS, a principal causa de choque foi o enfarte agudo do miocárdio (5 doentes); a hemólise foi a complicação relacionada com o dispositivo mais frequente (63,7%); a mortalidade intra-hospitalar, a 30 dias e um ano, foi, respetivamente, 58,3%, 66,6% e 83,3%. No grupo da HR-PCI, todos os doentes apresentavam doença multivaso (SYNTAX I score médio: 44,1±13,7); a mortalidade intra-hospitalar, a 30 dias e um ano, foi, respetivamente, 10,0%, 10,0% e 20,0%. Não houve mortes relacionadas com o dispositivo ou procedimento em ambos os grupos. Conclusão: Os resultados em curto e longo prazo da HR-PCI protegida por Impella® foram comparáveis aos da literatura disponível. No grupo de CS, os resultados intra-hospitalares e em curto prazo foram desanimadores, com elevada mortalidade e taxas de complicações apreciáveis.

Desde sus inicios en el siglo pasado, el cateterismo de arteria pulmonar (CAP) ha ido evolucionando hasta ser una técnica de evaluación hemodinámica invasiva que puede realizarse en la cama del paciente a través de un catéter Swan-Ganz; este procedimiento ha mantenido un curso intermitente en cuanto a su uso; no obstante, actualmente ha demostrado relevancia en escenarios específicos. El CAP permite el acceso a la circulación venosa central, el corazón derecho y la arteria pulmonar; realiza el cálculo de variables hemodinámicas de manera directa o indirecta mediante fórmulas y métodos establecidos. Esto hace posible realizar una evaluación y clasificación hemodinámica adecuada, realizar pruebas específicas (p. ej. prueba de vasorreactividad), que ayudan a definir el diagnóstico, la conducta terapéutica, monitorizar la respuesta al tratamiento, la evaluación previa a terapias avanzadas (p. ej. el trasplante cardiaco o dispositivos de asistencia circulatoria mecánica), y el pronóstico en los pacientes. En este artículo profundizamos sobre los conceptos y la utilidad del cateter de arteria pulmonar.

Copyright of Enfermería en Cardiologia is the property of Asociacion Espanola de Enfermeria en Cardiologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Revista de Ciencias Médicas de Pinar del Río is the property of Editorial Ciencias Medicas and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Resumo Fundamento: Em doentes com infarto agudo do miocárdio (IAM), choque cardiogênico (CC) e doença multivaso (DMV) persistem dúvidas sobre a intervenção nas artérias não responsáveis. Objetivos: 1) caracterizar a amostra de doentes com IAM, CC e DMV incluídos no Registo Nacional Português de Síndromes Coronárias Agudas (RNSCA); 2) comparar os eventos associados a diferentes estratégias de revascularização; e 3) identificar preditores de mortalidade intra-hospitalar nesta amostra. Métodos: Estudo observacional retrospetivo de doentes com IAM, CC e DMV incluídos no RNSCA entre 2010 e 2018. Compararam-se duas estratégias de revascularização: completa durante o procedimento índice (grupo 1); e completa diferida ou incompleta durante o internamento (grupo 2-3). O endpoint primário foi a ocorrência de reinfarto ou morte intra-hospitalar. A significância estatística foi definida por um valor p < 0,05. Resultados: Identificaram-se 127 doentes com IAM, CC e DMV (18,1% no grupo 1 e 81,9% no grupo 2-3), com idade média de 70 ± 12 anos e 92,9% com IAM com supradesnivelamento do segmento ST. O endpoint primário ocorreu em 47,8% dos doentes do grupo 1 e em 37,5% do grupo 2-3 (p = 0,359). As taxas de mortalidade intra-hospitalar, reinfarto, acidente vascular cerebral e hemorragia major foram também semelhantes nos dois grupos. Os preditores de mortalidade intra-hospitalar nesta amostra foram a presença na admissão de disfunção ventricular esquerda (OR 16,8), bloqueio completo de ramo direito (OR 7,6) e anemia (OR 5,2), (p ≤ 0,02). Conclusões: Entre os doentes com IAM, CC e DMV, incluídos no RNSCA, não se verificou diferença significativa entre revascularização completa no evento índex e completa diferida ou incompleta durante o internamento, relativamente à ocorrência de morte intra-hospitalar ou reinfarto. (Arq Bras Cardiol. 2021; 116(5):867-876)

Acute severe mitral regurgitation (MR) because of secondary left ventricular impaired regional contractility can present with severe acute heart failure, associated with a high risk for rapid decompensation, pulmonary edema and cardiogenic shock. Frequently, in these highly unstable patients, surgical risk can be prohibitive. Evidence for percutaneous repair of acute MR is scarce, but a few case series show that this approach could be safe and effective for bailing out hemodynamically unstable patients.We report a case of an 84-year-old man with acute ischemic severe MR post-acute myocardial infarction (MI), who remained hemodynamically unstable despite coronary revascularization, positive pressure non-invasive ventilation, vasodilator therapy and intra-aortic balloon pump (IABP) support. In heart team discussions, he was considered a high risk surgical candidate. We decided on rescue off-label percutaneous mitral valve repair with a MitraClip device (Abbott Vascular, Santa Clara, California), with good clinical result, allowing weaning from the supports and discharge seven days after the procedure. At one-year follow-up, the patient maintained a MV repair results and had a good functional status. In unstable patients with acute ischemic MR, percutaneous MV repair could be a rescue therapeutic option to consider, allowing hemodynamic compensation with potential persistent MR improvement up to one-year follow-up. Resumo: A insuficiência mitral (IM) aguda grave causada por alterações isquémicas secundárias loco-regionais do ventrículo esquerdo associa-se a elevado risco de descompensação hemodinâmica com edema pulmonar e choque cardiogénico. Frequentemente, nestes doentes instáveis, o risco cirúrgico pode ser proibitivo. É escassa a evidência existente relativamente à abordagem percutânea da IM aguda neste contexto, existindo apenas algumas séries de casos que parecem mostrar segurança e eficácia no resgate de doentes instáveis.Reportamos o caso de um doente de 84 anos, género masculino, com IM aguda grave isquémica após enfarte agudo do miocárdio, que permaneceu com instabilidade hemodinâmica apesar de revascularização coronária, ventilação não invasiva com pressão positiva, terapêutica com vasodilatadores e suporte de balão intra-aórtico. Após discussão em reunião de Heart Team, o doente foi considerado de elevado risco cirúrgico, tendo sido orientado para tratamento percutâneo da válvula mitral com dispositivo MitraClip. O procedimento decorreu sem intercorrências imediatas, permitindo redução com critérios de sucesso da IM. A melhoria do perfil hemodinâmico com a correção percutânea da IM permitiu rápido desmame da terapêutica de suporte em curso, com evolução clínica favorável subsequente e alta ao sétimo dia após procedimento. No seguimento clínico e ecocardiográfico a um ano verificou-se a persistência do resultado do tratamento percutâneo da IM e o doente apresentava boa capacidade funcional.Em pacientes instáveis com MR isquémica aguda, a reparação percutânea da VM poderia ser uma opção terapêutica de salvamento a considerar, permitindo uma compensação hemodinâmica com potencial melhoria persistente da MR até 1 ano de seguimento.

Objetivo. Conocer las características clínicas y determinar los factores relacionados a mayor mortalidad en pacientes con choque cardiogénico (CC) por infarto de miocardio en un hospital de referencia peruano. Materiales y métodos. Cohorte única prospectiva donde se evaluó la presentación, tratamiento y complicaciones de pacientes con CC por infarto de miocardio atendidos entre marzo 2019 a agosto 2020 en el Instituto Nacional Cardiovascular - INCOR. Se evaluaron los factores relacionados con mayor mortalidad hospitalaria y en el seguimiento, además del uso del score IABP shock II en la población de estudio. Resultados. Cuarenta pacientes fueron incluidos, el 75% con CC por disfunción ventricular izquierda, la mayoría varones con edad de 75 (69-82) años. Un 50% de casos presentaron CC luego del ingreso a emergencia. Los pacientes estratificados mediante el score IABP shock II como bajo, intermedio y alto riesgo, tuvieron una mortalidad intrahospitalaria de 37,5; 71;4 y 91,6% respectivamente. La mortalidad intrahospitalaria fue 70%, mayor en mujeres, mayores de 75 años y en los que desarrollaron el CC durante la hospitalización. En el análisis univariado, el lactato sérico > 4 mmol/L al ingreso se relacionó con mayor mortalidad (HR:2,8; IC:1,6-3,6, p=0,009). La sobrevida hasta el término del estudio fue de 12,8%. Conclusiones. EL CC por infarto de miocardio representa una entidad clínica de elevada mortalidad a pesar de la revascularización y el tratamiento disponible en nuestra realidad. El mayor predictor de mortalidad fue el valor de lactato sérico mayor a 4 mmol/L al ingreso. El score IABP shock II demostró ser un buen parámetro para estratificar el riesgo de muerte en nuestra población.

Objetivo. Determinar las características clínicas y epidemiológicas de los pacientes con dispositivos de soporte mecánico circulatorio (DSMC) de corta duración, posinfarto de miocardio (IAM) en un hospital de referencia nacional. Materiales y métodos. Estudio descriptivo, retrospectivo, de pacientes post IAM en los que se implantó dispositivos de soporte mecánico circulatorio de corta duración desde el año 2015 al 2020. Resultados. Se implantaron nueve dispositivos de asistencia en igual número de pacientes debido a choque cardiogénico post-IAM. Todos los pacientes fueron varones con IAM con elevación del segmento ST (IAMCEST). Se implantaron ocho dispositivos de oxigenación por membrana extracorpórea (ECMO) y una bomba de flujo centrífugo (en configuración LVAD). La mediana de tiempo de uso del dispositivo fue de ocho días. Las complicaciones más frecuentes fueron la hemorragia no fatal (55,6%), injuria renal aguda (44,4%) y la sepsis (44,4%). La mortalidad intrahospitalaria fue de 55,6%. Conclusiones. El uso de DSMC de corta duración posinfarto de miocardio es aún limitado en nuestra institución y tiene como principal representante al ECMO post-IAMCEST complicado con choque cardiogénico. A pesar del uso de estos dispositivos la mortalidad intrahospitalaria es elevada.

Objetivo: O transplante hepático (TxH) é o único tratamento eficaz para doença hepática terminal, seja crônica, subaguda ou aguda. O procedimento cirúrgico do transplante hepático, a maior cirurgia atual no corpo humano, contribui para o aumento das concentrações de catecolaminas, favorecendo a ocorrência da Síndrome de Takotsubo (STK). Essa é uma disfunção transitória do ventrículo esquerdo, ocasionada pelo aumento das catecolaminas durante eventos de elevado estresse fisiológico. A importância de considerar o diagnóstico da STK nas hipóteses formuladas para descompensação hemodinâmica tem como objetivo evitar suas complicações, principalmente o choque cardiogênico. O manejo do paciente pós TxH com STK ainda não é bem estabelecido, mas há algumas estratégias descritas na literatura. O conhecimento da causa base de origem das complicações confere maior eficácia às medidas terapêuticas a serem escolhidas, proporcionando boa evolução nos receptores de TxH com STK

Introduction and Objectives: Cardiogenic shock (CS) has long been considered a contraindication for the use of non-invasive ventilation (NIV). The main objective of this study was to analyze the effectiveness, measured as NIV success, in patients with respiratory failure due to CS. As secondary objective, we studied risk factors for NIV failure and compared the outcome of patients treated with NIV versus invasive mechanical ventilation (IMV)., Methods: Retrospective study on a prospective database, over a period of 25 years, of all consecutively patients admitted to an intensive care unit, with a diagnosis of CS and treated with NIV. A comparison was made between patients on NIV and patients on IMV using propensity score matching analysis., Results: Three hundred patients were included, mean age 73.8 years, mean SAPS II 49. The main cause of CS was acute myocardial infarction (AMI): 164 (54.7%). NIV failure occurred in 153 (51%) cases. Independent factors for NIV failure included D/E stages of CS, AMI, NIV related complications, and being transferred from the ward. In the propensity analysis, hospital mortality (OR 1.69, 95% CI 1.09-2.63) and 1 year mortality (OR 1.61, 95% CI 1.04-2.51) was higher in IMV. Mortality was lower with NIV (vs. EIT-IMV) in C stage (10.1% vs. 32.9%; p<0.001) but did not differ in D stage or E stage., Conclusions: NIV seems to be relatively effective and safe in the treatment of early-stage CS., (Copyright © 2023 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

A dissecção aórtica ocorre com a rotura da camada íntima da aorta, por onde influi sangue até a camada média. Esse conteúdo extravasado coagulou e formou um trombo que ficou contido nas estruturas adjacentes e tamponou a laceração arterial. A causa no relato foi o aneurisma de tronco braquioceláfico devido a intubação orotraqueal (IOT) prolongada já que, a dilatação do vaso é proporcional ao risco de ruptura. O objetivo do relato é exemplificar as complicações da IOT prolongada, como o aneurisma e a estenose agravados em dissecção de aorta e óbito. D. N.,18 anos, sexo masculino, manifestava estridor laríngeo importante, dispneia aos pequenos esforços, oximetria a 85% e com estenose de 90% em traqueobroncoscopia. Foi diagnosticado com estenose subglótica devido a IOT prolongada após queda de motocicleta há 5 meses, com necessidade de diversas dilatações de emergência. Foi internado para realizar a dilatação da estenose com velas de nº 7 a 14. No entanto, a de nº 13 sangrou ativamente pela traqueia, sendo optada pela IOT e, através dela, passou o broncoscópio para aspiração do sangramento e para ventilação. Após 15 minutos, evoluiu com parada cardiorrespiratória (PCR) e, realizaram a recuperação cardiorrespiratória associada a epinefrina e norepinefrina. Enquanto isso, optaram pela cervicotomia para avaliação do sangramento e da ausculta cardiopulmonar. Ainda, fizeram a toracotomia anterior esquerda que o diagnosticou com tamponamento cardíaco devido a um aneurisma de aorta de localização inespecífica com possível rotura, justificado por uma lesão arterial do tronco braquiocefálico, necessitando da mediastinotomia. Com isso, realizaram a abertura do pericárdio para remoção de coágulos e sangue e então, iniciaram a massagem cardíaca direta com retorno de pulso. Assim, iniciaram a aspiração em hemitórax esquerdo e esternotomia parcial, visualizando o sangramento ativo que indicou a rafia dos vasos supra aórticos, a correção de acidose metabólica e a reposição de concentrado de hemácias. Durante a lavagem da cavidade, surgiram sangramentos e hematomas murais na raiz de aorta ascendente. Logo, realizaram a esternotomia total e circulação extracorpórea total com canulação de femoral direita e átrio direito associada ao resfriamento corporal, à rafia do arco aórtico, do tronco braquiocefálico direito e das anastomoses. Ao retirar a circulação extracorpórea, o paciente ficou hipotenso e desencadeou com choque cardiogênico refratário que evoluiu à PCR em assistolia sem retorno da circulação espontânea mesmo com massagem cardíaca direta, administração de altas doses de drogas vasoativas e condutas do protocolo do ACLS. Após 6 horas e 20 minutos do início da cirurgia, o paciente evoluiu ao óbito. Apesar das indicações de dilatações traqueais após estenoses e reestenoses, a reconstrução cirúrgica é o tratamento preferencial, em vista ao aumento do risco de complicações nas dilatações frequentes.

Takotsubo cardiomyopathy is an entity characterized by acute and transient ventricular dysfunction, which is usually related to a triggering event (emotional or physical stress), and usually presents with regional systolic dysfunction of the left ventricle, however up to 30% may be biventricular. Depending on its severity in some cases the disease can condition refractory cardiogenic shock to management with inotropics and vasopressors, so for these cases circulatory assistance devices should be considered. We present the case of a young patient who had pulmonary valve change with biological prosthesis, which seven weeks after surgery went to the emergency department with pericardial effusion and tamponade physiology secondary to postpericardiotomy syndrome. For this reason pericardial window was practiced, however during the procedure she presented biventricular Takotsubo cardiomyopathy which conditioned cardiogenic shock with severe mitral and tricuspid regurgitation, and refractivity to medical treatment as well as intraaortic balloon pump, requiring circulatory support with venoarterial ECMO for 5 days. [ABSTRACT FROM AUTHOR]

In December 2019, several cases of pneumonia were reported, whose etiological agent would be named SARS-CoV-2 causing coronavirus disease (COVID-19). Even though the main symptomatic characteristic is respiratory, affectations have been reported in other systems, cardiovascular being one of the main ones. Cardiovascular disorders, which are less common, and conditioned by a pathophysiological process of systemic inflammation, are mainly represented by acute myocardial damage, followed by arrhythmias, with no specified classification by the authors. Cardiogenic shock, heart failure, venous or systemic thromboembolism, and acute coronary syndrome have also been described; all this in male sex predominant populations, in older ages, and with poor prognosis. An understanding of cardiological manifestations is necessary, through research that allows us to also know their relationship with other risk factors and the middle and long-term repercussions, in order to not only have the appropriate clinical suspicion in these patients but offering also timely and comprehensive care and management. [ABSTRACT FROM AUTHOR]

Objetivo. Determinar los factores predictivos de mortalidad en los pacientes con shock que habitan en gran altura a más de 3250 m s.n.m. Métodos. Se realizó un estudio observacional, prospectivo, y analítico, entre diciembre de 2015 y marzo de 2016, en dos Hospitales de Huancayo, Perú. Se incluyeron 46 pacientes con diagnóstico de shock distributivo, hipovolémico o cardiogénico. El instrumento de recolección de datos fue un cuestionario. Para el análisis estadístico se empleó la regresión logística binaria y múltiple. Se consideró significativo p < 0,05. Resultados. La edad promedio fue 67 +/-18 años (rango: 9 a 95); 25 (54,3 %) fueron varones y 21(47,3 %) mujeres. Fallecieron 32 (69,5 %) pacientes. El promedio de edad de fallecidos fue 70,3 +/- 9,6 años y de sobrevivientes 50,4 +/- 4,2 años; el tipo de shock más frecuente fue el distributivo y las comorbilidades más comunes fueron insuficiencia respiratoria, hipertensión arterial y diabetes mellitus. Los factores predictivos asociados a mortalidad son: sexo femenino (85,7 % vs. 14,3 %; p = 0,02; edad > a 50 años (74,3 % vs. 25,7 %; p = 0,023); tener patología previa (72,7 % vs. 27,3 %; p = 0,013); Saturación Venosa Central de Oxigeno, SVCO2 menor de 70 % (73,1 % vs. 26,9 %; p = 0,023), presentar APACHE II > a 11 puntos y SOFA > a 3 puntos, estuvieron asociados a una alta mortalidad. Conclusión. Los factores de predicción asociados a mortalidad fueron: sexo femenino, edad > 50 años, tener patología previa, SVCO2

Myocarditis is an inflammatory disease of the myocardium. Viral infections are the most common cause, although it can also be due to hypersensitivity reactions and autoimmune etiology, among other causes. The clinical spectrum of the disease is varied, from an asymptomatic course, followed by chest pain, arrhythmias and acute heart failure, to fulminant picture. The term fulminant refers to the development of cardiogenic shock with the need for vasopressor support, inotropic or assisted circulation devices either extracorporeal membrane oxygenation (ECMO) or intra-aortic counterpulsation balloon. About 10% of cases of heart failure due to myocarditis correspond to fulminant myocarditis. Influenza myocarditis has been considered an infrequent condition, however, its incidence has increased since 2009 as a result of the AH1N1 pandemic; otherwise, myocarditis due to Influenza type B remains an infrequent entity. We describe the experience in a cardiovascular center of 2 confirmed cases of fulminant myocarditis due to Influenza B that required circulatory assistance devices. [ABSTRACT FROM AUTHOR]

ABSTRACTBACKGROUND AND OBJECTIVES: Takotsubo cardiomyopathy, also known as broken heart syndrome is a stress-induced cardiomyopathy, which can be interpreted as an acute coronary syndrome as it progresses with suggestive electrocardiographic changes. The purpose of this article is to show the importance of proper monitoring during surgery, as well as the presence of an interdisciplinary team to diagnose the syndrome.CASE REPORT: Male patient, 66 years old, with diagnosis of gastric carcinoma, scheduled for diagnostic laparoscopy and possible gastrectomy. In the intraoperative period during laparoscopy, the patient always remained hemodynamically stable, but after conversion to open surgery he presented with ST segment elevation in DII. ECG during surgery was performed and confirmed ST-segment elevation in the inferior wall. The cardiology team was contacted and indicated the emergency catheterization. As the surgery had not yet begun irreversible steps, we opted for the laparotomy closure, and the patient was immediately taken to the hemodynamic room where catheterization was performed showing no coronary injury. The patient was taken to the hospital room where an echocardiogram was performed and showed slight to moderate systolic dysfunction, with akinesia of the mid-apical segments, suggestive of apical ballooning of the left ventricle. Faced with such echocardiographic finding and in the absence of coronary injury, the patient was diagnosed with intraoperative Takotsubo syndrome.CONCLUSION: Because the patient was properly monitored, the early detection of ST-segment elevation was possible. The presence of an interdisciplinary team favored the syndrome early diagnosis, so the patient was again submitted to safely intervention, with the necessary security measures taken for an uneventful new surgical intervention.

ABSTRACT The objective of this study was to report a rare fatal complication in the postoperative period of transsphenoidal surgery of the pituitary gland (adenoma), with a brief review of the subject. The patient was a 54-year-old white man with acromegaly and severe heart failure, who after microsurgery developed blood pressure instability within 32 hours after the procedure and died. The autopsy revealed: hypertrophy and ventricular dilation with myocarditis, pericarditis and myocardial fibrosis; mesenteric ischemia with transmural coagulation necrosis of the intestinal loops; acute tubular necrosis; and hepatic steatosis. The findings are consistent with cardiogenic shock and abdominal sepsis due to necrosis of the intestinal loops.

La miocarditis es una enfermedad inflamatoria del músculo cardíaco, es una causa importante en todo el mundo de miocardiopatía dilatada. La infección viral es también una importante causa de miocarditis, y el espectro de los virus que causan la miocarditis ha cambiado en las últimas dos décadas. Su manifestación clínica principal, aunque no exclusiva, es un cuadro de insuficiencia cardíaca aguda. Presentamos el caso de una paciente cursando un cuadro de filiación cardiovascular, caracterizado por dolor torácico, falla cardíaca y arritmias malignas, en que se realizó diagnóstico de miocarditis con evolución fulminante. Se realizó monitoreo hemodinámico avanzado y medidas de soporte circulatorio mecánico con malos resultados clínicos.

Introduction and Objectives: Acute total occlusion of the unprotected left main coronary artery (LMCA) is a dramatic event. There are limited data regarding this population. We aimed to describe the clinical presentation and outcomes of patients and to determine predictors of in-hospital mortality., Methods: This retrospective study included patients presenting with acute (<12 h) myocardial infarction due to total occlusion of the LMCA (TIMI flow 0) between January 2008 and December 2020 in three tertiary hospitals., Results: During this period, 11036 emergent coronary angiographies were performed, 59 (0.5%) of which revealed acute total occlusion of the LMCA. Patients' mean age was 61.2 (SD±12.2) years and 73% were male. No patients had left dominance. At presentation, 73% were in cardiogenic shock, aborted cardiac arrest occurred in 27% and 97% underwent myocardial revascularization. Primary percutaneous coronary intervention was performed in 90% of cases and angiographic success was achieved in 56% of procedures, while 7% of patients underwent surgical revascularization. In-hospital mortality was 58%. Among survivors, 92% and 67% were alive after one and five years, respectively. After multivariate analysis, only cardiogenic shock and angiographic success were independent predictors of in-hospital mortality. Use of mechanical circulatory support and presence of well-developed collateral circulation were not predictive of short-term prognosis., Conclusion: Acute total occlusion of the LMCA is associated with a dismal prognosis. Cardiogenic shock and angiographic success play a major role in predicting the prognosis of these patients. The effect of mechanical circulatory support on patient prognosis remains to be determined., (Copyright © 2023. Publicado por Elsevier España, S.L.U.)

Over time, there has been discussion regarding the finding of left bundle branch block in the bundle of His as a possible ST-segment equivalent, in patients seeking medical attention with chest pain. It is clear that, in particular conditions such as hemodynamic instability or cardiogenic shock, this premise is met and patients must undergo emer- gency invasive procedures. However, there are other conditions that warrant further field work to treat these patients. [ABSTRACT FROM AUTHOR]

We report the case of a female patient, 58 years of age, without known heart disease, who underwent liver transplantation without complications. On the second postoperative day, the patient developed cardiogenic shock secondary to stress-induced cardiomyopathy (Takotsubo-like syndrome). The patient was successfully managed with veno-arterial peripheral extracorporeal membrane oxygenation for 6 days, with complete recovery of cardiac function and of the hepatic graft. Coronary syndrome and acute myocarditis were excluded as the causes of the shock. The use of extracorporeal membrane oxygenation in this scenario is possible and safe, considering its specialized protocols and treatment. [ABSTRACT FROM AUTHOR]

ABSTRACT Kounis syndrome is defined as the coincidental occurrence of allergic reaction and acute coronary syndrome secondary to vasospasm. Anti-inflammatory drugs are included as one of the multiple causes. Current data available about this syndrome come from case reports. We present the case of a patient who suffered Kounis syndrome with cardiogenic shock and asystole after intravenous infusion of Metamizole, and in which no lesions were observed in coronariography.

O feocromocitoma é um tumor de células cromafins secretor de catecolaminas tipicamente localizado na medula suprarrenal. Apresentamos o caso de uma doente previamente assintomática do ponto de vista cardiovascular em que um feocromocitoma silencioso se apresentou como crise adrenérgica associada a choque cardiogénico no peri-operatório de uma cirurgia eletiva não suprarrenal. Discute-se o tratamento agudo em ambiente de cuidados intensivos, bem como os desafios diagnósticos clínicos e bioquímicos. Recebido: 26/09/2016 - Aceite: 17/05/2017

BACKGROUND: Coronary artery disease is the most common single cause of death in all countries of the world, corresponding to 12.8% of all deaths. Complications in the acute phase may lead the patient to a state of cardiogenic shock being the leading cause of death in patients hospitalized for acute myocardial infarction with 50% mortality despite reperfusion therapy, optimal medical treatment and intraaortic balloon support. OBJECTIVE: To reduce mortality secondary to cardiogenic shock due to anteroapical ST-segment elevation acute myocardial infarction (STEMI). MATERIALS AND METHODS: We included patients with anteorapical STEMI who coronary blood flow was restored by primary angioplasty and continue with cardiogenic shock despite various supportive therapies. By angioplasty technique the "containment balloon", an angioplasty balloon was placed on the left anterior descending artery, which was the diameter according to the vessel and 80 mm in length covering the entire course of the artery and it was inflated with contrast undiluted, leaving it for 12 hours, new measurements were made (pulmonary capillary wedge pressure, cardiac index) with the pulmonary artery catheter during this time. At the end of 12 hours the balloon was deflated and removed from the coronary, then bare metal stents were placed distal to proximal. RESULTS: In this study we observed higher mortality with standard treatment than the reported in the literature. However, making an intervention with the containment balloon this mortality is reduced by 66.6 % (p<0.01) in the control group. It could be demonstrated an increase in ejection fraction at 48 hours average of 34% (p<0.01) in patients treated by containment balloon. CONCLUSION: It is a novel, useful, reproducible and no learning curve technique with superior survival benefit in patients with cardiogenic shock due to anteroapical STEMI. The cost of this technique is less than the cost of different ventricular assist devices. [ABSTRACT FROM AUTHOR]

Aims: To assess the clinical profile and factors associated with 30-day mortality in patients with acute heart failure (AHF) admitted to the intensive care unit (ICU)., Design: Prospective, multicentre cohort study., Scope: Thirty-two Spanish ICUs., Patients: Adult patients admitted to the ICU between April and June 2017., Intervention: Patients were classified into three groups according to AHF status: without AHF (no AHF); AHF as the primary reason for ICU admission (primary AHF); and AHF developed during the ICU stay (secondary AHF)., Main Variables of Interest: Incidence of AHF and 30-day mortality., Results: A total of 4330 patients were included. Of these, 627 patients (14.5%) had primary (n=319; 7.4%) or secondary (n=308; 7.1%) AHF. Among the main precipitating factors, fluid overload was more common in the secondary AHF group than in the primary group (12.9% vs 23.4%, p<0.001). Patients with AHF had a higher risk of 30-day mortality than those without AHF (OR 2.45; 95% CI: 1.93-3.11). APACHE II, cardiogenic shock, left ventricular ejection fraction, early inotropic therapy, and diagnostic delay were independently associated with 30-day mortality in AHF patients. Diagnostic delay was associated with a significant increase in 30-day mortality in the secondary group (OR 6.82; 95% CI 3.31-14.04)., Conclusions: The incidence of primary and secondary AHF was similar in this cohort of ICU patients. The risk of developing AHF in ICU patients can be reduced by avoiding modifiable precipitating factors, particularly fluid overload. Diagnostic delay was associated with significantly higher mortality rates in patients with secondary AHF., (Copyright © 2022 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.)

Apesar dos avanços no tratamento de portadores de insuficiência cardíaca aguda, os resultados permanecem insatisfatórios nos portadores de choque cardiogênico refratário. Uma opção para o tratamento dessa desafiadora e grave situação clínica é o implante de dispositivos de assistência ventricular temporária. O objetivo desta comunicação é apresentar um caso de choque cardiogênico refratário, com indicação de assistência ventricular, que evoluiu com falência ventricular direita após o implante de assistência esquerda com necessidade de conversão para o suporte biventricular.