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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Percutaneous mechanical support in acute coronary syndromes

Abstract

Despite advances in interventional cardiology, persistently disappointing outcomes in patients with cardiogenic shock complicating myocardial infarction, together with the lack of evidence the that intra-aortic balloon pump improves outcomes in this patient population have led to a re-evaluation of other types of mechanical circulatory support. The increase in extracorporeal membrane oxygenation (ECMO) prompted by the H1N1 pandemic led to an increase in experience in using this technique in critically ill adult patients, and its use is now expanding in both respiratory and cardiac failure. Despite enthusiasm for the technique, high-quality evidence is lacking for its benefit. Nonetheless, ECMO and other types of percutaneous mechanical circulatory support do provide critical care clinicians with new supportive therapies that may prove to benefit patients, both from the high level of support that can be offered, and also minimising the use of potentially toxic inotropic agents.

Key words: cardiogenic shock, heart failure, mechanical circulatory support, extracorporeal membrane oxygenation, ECMO, myocardial infarction, acute coronary syndromes

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Post-traumatic myocardial infarction with hemorrhage and microvascular damage in a child with myocardial bridge: is coronary anatomy actor or bystander?

Abstract

We present the case of a 13 year old patient with myocardial bridge in left anterior descending coronary artery, who develops a myocardial infarction after a cardiothoracic trauma.

About 24 hours after admission for trauma, an Electrocardiogram (ECG) showed an ST-segment elevation on anterior-lateral leads and QS complex referable to anterior-septal infarction, and an increase in troponin T serum levels was noted. An impaired left ventricular ejection fraction with diffuse regional wall motion abnormalities involving the left ventricular apex and interventricular septum were seen at transthoracic echocardiography. Contrast enhanced cardiac magnetic resonance showed a widespread myocardial edema and necrosis at the level of left ventricular apex and interventricular septum. Intramural hemorrhage and signs of microvascular damage were found mainly at the mid-ventricular level of the antero-septal and anterior segments of myocardium. The coronary angiography revealed normal coronary arteries except for a myocardial bridge on distal part of left anterior descending coronary artery. A myocardial infarction with hemorrhage and microvascular damage was diagnosed, but the absence of a correspondence between site of the most severe myocardial injury and distal location of myocardial bridge was noted. Whether myocardial infarction and microvascular damage have been caused only by traumatic hit, or also by the contribution of myocardial bridge, is unknown. An intense constriction of left anterior descending coronary artery at the level of myocardial bridge could have determined thrombus formation with subsequent septal and distal embolization and myocardial infarction.

Key words: myocardial bridge, myocardial infarction, contrast-enhanced cardiac magnetic resonance, coronary arteries, thrombus, thoracic trauma.

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A seven-year follow-up of discharged patients after out-of-hospital cardiac arrest with respect to ST-segment elevation myocardial infarction

Abstract

Introduction. The aim of this multicentre prospective study was to describe the seven-year survival of patients, from the region of East Bohemia, after out-of-hospital cardiac arrest (OHCA), occurring between  2002 and  2004. The main focus of this study was on the survival of patients with ST-segment elevated myocardial infarction (STEMI).
Patients and Methods. A total 718 patients  with OHCA were included in the study. Of these patients, 149 were admitted to hospital. The main cohort of our study consisted of 53 patients (41 men; median 59; average 58±13), who survived acute hospitalization. In these patients, STEMI was the main cause of OHCA in 15 cases (28%), whereas without STEMI was found in 38 cases (72%). Patients who survived hospitalization were periodically followed-up at six-monthly intervals.
Results. In the first follow-up year, 42 patients survived (79% of 53 patients), in the third year 38 patients (72%), in the fifth year 33 patients (62%) and in the seventh year 31 patients (59%). Ninety-four percent of patients were in good neurological condition after the seventh follow-up year. The whole period of seven years was survived by 12 (80%) out of 15 patients with STEMI, and by 19 (50%) out of 38 patients without STEMI. In patients who survived the seventh year after STEMI, direct percutaneous coronary intervention was performed in 11 cases.
Conclusions. Fifty-nine percent of patients discharged from hospital after OHCA   survived until the seventh year. The highest rate of survival during this period was seen in patients with STEMI, i.e. in 80%.

 

Key words: cardiac arrest, myocardial infarction, out-of-hospital cardiac arrest, sudden cardiac death, survivors, ventricular fibrillation

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Anesthetics and cardioprotection

Abstract

The prevalence of the cardiovascular disease significantly affects the outcome of both cardiac and non-cardiac surgery, and perioperative cardiac morbidity is one of the leading causes of death following anesthesia and surgery. The considerable incidence of myocardial infarction, congestive heart failure, myocardial ischemia, or serious dysrhythmias during the intraoperative or postoperative periods, has led many studies to examine medical factors and interventions for decreasing cardiac risk in patients with cardiovascular disease. An extensive amount of work has focused on whether any one anesthetic agent or technique is particularly beneficial for patients with coronary artery disease. Experimental studies conducted in our laboratory have clearly shown that volatile anesthetics may exert profound cardioprotection against myocardial ischemia and reperfusion injury. This article examines the recent evidence about the importance of mitochondria, reactive oxygen species and the KATP channels in cardioprotective signaling by volatile anesthetics. Moreover, the article addresses current concepts and controversies regarding specific roles of the mitochondrial and the sarcolemmal KATP channels in anesthetic-induced preconditioning.

Key words: preconditioning, volatile anesthetics, heart, coronary disease, ischemia, myocardial infarction, mitochondria.

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