Sudden Hemodynamic Deterioration Research Articles

Ventricular Septal Rupture (VSR) in Post-Acute Anterior Myocardial Infarction Patients : A Case Series

Case Summary: We present 2 cases of post-STEMI VSR. They had anterior AMI without reperfusion therapy because of patient delay and limited resources. Thereafter apical VSR occurs on 5th day. VSR was suspected because of sudden hemodynamic deterioration and new holosystolic murmur (Grade III/VI) at left parasternal line of fourth-fifth ICS. Then it was confirmed by echocardiography. Both patients underwent hemodynamic stabilization while waiting for surgical therapy. Unfortunately, they deceased because of cardiogenic shock accompanied by other comorbidities. Discussion: VSR causes shunt from left to the right ventricle, which overloads the RV, leading to cardiogenic shock. The peak incidence of VSR in the first 24 hours or 3-5 days post-AMI. This fits both of our cases. VSR occurs in total coronary occlusion, which then causes coagulation necrosis in the ischemic area, characterized by neutrophils that trigger apoptosis and lytic enzymes, so that septum becomes thin, brittle then ruptures. VSR is most common in anterior AMI and the defect is at apical septum, as in our patients. Definitive therapy for VSR is surgical closure, but the best timing is still under debate. This article is expected to make us more aware of post-AMI VSR, so we can quickly diagnose and promptly treat the patients with multidisciplinary approach. This is very important to optimize patient’s outcomes even in limited resources area.

Clinical features of patients with septic shock-triggered Takotsubo syndrome: a single-center 7 case series

BackgroundMyocardial dysfunction is common in septic shock and has long been recognized. Takotsubo syndrome is an acute and usually reversible myocardial injury without evidence of an obstructive coronary artery disease, yet little is known about this syndrome in septic shock patients.Case presentationAmong 84 septic shock patients admitted to the ICU over a period of 8 months, 7 patients (8.3%) were diagnosed with Takotsubo syndrome. The percentage of men was 71%, and the mean age was 58 (19–87) years. Sudden hemodynamic deterioration and/or dyspnea were the presenting symptoms in 6 patients. T-wave inversion was the major ECG anomaly in 5 patients. The mean left ventricular ejection fraction was 31.8% (20.0–53.0). Mild elevation of cardiac troponin disproportionate to the extent of regional wall motion abnormalities was present in all patients. Cardiac complications occurred in 6 patients. The mean time to recover the cardiac function was 6.5 (3–11) days. In-hospital death was observed in 2 patients.ConclusionsTakotsubo syndrome is not uncommon in septic shock patients and may be the cause of some patients with sepsis-induced myocardial dysfunction. New-onset hemodynamic and respiratory worsening could arouse the suspicion of Takotsubo syndrome and prompt the screening for this syndrome using echocardiography in this clinical context.

Acute pulmonary edema due to severe preeclampsia in advanced maternal age women.

Acute pulmonary edema is a rare complication in women with preeclampsia especially at advanced maternal age. We aimed to determine the cardiovascular hemodynamics in advanced maternal age women who developed acute pulmonary edema and preeclampsia. Retrospective cohort study of women aged over 45years giving birth at single university affiliated tertiary medical center which developed acute pulmonary edema due to severe preeclampsia. Clinical features were identified in order to predict and potentially prevent this severe complication of pregnancy. Advanced maternal age women who developed acute pulmonary edema due to preeclampsia. Overall, during the study period 90,540 women delivered in our hospital, of them, 540 women (0.6%) above the age of 45years gave birth. Of those, 67 women (12.4%) had preeclampsia in which 4 women (6%) were complicated with acute pulmonary edema. The common clinical relevant characteristics for all four women were: preterm delivery by cesarean section for preeclampsia with severe features, non-restrictive fluid management around the time of delivery, post-partum pain control medication with non-steroidal anti-inflammatory drug, blood pressure stabilization with oral labetalol and a sudden hemodynamic deterioration to hypertensive crisis and pulmonary edema between post-operative days 4-9. Although the precise trigger for the sudden presentation of acute pulmonary edema remains unknown, we suggest that there is a multi-factorial combination of etiologies that are common to women of advanced maternal age and women with preeclampsia that could have contributed to the development of pulmonary edema.

Rupture of Sinus of Valsalva Mimicking Aortic Root Dissection: Surgical Management and Factors Influencing Immediate Survival

Rupture of giant aneurysm of sinus of Valsalva usually requires surgery to prevent life-threatening complications from occurring. We report the case of a 55-year-old patient with a previous history of aortic valve replacement who was urgently referred to our institution with a superior vena cava syndrome and dyspnea. CT-scan initially misdiagnosed a dissection of the aortic root that was ultimately a contained rupture of a giant aneurysm of the non-coronary sinus of Valsalva. Despite a sudden hemodynamic deterioration with a collapse and cardiac arrest, urgent salvage surgery was successfully performed with an uneventful outcome. Physiopathogeny of hemodynamic profiles influencing immediate survival and surgical technique are discussed in this report.

Transthoracic echocardiography during prone position ventilation: Lessons from the COVID-19 pandemic.

ObjectiveThe current coronavirus disease 2019 (COVID‐19 outbreak) demands an increased need for hospitalizations in emergency departments (EDs) and critical care units. Owing to refractory hypoxemia, prone position ventilation has been used more frequently and patients will need repeated hemodynamic assessments. Our main objective was to show the feasibility of obtaining images to measure multiple parameters with transthoracic echocardiography during the prone position ventilation.MethodsWe enrolled 15 consecutive mechanically ventilated patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection that required prone position ventilation as a rescue maneuver for refractory hypoxemia. The studies were performed by 2 operators with training in critical care echocardiography. Measurements were done outside the patient's room and the analysis of the images was performed by 3 cardiologists with training in echocardiography.ResultsAdequate image acquisition of the left ventricle was possible in all cases; we were not able to visualize the right ventricular free wall only in 1 patient. The mean tricuspid annular plane systolic excursion was 17.8 mm, tricuspid peak systolic S wave tissue Doppler velocity 11.5 cm/s, and the right ventricular basal diameter 36.6 mm; left ventricle qualitative function was reduced in 6 patients; pericardial effusion or valvular abnormalities were not observed.ConclusionWe showed that echocardiographic images can be obtained to measure multiple parameters during the prone position ventilation. This technique has special value in situations where there is sudden hemodynamic deterioration and it is not possible to return the patient in the supine position.

Non-perforation tension pneumoperitoneum resulting from primary non-aerobic bacterial peritonitis in a previously healthy middle-aged man: a case report

BackgroundTension pneumoperitoneum is a rare surgical emergency in which free intraperitoneal gas accumulates under pressure. The known sources of free gas are perforated hollow viscera. We believe this is the first published case of a tension non-perforation pneumoperitoneum secondary to anaerobic gas production. This occurred in a background of primary non-aerobic bacterial peritonitis, which developed in an immunocompetent adult man.Case presentationA previously healthy 45-year-old Bulgarian man presented with a 3-week history of abdominal pain. He displayed signs of shock, peritonitis, and abdominal compartment syndrome. A plain abdominal X-ray showed the pathognomonic “saddlebag sign” with his liver displaced downwards and medially. An emergency laparotomy released pressurized gas, accompanied by 3100 mL of foamy pus. A sudden hemodynamic deterioration occurred soon after decompression. The sources of infection and tension pneumoperitoneum were not found. The peritoneal exudate sample did not recover aerobes. A laparostomy was created and three planned re-operations were performed. During the second re-laparotomy we placed an intraperitoneal silo and his abdomen was closed with skin sutures. Definitive fascial closure was achieved through separation of his two rectus muscles from their posterior sheaths. He was discharged in good health on the 25th postoperative day.ConclusionsOur case provides evidence supporting the theory that anaerobic infection may underlie the etiology of tension pneumoperitoneum. Prior to decompressive laparotomy the patient should receive an intravenous volume bolus to compensate for possible hypotension. If laparostomy leads to lateralization of the rectus muscles with a gap of 6 cm or less, the posterior part of the components separation technique is effective in achieving fascial closure. We present an original classification of tension pneumoperitoneum defining it as primary or secondary.Electronic supplementary materialThe online version of this article (doi:10.1186/s13256-016-0945-0) contains supplementary material, which is available to authorized users.

Incremental Value of Three‐Dimensional Transthoracic Echocardiography in the Assessment of Ruptured Aneurysm of Anterior Mitral Leaflet

The mitral valve aneurysm is a rare complication of infective endocarditis involving mitral or aortic valve. The perforation of the mitral valve aneurysm can lead to significant mitral regurgitation (MR) or thromboembolism, which can cause sudden hemodynamic deterioration. We describe here a case of healed infective endocarditis of the aortic valve with ruptured mitral valve aneurysm that led to severe MR. The aneurysm of the anterior mitral leaflet was diagnosed by two-dimensional transthoracic echocardiography. In this case, three-dimensional transthoracic echocardiography demonstrated the detailed morphology of mitral valve aneurysm which resulted in successful surgical repair of the aneurysm.

Cardiogenic shock following administration of propofol and fentanyl in a healthy woman: a case report

IntroductionCardiogenic shock is very uncommon in healthy people. The differential diagnosis for patients with acute heart failure in previously healthy hearts includes acute myocardial infarction and myocarditis. However, many drugs can also depress myocardial function. Propofol and fentanyl are frequently used during different medical procedures. The cardiovascular depressive effect of both drugs has been well established, but the development of cardiogenic shock is very rare when these agents are used.Case presentationAfter a minor surgical intervention, a 32-year-old Caucasian woman with no significant medical history went into sudden hemodynamic deterioration due to acute heart failure. An urgent echocardiogram showed severe biventricular dysfunction and an estimated left ventricular ejection fraction of 20%. Extracorporeal life support and mechanical ventilation were required. Five days later her ventricular function had fully recovered, which allowed the progressive withdrawal of medical treatment. Prior to her hospital discharge, cardiac MRI showed neither edema nor pathological deposits on the delayed contrast enhancement sequences. At her six-month follow-up examination, the patient was asymptomatic and did not require treatment.ConclusionAlthough there are many causes of cardiogenic shock, the presence of abrupt hemodynamic deterioration and the absence of a clear cause could be related to the use of propofol and fentanyl.

Seizure-associated Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is characterized by chest pain, dyspnea, electrocardiographic changes resembling an acute coronary syndrome, and transient wall-motion abnormalities without identifiable coronary culprit lesion explaining the wall-motion abnormality. Takotsubo cardiomyopathy occurs frequently after emotional or physical stress. Seizures have been reported as triggers of takotsubo cardiomyopathy. It is unknown if seizure-associated takotsubo cardiomyopathy differs from takotsubo cardiomyopathy associated with other triggers. Seizure-associated takotsubo cardiomyopathy cases from the literature were compared with takotsubo cardiomyopathy series comprising 30 or more patients. Thirty-six seizure-associated takotsubo cardiomyopathy cases (6 male, mean-age 61.5 years) were found. Seizure-type were tonic-clonic (n = 13), generalized (n = 5), status epilepticus (n = 6), grand mal (n = 2), or not reported (n = 13). Twelve patients had a history of epilepsy, in 15 patients takotsubo cardiomyopathy-associated seizure was the first or the information was not given (n = 9). In 17 patients takotsubo cardiomyopathy occurred immediately after the seizure, in 9 patients 1-72 h postictally, and in 10 patients, the interval was not reported. In 20 patients neurologic disorders were reported and in 14 psychiatric disorders were reported. There were medical comorbidities in 17 patients, arterial hypertension (n = 11), hyponatremia (n = 2), and cancer (n = 2). Compared with 974 patients reported in takotsubo cardiomyopathy -series, patients with seizure-associated takotsubo cardiomyopathy were younger (61.5 vs. 68.5 years, p < 0.0001), more frequently males (17 vs. 9%, p = 0.004), had less frequent chest pain (6 vs.76%, p < 0.005), more frequent cardiogenic shock (25 vs. 8%, p = 0.003), and more frequent recurrency (14 vs. 3%, p = 0.004). Seizure-associated takotsubo cardiomyopathy manifests frequently as sudden hemodynamic deterioration, which could result in death in the absence of adequate help. Probably some cases of sudden unexpected death in epilepsy are attributable to takotsubo cardiomyopathy.

Anesthesia management for retrograde aortic valve replacement

To the Editor, We read with great interest the article, ‘‘Case series: Anesthesia for retrograde percutaneous aortic valve replacement—experience with the first 40 patients’’. Ree et al. report their experiences with the retrograde aortic valve replacement procedure, and the preliminary results of the two new valve application techniques, the transfemoral and transapical approaches, are encouraging. Since anesthesiologists must deal with the added co-morbidities associated with elderly patients, this article is of utmost interest, because the number of minimally invasive aortic valve replacement procedures is increasing worldwide. Whereas this procedure is performed under general anesthesia in 90% of cases, other groups prefer and propagate regional anesthesia and conscious sedation for the retrograde approach. Ree et al. performed the procedures in the cardiac catheterization laboratory, and, unfortunately, it was not possible to deliver the prosthetic valve in five patients, and, in two patients, the valve was malpositioned. These results dictate the operating room setup for minimally invasive aortic valve replacement. Anesthesiologists must be prepared for sudden hemodynamic deterioration which may require inotropic support, ventricular pacing, or emergency cardiopulmonary bypass; thus, the setup of the room must lend itself to the possibility of an emergency cardiopulmonary bypass. The authors reported that the most common procedural complications were myocardial ischemia and arrhythmia following rapid ventricular pacing. Did they maintain a specific mean arterial pressure before commencing the rapid ventricular pacing? Also, the authors treated intraoperative hypotension (systolic arterial pressure \90 mmHg) with intravenous crystalloid infusion as well as inotropic agents. We routinely experience a significant decline in the mean arterial pressure for both balloon valvuloplasty and valve implantation after rapid ventricular pacing. In our experience, it is important to increase the mean arterial pressure (MAP [ 75 mmHg) before starting rapid ventricular pacing, especially if the procedure is performed under general anesthesia. If the ‘‘starting point’’ of the mean arterial pressure is higher before initiating rapid ventricular pacing, the necessary time to stabilize the patient is shorter. A prolonged period of hypotension after rapid ventricular pacing may be the risk factor for myocardial ischemia after rapid ventricular pacing. These initial experiences necessitate a thorough understanding of anesthesia management and the hemodynamic effects of retrograde valve replacement in order to ensure successful outcomes with this new approach for percutaneous retrograde replacement of the aortic valve for high risk patients.

Takotsubo Cardiomyopathy (Acute Left Ventricular Apical Ballooning Syndrome) Occurring in the Intensive Care Unit

Diagnosis of Takotsubo cardiomyopathy (also known as stress cardiomyopathy or acute left ventricular apical ballooning syndrome) can be challenging in patients who are being treated for other diseases in the intensive care unit, because symptoms could erroneously be attributed to the underlying disease or patients may not experience symptoms due to analgesia and sedation. The aim of our study was to assess clinical features of Takotsubo cardiomyopathy occurring in the intensive care unit. Prospective observational study. University hospital. Six consecutive patients diagnosed with Takotsubo cardiomyopathy who were being treated for other diseases in the intensive care unit. None. Sudden hemodynamic deterioration (i.e., sudden hypotension, tachycardia or drop in monitored stroke volume) requiring vasopressor support was the presenting symptom in five of the six patients. Only one patient was able to report angina-like chest pain, all others were unable to experience symptoms due to analgesia and sedation. The electrocardiogram was abnormal in all patients upon diagnosis, demonstrating either ST-segment elevation (n=2) and/or T-wave inversion (n=5). Mild elevation of cardiac enzymes disproportionate to the extent of wall motion abnormalities on left ventriculography was present in all patients. All patients survived their acute event. Sudden hemodynamic deterioration requiring vasopressor support and/or ECG abnormalities consisting of ST-segment elevation, ST-segment depression or T-wave inversion may be the presenting symptom of Takotsubo cardiomyopathy in the intensive care unit and should be included in the diagnostic algorithm.

Off-Pump Open Pulmonary Embolectomy for Major Bilateral Pulmonary Emboli: Report of a Case

Acute massive or submassive pulmonary artery thromboembolism causes sudden hemodynamic deterioration, warranting immediate surgery. We report the case of a 67-year-old woman who suffered a syncopal attack resulting in shock, 3 weeks after undergoing orthopedic surgery. Preoperative radiologic imaging studies, including a lung perfusion scan, chest scan, and venography, showed a major bilateral pulmonary artery embolism (PE) originating from a leg vein. An inferior vena cava filter was inserted preoperatively during the venography. We performed an open pulmonary embolectomy without cardiopulmonary bypass by using a submammary trans-sternal bilateral thoracotomy approach. The patient recovered uneventfully and has been well for 13 months.

Indications and impact of postoperative transesophageal echocardiography in cardiac surgical patients.

Transesophageal echocardiography (TEE) has gained widespread acceptance among intensivists as a tool to facilitate decision-making in the management of critically ill patients. This observational study analyzes the indications and impact of TEE and the outcome in patients following cardiac surgery. Standardized reports containing indication, main diagnosis, and impact on patient management were completed during TEE. Intensive care unit in a university hospital. Postoperative cardiac surgery patients requiring TEE. TEE in sedated and mechanically ventilated patients. Reports were obtained in 301 adult patients between June 1996 and June 2000. Indications were postoperative control of left ventricular function in 102 (34%) cases; unexplained, sudden hemodynamic deterioration in 89 (29%); suspicion of pericardial tamponade in 41 (14%); cardiac ischemia in 26 (9%); and "other" in 43 (14%). In 136 patients (45%), a new diagnosis was established or an important pathology was excluded. Pericardial tamponade was diagnosed in 34 cases (11%) and excluded in 36 cases (12%). Other diagnoses included severe left ventricular failure, large pleural effusion, and others. Therapeutic impact was found in 220 cases (73%): change of pharmacologic treatment and/or fluid therapy in 118 cases (40%), resternotomy in 43 (14%), no reoperation necessary in 39 (13%), and various in 20 (7%). No impact was found in 81 cases (27%). In a subgroup of patients in whom preoperative risk scores were evaluated, the indication for a postoperative TEE was significantly associated with a prolonged stay in the intensive care unit: 7 (5.6, 8.4) days vs. 1 (0.8, 1.2) day (median, [95% confidence interval]) (p <.0001), more neurologic complications (18/137 = 13.1% vs. 21/680 = 3.0%) (p <.0001), and increased mortality (34/153 = 22.2% vs. 18/709 = 2.5%) (p <.0001). Corrected for preoperative risk scores, these differences were still significant. Although TEE provided important findings and therapeutic impact in postoperative cardiac surgical patients, patients with comparable preoperative risk who had postoperative TEE examinations had a significantly worse outcome than those without the need for postoperative TEE.

Acute cardiac rupture complicating pre-discharge exercise testing. A case report with complete echocardiographic follow-up

The case of a 76 year-old male who suffered acute free wall rupture and sudden hemodynamic deterioration during the recovery phase of a pre-discharge exercise testing (performed 7 days after a noncomplicated myocardial infarction) is presented. Usefulness of echocardiography in early diagnosis, management (guiding pericardiocentesis) and follow-up is remarked and, on the other hand, medical treatment after a successful resuscitation is confirmed as an alternative option in these cases.

Hantavirus infections in the United States: diagnosis and treatment.

Definitive diagnosis of acute hantavirus infection requires demonstration of specific IgG and IgM antibodies and a compatible clinical course; most persons with acute illness will also have viral RNA in PBMC which can be detected after RT-PCR amplification. Characteristic hematologic and hemodynamic findings are helpful in establishing a presumptive diagnosis of HPS in persons with cardiopulmonary symptoms and signs while awaiting the results of serologic testing and PCR. Diagnosis during the prodromal phase is difficult although very limited data suggest that most these patients also have hantavirus IgG and IgM antibodies. Patients with suspected hantavirus infection should be treated in a critical care unit, as sudden hemodynamic deterioration can occur at any time. Hemodynamic monitoring is encouraged in patients with cardiopulmonary symptoms and signs, and inotropic support and vasopressors should be used rather than fluids. An uncontrolled study of ribavirin therapy was inconclusive and a placebo-controlled trial is therefore planned. The latter study aims to enroll persons with prodromal findings and early cardiopulmonary disease.

Sudden blowout rupture of the myocardium after infarction: Urgent management: Report of four cases

Blowout rupture of the myocardium is intended to describe a syndrome of sudden hemodynamic deterioration after myocardial infarction. Characterized by abrupt hypotension, cardiac tamponade, or electromechanical dissociation, it is an emergency of the first order with no time for cardiac catheterization. Frequently one must make the diagnosis and race for the operating room almost simultaneously. We have managed four such patients, one with a ruptured false aneurysm and three patients with acute rupture of recently infarcted myocardium. All patients were placed on femoro-femoral bypass initially and all survived operation. Two patients died in the hospital of irreversible brain damage and two are long-term survivors. A high index of suspicion, a well-coordinated operating team, and a willingness to take the bold step to the operating room, frequently on the basis of clinical judgment alone, are necessary to salvage patients with this syndrome.