Churg-Strauss syndrome presenting with acute myocarditis and cardiogenic shock

Churg-Strauss syndrome (CSS) is a multisystem disorder characterised by asthma, prominent peripheral blood eosinophilia, and vasculitis signs. We report the case of a 22 year-old man admitted to the intensive care unit for acute myocarditis complicated with cardiogenic shock. Eosinophilia, history of asthma, lung infiltrates, paranasal sinusitis, glomerulonephritis, and abdominal pain suggested the diagnosis of CSS. Cardiac MRI confirmed cardiac involvement with a diffuse subendocardial delayed enhancement of the left ventricular wall, and a left ventricular ejection fraction (LVEF) of 30%. Acute myocarditis was confirmed with myocardial biopsy. The patient was successfully treated with systemic corticosteroids, intravenous cyclophosphamide, vasopressor inotropes, intra-aortic balloon pump and mechanical ventilation, and was discharged 21 days later. One year after diagnosis, the patient was asymptomatic. The eosinophilic cell count was normal. Follow-up MRI at one year showed LVEF of 40% with persistent delayed enhancement. Cardiac involvement by CSS requires immediate therapy with corticosteroids and cyclophosphamide, which may allow recovery of the cardiac function.     

持续肾脏替代治疗心源性休克并发急性肾功能衰竭

目的:总结10例心源性休克并发急性肾功能衰竭应用持续肾脏替代治疗的临床经验. 方法:2004年10月至2008年2月,对10例急性心肌梗死合并心源性休克并发急性肾功能衰竭患者应用持续肾脏替代治疗,所有患者都有难以控制的心源性休克,7例患者予急诊冠状动脉介入治疗,其中6例患者开通梗死相关血管;9例患者予气管插管,呼吸机辅助呼吸;1例患者予无创呼吸机辅助;10例患者均予主动脉内气囊泵辅助;患者均行深静脉穿刺,前稀释连续性静脉-静脉血液滤过.结果:持续肾脏替代支持72~480 h,平均216 h.6例患者顺利脱离持续肾脏替代治疗,5例存活,1例死亡;4例患者心源性休克不能纠正死亡.5例存活病例随访1个月~3年,均存活.结论:持续肾脏替代治疗可对心源性休克并发急性肾功能衰竭提供有效支持治疗,延长这部分高危患者的生命.     

Spontaneous recovery from cardiogenic shock and renal failure

A patient is described with an unexpected and spontaneous recovery from cardiogenic shock and acute severe oliguric renal failure despite her refusal to receive appropriate therapeutic action. The uniqueness of this patient's course and the need to individualize ethical decisions are emphasized.     

早期发生急性肾衰竭与急性心肌梗死后心源性休克患者预后的关系

目的了解急性心肌梗死后心源性休克患者早期发生急性肾衰竭与其预后的关系.方法回顾性分析解放军总医院1993～2003年间,因急性心肌梗死或冠心病心绞痛住院,并出现心源性休克的病例,以24h内是否出现急性肾衰竭为标准,比较其住院期间死亡率,并采用多元Logistic回归分析,评估早期发生急性肾衰竭对患者预后的影响.结果符合统计分析标准的患者共172例,其中51例(30%)于24h内出现急性肾衰竭.有无早期发生急性肾衰竭的患者,其住院死亡率分别为90%(46/51)和56%(68/121).逐步回归分析表明,早期发生急性肾衰竭是影响急性心肌梗死后心源性休克患者预后的独立因素(OR=6.7,95%可信限2.5～18;P＜0.001).结论急性心肌梗死后心源性休克患者,早期发生急性肾衰竭,与其住院死亡率显著相关,可作为判断患者不良预后的指标.     

The characteristics of acute renal failure in cardiogenic shock in the elderly

Four patients are presented aged over 65 years in whom a state of cardiogenic shock was present due to myocardial infarction of the following localization: anterior in two and posterior in two. According to the parameters all patients satisfied the criteria of cardiogenic shock. Of the four patients three died. In all patients parameters of renal lesion were analyzed after establishment of diureses: sodium in urine, creatinine quotient in urine and plasma, osmolality of urine, osmolality quotient of urine and plasma, the renal failure index and the excretional fraction of filtered sodium. The parameters quoted were analyzed the day after diuresis was established. All parameters, apart from sodium in urine, indicated functional oliguria. In corroboration of this were the values of creatinine clearance which were determined the day after establishing diuresis, amounting in all patients to more than 20 ml/min./1.73 m2, i.e. ranging from 20.6 to 59.0 ml/min./1.73 m2. Of the cases which ended fatally all had fibroses and myocardial scars, apart from recent infarction of the myocardium, generalized atherosclerosis particularly of the coronary arteries, and in all patients hypertrophy of the left ventricle and dilatation of the whole heart. In one patient anaemic infarction of one kidney was found and in another acute tubular necrosis (with the renal failure index of 0.3 and the excretional fraction of filtered sodium of 0.2), while in third patient no renal changes were found.     

Pheochromocytoma crisis presenting with cardiogenic shock

Pheochromocytoma is a catecholamine-secreting tumor of the adrenal glands whose typical presentation includes the triad of headache, palpitations, and diaphoresis. Pheochromocytoma crisis is an urgent medical condition whose diagnosis and management constitute a challenge for physicians. We present the case of a 55-year-old man who developed cardiogenic shock in the setting of a pheochromocytoma crisis. After stabilizing blood pressure with combined administration of α- and β-blockers, the tumor was surgically removed. Our diagnostic and therapeutic challenges are discussed.     

Microvascular alterations in patients with acute severe heart failure and cardiogenic shock

Background

Microvascular blood flow alterations may impair tissue oxygenation and may participate in the development of multiple organ failure in patients with severe heart failure. We hypothesized that microvascular blood flow alterations are present in patients with severe heart failure and cardiogenic shock.

Methods

We used an orthogonal polarization spectral imaging technique to investigate the sublingual microcirculation in 40 patients with acute severe heart failure, including 31 patients with cardiogenic shock, and in a control group of 15 patients who were examined the day before cardiac surgery. The effects of topical application of acetylcholine (10-2M) were also tested in 5 patients with cardiogenic shock. Five sublingual areas were recorded, allocated a random number, and later analyzed semiquantitatively. Data were analyzed with non-parametric tests and presented as medians (percentiles 25-75).

Results

The density of all the vessels was similar in the 3 groups. The proportion of perfused small (<20 μm) vessels was lower in patients with cardiac failure and cardiogenic shock than in control patients (63% [46%-65%] and 49% [38%-64%] vs 92% [90%-93%] , P <.001). The perfusion of large vessels was preserved in all groups. The proportion of perfused vessels was higher in patients who survived than in patients who did not survive in all vessels (90% [84%-93%] vs 81% [74%-87%] , P <.05) and in small vessels (64% [49%-68%] vs 43% [37%-62%], P <.05). The topical application of acetylcholine totally reversed these alterations

Conclusions

Microvascular blood flow alterations are frequently observed in patients with severe heart failure and are more severe in patients who do not survive.     

Cardiovascular failure and cardiogenic shock

Cardiovascular system failure is commonly faced by the intensivist. Heart failure can occur due to a host of predisposing cardiac disorders or as secondary effects of systemic illness. When the heart is unable to provide an adequate cardiac output to maintain adequate tissue perfusion, cardiogenic shock ensues. Without prompt diagnosis and appropriate management, these patients have significant morbidity and mortality, with in-hospital mortality approaching 60% for all age groups. Accurate and rapid identification of cardiogenic shock as a medical emergency, with expeditious implementation of appropriate therapy, can lead to improved clinical outcomes. In this review, we discuss optimal strategies for diagnosis and monitoring of cardiogenic shock. We discuss the diverse therapeutic strategies employed for cardiogenic shock, including pharmacological (e.g., vasoactive agents, fibrinolytic agents), mechanical (e.g., intraaortic balloon pumps, left ventricular assist devices, percutaneous coronary intervention [PCI]), and surgical approaches such as coronary artery bypass graft (CABG), valvular repair or replacement (e.g., for acute mitral regurgitation, ventricular septal rupture, or free wall rupture).     

Phaeochromocytoma and catecholamine induced cardiomyopathy presenting as heart failure

Phaeochromocytoma is rare and usually presents as paroxysmal or sustained hypertension; none the less, it can also cause severe acute pulmonary oedema in normotensive individuals. Six patients with phaeochromocytoma presenting in Cornwall and West Devon between 1982 and 1986 are described. Five of them died of pulmonary oedema within 24 hours of the onset of symptoms. At necropsy all five had normal sized hearts and in the four hearts examined by histology there was evidence of catecholamine induced heart disease in the form of focal myocardial necrosis. The sixth patient presented with arterial spasms and pulmonary oedema. Surgical removal of the causative tumour was successful in this patient.     

Management of acute cardiogenic shock

The present state of the art in mechanical cardiac assist technology has permitted application of machines to a variety of conditions that confound the cardiologist and cardiac surgeon alike. Decades of research and development have allowed the present devices to be used as bridges to native heart recovery and bridges to transplantation. We are now entering the era in which devices are being placed for permanent assist or replacement. Although the acute cardiogenic shock patient remains problematic, we now have at our disposable a variety of tools that have enabled us to salvage more patients than ever before. The experience with these systems continues to grow, with leading centers and investigators contributing meaningful information toward the application and development of the latest technologies. It has been said that mechanical therapies precede biological therapies. We are at the crossroads in which a combination of biological therapies with mechanical therapies is underway. Current research is investigating the role of mechanical cardiac support while biological therapies are introduced into the failing heart. In the meantime, the role of mechanical cardiac assist and replacement has matured into an effective means of treating acute cardiogenic shock of any variety.     

Phaeochromocytoma and catecholamine induced cardiomyopathy presenting as heart failure.

Phaeochromocytoma is rare and usually presents as paroxysmal or sustained hypertension; none the less, it can also cause severe acute pulmonary oedema in normotensive individuals. Six patients with phaeochromocytoma presenting in Cornwall and West Devon between 1982 and 1986 are described. Five of them died of pulmonary oedema within 24 hours of the onset of symptoms. At necropsy all five had normal sized hearts and in the four hearts examined by histology there was evidence of catecholamine induced heart disease in the form of focal myocardial necrosis. The sixth patient presented with arterial spasms and pulmonary oedema. Surgical removal of the causative tumour was successful in this patient.     

Papillary fibroelastoma of the ascending aorta presenting with cardiogenic shock

We describe an uncommon case of a 58-year-old woman who presented with cardiogenic shock. The echocardiography examination revealed a papillary fibroadenoma located in the ascending aorta which was subsequently surgically treated.     

Primary aldosteronism presenting as myoglobinuric acute renal failure

Hypokalemia is an uncommon cause of rhabdomyolysis with acute tubular necrosis. We recently treated a patient in whom severe hypokalemia attributed to diuretic therapy antedated acute myoglobinuric renal failure by six months. After recovery, hypokalemia persisted and subsequent evaluation disclosed primary aldosteronism. This case is a unique presentation for primary aldosteronism and illustrates the importance of diagnosis before treatment in hypertension as well as the hazards of hypokalemia.