- Acute severe mitral regurgitation with cardiogenic shock following balloon mitral valvuloplasty: echocardiographic findings and outcomes following surgery. [Journal Article]
- CICardiovasc Interv Ther 2018 Nov 09
- Acute severe mitral regurgitation (MR) is the commonest indication for emergency surgery following a balloon mitral valvuloplasty (BMV). It results in hemodynamic compromise with cardiogenic shock an...
Acute severe mitral regurgitation (MR) is the commonest indication for emergency surgery following a balloon mitral valvuloplasty (BMV). It results in hemodynamic compromise with cardiogenic shock and or acute pulmonary edema. These patients deteriorate fast and often require respiratory and critical care support, followed by urgent mitral valve replacement (MVR). We analyzed the data of 1224 BMV procedures done over the 18-year period. We had 85 patients (6.9%) with acute severe MR and cardiogenic shock. The clinical profile, echocardiographic features and operative findings were studied. The echocardiography scores were compared for association with occurrence of MR. The immediate and long-term clinical outcomes of these acutely sick patients were studied. Of the 85 patients, 84 underwent MVR. Anterior mitral leaflet tear was observed in 65 (75%) cases, para-commissural with annular tear in 8 (9.4%), Chordal injury in 7 (8%) and torn posterior leaflet in 5 (5.8%). We documented severe MR in 88 patients (7.1%), with 85 (6.9%) among them developing features of cardiogenic shock. None of the echocardiographic scoring systems were predictive of the occurrence of MR. The 30-day mortality was 4.7%. The mean clinical follow-up period after discharge was 9.3 ± 0.9 years (range 2.2-17.8) with no late mortality. Acute severe MR had an incidence of 7% in this study. Injury to the anterior mitral leaflet was the commonest cause. The long-term outcomes were good with timely intervention and valve replacement surgery despite the fact that the majority (96%) presented with cardiogenic shock. None of the present valve scoring systems could predict the occurrence of severe MR.
- Urgent transcatheter aortic valve replacement for severe acute aortic regurgitation following open mitral valve surgery. [Case Reports]
- CCCatheter Cardiovasc Interv 2018 Nov 08
- Transcatheter aortic valve replacement (TAVR) is not currently approved for pure native valve aortic incompetence, and is typically performed on a compassionate basis in selected patients who are at ...
Transcatheter aortic valve replacement (TAVR) is not currently approved for pure native valve aortic incompetence, and is typically performed on a compassionate basis in selected patients who are at high risk for conventional surgery. We describe the first use of TAVR to treat iatrogenic severe acute pure aortic incompetence following mitral valve surgery. A 71-year-old gentleman developed life-threatening acute aortic regurgitation (AR) within hours of a very challenging fifth open heart mitral valve replacement. Careful inspection of echocardiographic and computed tomographic imaging identified the cause as a disrupted left coronary cusp at the commissure caused by the surgical mitral annular reconstruction. Medical management with afterload reduction failed with recurrent pulmonary edema, and a sixth open heart surgery was deemed prohibitively high risk. The lack of aortic annular calcium onto which anchors a transcatheter valve was a concern for TAVR. However, we postulated that the struts of the mitral valve bioprosthesis would offer some support to the TAVR valve. We opted for a self-expanding system because of concerns about potential unfavorable interaction between the balloon onto which balloon-expandable bioprosthesis is mounted and the struts of the mitral bioprosthesis, and because the Evolut R system has additional anchoring points at the crown which might enhance transcatheter valve stability in the non-calcified annulus, compared with the Edwards Sapien system. Transfemoral TAVR, performed with a Medtronic Evolut R 34 mm system under general anesthesia and using moderately rapid ventricular pacing, was successful with minimal residual AR. On follow-up 1 month later the patient was asymptomatic, and the aortic and mitral bioprostheses were functioning normally on echocardiogram.
- Thrombotic microangiopathy associated with Gemcitabine use: presentation and outcome in a national French retrospective cohort. [Journal Article]
- BJBr J Clin Pharmacol 2018 Nov 05
- CONCLUSIONS: This large cohort confirms the severity of G-TMA, associated with severe renal failure and death. Edema and hypertension could be monitored in patients treated with Gemcitabine to detect early TMA. The benefit of PE or Eculizumab deserves further investigation.
- Lung repair and regeneration in ARDS: Role of PECAM1 and Wnt signaling. [Review]
- ChestChest 2018 Oct 27
- The acute respiratory distress syndrome (ARDS) is an acute inflammatory pulmonary process triggered by severe pulmonary and systemic insults to the alveolar-capillary membrane. This leads to increase...
The acute respiratory distress syndrome (ARDS) is an acute inflammatory pulmonary process triggered by severe pulmonary and systemic insults to the alveolar-capillary membrane. This leads to increased vascular permeability, development of interstitial and alveolar protein-rich edema, leading to acute hypoxemic respiratory failure. Supportive treatment includes the use of lung protective ventilatory strategies which decrease the work of breathing, can improve oxygenation, and minimize ventilator-induced lung injury. Despite substantial advances in supportive measures, there are no specific pharmacologic treatments for ARDS, and the overall hospital mortality rate remains about 40% in most series. The pathophysiology of ARDS involves interactions among multiple mechanisms, including immune cell infiltration, cytokine storm, alveolar-capillary barrier disruption, cell apoptosis and development of fibrosis. In this short review, we will review a couple of new developments in the molecular basis of lung injury with a focus on possible novel pharmacological interventions aimed at improving outcomes of ARDS patients. Our focus will be on platelet-endothelial cell adhesion molecule-1 (PECAM1) which contributes to the maintenance and restoration of vascular integrity following barrier disruption. We will also highlight the wingless-related integration site (Wnt) signaling pathway which appears to be a central mechanism for lung healing as well as for fibrotic development.
- New onset acute pulmonary edema after methylergonovine given during cesarean delivery of a patient with undiagnosed Raynaud's disease. [Journal Article]
- IJInt J Obstet Anesth 2018; 36:111-114
- Raynaud's disease is a medical condition in which arterial spasm causes episodes of reduced blood flow, in the setting of certain triggers such as cold weather. Patients with this condition are at ri...
Raynaud's disease is a medical condition in which arterial spasm causes episodes of reduced blood flow, in the setting of certain triggers such as cold weather. Patients with this condition are at risk of adverse reactions if they receive medications with vasoactive properties. Methylergonovine maleate is one drug used during cesarean delivery to treat postpartum hemorrhage due to uterine atony. By acting directly on uterine and vascular smooth muscle, it produces cardiovascular responses such as coronary vasospasm, myocardial infarction, and even cardiac arrest. However, pulmonary events have rarely been reported. We report our anesthetic management of a 36-year-old patient, with undiagnosed Raynaud's disease and undergoing cesarean delivery, who experienced new onset acute pulmonary edema after methylergonovine administration to manage postpartum hemorrhage.
- Noninvasive ventilation in acute hypoxemic respiratory failure: A systematic review and meta-analysis. [Review]
- JCJ Crit Care 2018 Oct 19; 49:84-91
- CONCLUSIONS: NIV showed a significant protective effect for intubation in immunosuppressed patients (cancer and transplants) and in patients with APE/CAP. However, the benefits of NIV for other etiologies are not clear and more trials are needed to prove these effects.
- Fas activation alters tight junction proteins in acute lung injury. [Journal Article]
- TThorax 2018 Nov 01
- Background: The acute respiratory distress syndrome (ARDS) is characterized by protein-rich oedema in the alveolar spaces, a feature in which Fas-mediated apoptosis of the alveolar epithelium has bee...
Background: The acute respiratory distress syndrome (ARDS) is characterized by protein-rich oedema in the alveolar spaces, a feature in which Fas-mediated apoptosis of the alveolar epithelium has been involved. Objective: To determine whether Fas activation increases protein permeability by mechanisms involving disruption of the paracellular tight junction (TJ) proteins in the pulmonary alveoli. Methods: Protein permeability and the expression of TJ proteins were assessed in vivo in wild-type and Fas-deficient lpr mice 16 hours after the intratracheal instillation of recombinant human soluble Fas ligand (rh-sFasL), and at different time points in vitro in human pulmonary alveolar epithelial cells (HPAEpiC) exposed to rh-sFasL Results: Activation of the Fas pathway increased protein permeability in mouse lungs and altered the expression of the TJ proteins occludin and zonula occludens-1 in the alveolar-capillary membrane in vivo and in human alveolar epithelial cell monolayers in vitro. Blockade of caspase-3, but not inhibition of tyrosine kinase dependent pathways, prevented the alterations in TJ protein expression and permeability induced by the Fas/FasL system in human alveolar cell monolayers in vitro. We also observed that both the Fas-induced increase of protein permeability and disruption of TJ proteins occurred before cell death could be detected in the cell monolayers in vitro. Conclusion: Targeting caspase pathways could prevent the disruption of TJs and reduce the formation of lung oedema in the early stages of ARDS.
- Delay in antibiotic therapy results in fatal disease outcome in murine pneumococcal pneumonia. [Journal Article]
- CCCrit Care 2018 Nov 01; 22(1):287
- CONCLUSIONS: Our data show that only early antibiotic therapy, administered prior to breakdown of the alveolar-capillary barrier and systemic inflammation, led to restored fitness and rescued mice from fatal streptococcal pneumonia. The findings highlight the importance of identifying CAP patients prior to lung barrier failure and systemic inflammation and of handling CAP as a medical emergency.
- Shared Features of Endothelial Dysfunction between Sepsis and Its Preceding Risk Factors (Aging and Chronic Disease). [Review]
- JCJ Clin Med 2018 Oct 30; 7(11)
- Acute vascular endothelial dysfunction is a central event in the pathogenesis of sepsis, increasing vascular permeability, promoting activation of the coagulation cascade, tissue edema and compromisi...
Acute vascular endothelial dysfunction is a central event in the pathogenesis of sepsis, increasing vascular permeability, promoting activation of the coagulation cascade, tissue edema and compromising perfusion of vital organs. Aging and chronic diseases (hypertension, dyslipidaemia, diabetes mellitus, chronic kidney disease, cardiovascular disease, cerebrovascular disease, chronic pulmonary disease, liver disease, or cancer) are recognized risk factors for sepsis. In this article we review the features of endothelial dysfunction shared by sepsis, aging and the chronic conditions preceding this disease. Clinical studies and review articles on endothelial dysfunction in sepsis, aging and chronic diseases available in PubMed were considered. The main features of endothelial dysfunction shared by sepsis, aging and chronic diseases were: (1) increased oxidative stress and systemic inflammation, (2) glycocalyx degradation and shedding, (3) disassembly of intercellular junctions, endothelial cell death, blood-tissue barrier disruption, (4) enhanced leukocyte adhesion and extravasation, (5) induction of a pro-coagulant and anti-fibrinolytic state. In addition, chronic diseases impair the mechanisms of endothelial reparation. In conclusion, sepsis, aging and chronic diseases induce similar features of endothelial dysfunction. The potential contribution of pre-existent endothelial dysfunction to sepsis pathogenesis deserves to be further investigated.
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- [Severe reversible penile ischaemia after terlipressin treatment of hepatorenal syndrome]. [Journal Article]
- ULUgeskr Laeger 2018 Oct 22; 180(43)
- This case report presents a 70-year-old man with alcoholic liver cirrhosis, who was hospitalised due to pulmonary oedema, and who developed acute renal injury. Though the criteria were not fulfilled,...
This case report presents a 70-year-old man with alcoholic liver cirrhosis, who was hospitalised due to pulmonary oedema, and who developed acute renal injury. Though the criteria were not fulfilled, hepatorenal syndrome was suspected and treated with terlipressin, after which the patient developed severe penile ischaemia. Hepatorenal syndrome is one of many potential causes of acute kidney injury in patients with acute or chronic liver disease. The syndrome is an exclusion diagnosis, and other causes of liver and renal failure should be investigated, before treatment is started. A flow chart can be used for a correct diagnosis.