Percutaneous ventricular assist device placement during active cardiopulmonary resuscitation for severe refractory cardiogenic shock after acute myocardial infarction

Cardiogenic shock after acute myocardial infarction is associated with a high mortality rate despite modern reperfusion methods and intra-aortic balloon pump support. For myocardial infarction patients in cardiogenic shock that is refractory to intra-aortic ballon pump counterpulsation and pressors (severe refractory cardiogenic shock), there are limited means to rapidly provide additional hemodynamic support. We present the case of a 49-year-old man who presented with an anterior wall acute myocardial infarction complicated by cardiogenic shock. After resuscitation and stabilization with intra-aortic balloon pump and pressor support, the patient underwent successful emergent percutaneous transluminal coronary angioplasty and stenting of the left anterior descending coronary artery. Forty-eight hours later, the patient again went into severe refractory cardiogenic shock; pulseless electrical activity arrest followed. Cardiopulmonary resuscitation was started, and the patient underwent urgent placement of a TandemHeart percutaneous ventricular assist device. The device enabled the reversal of terminal hemodynamic collapse during active cardiopulmonary resuscitation, subsequent stabilization of the patient, and discharge of the patient from the hospital after device removal. In this patient, the percutaneous ventricular assist device was successful in the treatment of severe refractory cardiogenic shock after acute myocardial infarction.     

Left ventricular hydatid cyst with myocardial infarction in a patient with severe rheumatic mitral stenosis

Cardiac echinococcosis is rare, and the most serious of all hydatid infestations. We report a case of 30-year-old female who had a hydatid cyst, myocardial infarction and severe rheumatic mitral stenosis. Following mitral valvotomy, the hydatid cyst and the left ventricular aneurysm were totally excised under cardiopulmonary bypass. The patient was discharged on the post-operative day 15 with the advice to continue albendazole for 5 years.     

Repeated resuscitation in a patient with myocardial infarction

A patient is reported who succumbed to myocardial infarction in a medical ward and was resuscitated on three occasions. On the first occasion, closed and open chest cardiac massage resulted in restitution of cardiac and cerebral function. Twelve days later, cardiac action stopped twice and was successfully restarted by closed chest cardiac massage. On one of these occasions, ventricular fibrillation stopped, and sinus rhythm appeared while the heart was massaged. However, the patient began to bleed from a pre-existing duodenal ulcer and died of hemorrhagic shock 14 days after occurrence of the myocardial infarction. The relationship between the cerebral lesion and the appearance or reactivation of peptic ulcer is discussed.     

Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarction.

Prolonged external cardiac massage is often regarded as a contraindication for thrombolytic therapy because of the risk of fatal hemorrhage. The influence of cardiopulmonary resuscitation on complications of thrombolytic bleeding was assessed analyzing data of all patients with myocardial infarction admitted to our clinic during the 10-year period between 1978 and 1987. From the total of 2,147 patients with acute myocardial infarction, 590 received thrombolytic therapy (intracoronary in 229, intravenous in 400). Of these, 43 patients underwent prolonged cardiopulmonary resuscitation and received thrombolysis within a time interval of less than 24 hours. In 21 patients, resuscitation was performed within a short period of time (5 minutes to 20 hours) after thrombolysis (10 intracoronary, 10 intravenous, 1 intravenous + intracoronary) had been initiated; 9 of these patients survived (43%). In the other 22 patients, thrombolytic therapy was initiated during ongoing resuscitation (n = 6: intravenous in 5, intravenous + intracoronary in 1) or in the early phase (10 to 120 minutes) after successful resuscitation (n = 16: intracoronary in 10, intravenous in 4, intravenous + intracoronary in 2). From this group, 14 patients survived (in-hospital mortality 36%). The mean duration of cardiopulmonary resuscitation was 36 +/- 32 minutes (range 4 to 120). Autopsy studies were performed in 16 of 20 decreased patients. Bleeding complications occurred in 8 of 43 patients. No case of bleeding was directly related to cardiocompression despite the often traumatic procedure with rib fractures verified in 17 patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intracavitary cardiac hydatid cysts with a high risk of thromboemboli

Hydatid cysts are a serious health problem in many countries that raise farm animals, and they usually involve the liver and lungs. Although cardiac involvement is a rare manifestation of hydatid cyst disease, its early diagnosis and surgical management are crucial. Patients with cardiac hydatidosis may develop acute life-threatening complications secondary to their invasion of surrounding cardiac structures, such as cyst rupture together with systemic and pulmonary dissemination. Therefore, surgical excision is the definitive method of treatment for cardiac hydatid cysts in order to prevent these potential life-threatening complications, even for asymptomatic patients. Herein, we report the case of a 36-year-old man who initially presented with pleuritic chest pain, hemoptysis, and dyspnea. This was followed by the revelation of multiple cardiopericardial hydatid cysts which were discovered via transesophageal echocardiography and multislice computed tomography. In this case, there was a higher risk of cyst rupture and thromboembolism during systemic and pulmonary circulation due to the invasive nature of the cysts which were located in the left atrium as well as between the pulmonary artery and aorta. The patient successfully underwent the removal of the multiple cardiac cysts under cardiopulmonary bypass by taking into account their relationship with the surrounding cardiac structures and the potential risk of local, systemic, and pulmonary dissemination. A pathological evaluation of the surgical specimens confirmed the diagnosis of cardiac echinococcosis and the aggressive nature of the cardiopericardial hydatid cysts by demonstrating their myocardial invasion.     

Thrombolytic therapy in acute myocardial infarction following prolonged cardiopulmonary resuscitation.

Thrombolytic therapy was administered to a 49-year-old woman with an acute anterior wall myocardial infarction after having prolonged cardiopulmonary resuscitation for 13 minutes. On admission, there was no clinical or radiographic evidence of gross trauma. There was no significant morbidity and the patient recovered to a completely functional status. The literature of thrombolytic therapy after cardiopulmonary resuscitation is reviewed. In the absence of gross trauma from cardiopulmonary resuscitation, thrombolytic therapy in acute myocardial infarction should not necessarily be excluded because of the duration of resuscitation. Further experience with such patients will shed additional light on efficacy and safety.     

Enhanced left ventricular performance with phentolamine in acute myocardial infarction

The hemodynamic effects of phentolamine (Regitine) were evaluated in nine patients with increased left ventricular filling pressure and clinical left ventricular failure (Group A) and five patients with normal left ventricular filling pressure and an uncomplicated course (Group B) within 48 hours of an acute myocardial infarction. Decreased afterload was noted in both groups after administration of phentolamine. Improved left ventricular performance was noted only in Group A and was manifested by a decrease in left ventricular filling pressure (from 23.9 to 13.6 mm Hg), increase in cardiac index (from 2.1 to 2.9 liters/min per m²), increase in stroke volume index (from 22.5 to 29.3 cc/beat per m²), and little change in heart rate (from 94.2 to 99.8 beats/min). In contrast, a decrease in stroke volume index (32 to 26 cc/beat per m²) and a greater increase in heart rate (77 to 94 beats/min) were noted in Group B. Reduction of preload, which accompanies a reduction in afterload with administration of phentolamine, may have caused a greater decrease in end-diastolic volume in Group B, resulting in the reduced stroke volume index and compensatory increase in heart rate. Our findings suggest that afterload reduction induced by administration of phentolamine enhances depressed left ventricular function in patients with increased left ventricular filling pressure after myocardial infarction. Careful monitoring to prevent complications is required.     

心肌存活性对急性心肌梗死后左室重构和左心功能的影响

目的:探讨急性心肌梗死(AMI)患者梗死区心肌存活性对心脏功能的影响.方法:采用回顾性对比研究的方法,62例AMI患者以99mTc-MIBI SPECT静息显像及18F-FDG SPECT心肌代谢显像的检查结果分为梗死区有存活心肌组和无存活心肌组,介入治疗后随访12个月,应用超声心动图评价2组患者的心脏功能.结果:有存活心肌组左室射血分数均显著高于无存活心肌组[术前:(54.25±1.60)%:(47.20±1.83)%,P＜0.01;12个月:(58.09±1.88)%:(50.00±2.06)%,P＜0.01],有存活心肌组左室舒张末期内径均显著优于无存活心肌组[术前:(51.31±0.95)mm:(54.33±1.07)mm,P＜0.05;12个月:(51.65±1.12)mm:(56.10±1.38)mm,P＜0.05].左房内径及舒张期二尖瓣血流速度峰值的比值2组随访时均无显著变化.结论:AMI后梗死区有存活心肌的患者心脏整体收缩功能及左室重构显著优于无存活心肌的患者,但心肌存活性对左心室舒张功能无明显影响.     

Pulmonary capillary bleeding in a patient with severe left ventricular failure after acute myocardial infarction under anti-thrombotic therapy

A 52-year-old man who was admitted for cardiogenic shock after acute myocardial infarction developed severe left ventricular dysfunction despite reperfusion therapy with coronary stents. After the 40th hospital day, he started to have cough and pulmonary infiltrates. Antimicrobial therapies and subsequent prednisolone for bronchiolitis obliterans organizing pneumonia were ineffective. Bronchoscopic examination revealed diffuse pulmonary bleeding and exudation of hemosiderin-containing macrophages in bronchial lavage fluid. Pulmonary capillary bleeding has been reported in the terminal stage of patients with mitral stenosis in the pre-cardiac surgery era. This complication reemerges in patients with severe heart failure receiving intensive anti-coagulation therapy after implanting a sirolimus-eluting coronary stent.     

急性心肌梗死早期左室重构与发病时间

目的 采用心肌静息门控单光子发射计算机体层摄影术（ＧＳＰＥＣＴ）研究了急性心肌梗列死（ＡＭＩ）早期左室的重构特点。方法 ＡＭＩ患者３７例,根据发病时间分作四个亚组,第一亚组（１６例）,第二亚组（７例）,第三亚组（１１例）和第四亚组（３例）,患者发病时间分别为≤３小时,〉３小时￣≤６小时,〉６小时￣≤１２小时和〉１２小时。患者入院后即注射显影剂＾９９ｍ锝甲氧基异丁基异腈,２小时后采用双探头ＧＳＰＥＣ     

Chemokines and left ventricular function in patients with acute myocardial infarction

BACKGROUND: Leukocytes are activated in the inflammatory process involving locally atherosclerotic lesions through adhesive molecules attaching to the surface of endothelial cells, especially during acute myocardial infarction. The aim of the study was to assess MCP-1, MIP-1alpha, and RANTES serum levels in patients with STEMI and to correlate them with the severity of left ventricle (LV) dysfunction. METHODS: Forty patients were initially divided into two groups, with group 1 having an ejection fraction (EF) above 40% and group 2 an EF of 40% or less. Next, the patients were divided on the basis of wall motion score index (WMSI): group 3 had a WMSI of 1.3 or lower and group 4 had a WMSI above 1.3. A control group of ten volunteers was also included in the study. Serum samples were taken at admission as well as 3, 24, 48, 72 h, and 7 days after. RESULTS: The baseline serum levels of MCP-1 and RANTES in group 1 were significantly higher than in the controls (p<0.05 and p<0.005, respectively). The highest concentrations of chemokines were observed 3 h after admission. The serum levels of MIP-1alpha on admission and 3 h later were significantly higher in group 1 than in group 2 (p<0.03 and p<0.01, respectively). Maximum MIP-1 concentrations were observed 3 h after admission in group 3 and 24 h after admission in group 4 (p<0.006). In group 1, MIP-1alpha 3 h after admission correlated positively with the EF (r=0.444, p<0.05). In group 1 there was a negative correlation between MIP-1alpha concentration 3 h after admission and LV end-diastolic dimension (r=-0.492, p<0.02). CONCLUSIONS: Patients with myocardial infarction with an elevated ST segment had a significant increase in MCP-1, MIP-1alpha, and RANTES serum levels.     

Dynamics of left ventricular remodeling in patients with acute myocardial infarction

Dynamics of structural and functional left ventricular parameters was investigated in 51 patients with acute anterior myocardial infarction by means of serial (on days 1, 2, 3, 5, 7, 10 and 21 of infarction) echocardiographical study. Increase of end-diastolic volume index relative to initial values became significant on 5th-7th days and continued to progress until 3rd week of infarction. Left ventricular cavity became dilated and attained more occurred shape predominantly at the account of increased transverse diameters. Abnormalities of left ventricular contractile and pump functions were most pronounced during first 3 days of the disease. Between 5th and 10th days improvement and stabilization of myocardial functional state took place accompanied by progression of left ventricular dilation and increase of its sphericity with lessening of degree of myocardial asynergy.     

Mechanical reperfusion during acute myocardial infarction in a patient with dextrocardia

Mechanical reperfusion is the preferred treatment for acute ST-elevation myocardial infarction, we describe a case of successful primary angioplasty and stenting in a patient with dextrocardia and situs inversus. Dextrocardia with complete situs inversus is a rare condition, occurring in about 2 in 10,000 live births. However, ischemic heart disease and myocardial infarction have been reported in patients with dextrocardia, and hence the coexistence of myocardial infarction and dextrocardia is not unusual. The incidence of atherosclerosis in this group is not known, but is considered to be the same as that in the general population. There have been a few reports of percutaneous coronary intervention in these patients. We describe a case of primary angioplasty and stenting in a patient with dextrocardia and situs inversus and the electrocardiographic correlation of successful myocardial reperfusion.     

Indirect assessment of left ventricular performance in acute myocardial infarction

One hundred patients admitted to a cardiac care unit had indirect serial determinations of left ventricular systolic ejection times. Patients were divided into groups with transmural infarction, nontransmural infarction, and no infarction, according to clinical, biochemical, and electrocardiographic criteria. Total electromechanical systole and left ventricular ejection time were shortened in acute myocardial infarction, whereas the pre-ejection period and its components, the Q-S1 and isovolumic contraction time intervals, were prolonged. The most abnormal measurements were observed in patients with transmural infarction. Patients with nontransmural infarction demonstrated less severe abnormalities of the systolic ejection times, and the patients without infarction were the least affected. Some of the greatest deviations in the measured intervals were observed in the transmural infarction patients who died. Indirect measurement of left ventricular systolic ejection time is a valuable adjunct in the bedside assessment of left ventricular performance and provides a prognostic index for patients with acute myocardial infarction.     

Prediction of left ventricular remodeling after acute myocardial infarction

Prediction of adverse left ventricular remodeling after acute myocardial infarction (AMI) may have important clinical implications. In this study, we evaluated the incidence of unfavorable changes of left ventricular volumes and ejection fraction after AMI. The ability of several cardiac markers, electrocardiographic and echocardiographic (including tissue Doppler) variables to predict adverse remodeling was demonstrated. The prognostic algorithm based on the investigated variables may help improve the treatment of patients after AMI.