Egyptian Journal of Critical Care Medicine最新文献

High-risk percutaneous coronary intervention (PCI) remains a viable revascularization strategy for complex coronary arteries diseases. Selective PCI supported by extracorporeal membrane oxygenation (ECMO) is also a viable alternative for patients those are at very high risk for coronary artery bypass grafting (CABG). Extracorporeal membrane oxygenation (ECMO) can direct blood flow from the body to membrane oxygenator then return it back to the body. Thus completely/partially replacing the function of the heart and lungs to increasing the likelihood of functional recovery. We will present a case of refractory CPR post STMI rescued by ECPR with revascularization of three coronary vessels after percutaneous coronary intervention (PCI) under mechanical support of extracorporeal membrane oxygenation (ECMO) after exclusion of surgical choice due to patient risk condition. We think that in selected group of highly critical cases PCI with MCS could replace the need of major surgical intervention like CABG.

Background

The effect of revascularization by PCI for acute coronary syndrome (ACS) on the severity of ischemic mitral regurge (IMR) is still unclear.

Objective

To evaluate the effect of successful total revascularization by PCI for ACS on the degree of IMR.

Methods

A total of 240 patients presenting with ACS for the first time were studied by this an open-label, multicenter, prospective clinical trial between July 2015 to February 2017. All patients were subjected for clinical assessment, transthoracic echocardiographic assessment and coronary angiography. The patients divided into two groups: group A; those who had undergone successful total revascularization of a significant coronary artery disease using PCI, and group B; those who had optimal medical treatment with no total revascularization, failed PCI or for CABG. Group A patients subdivided into subgroup I, patients with improvement of the IMR; and subgroup II, patients with no improvement of IMR.

Results

Only 65% of the patients showed IMR and 149 of them underwent successful complete revascularization by PCI; 68% of them showed IMR improvement and 32% showed no improvement. There was a significant improvement of the IMR degree after total revascularization by PCI. Moreover, this improvement was significant in subgroup I (p < 0.001). Percutaneous coronary intervention, EF and SWMI were significant predictors of IMR improvement following successful complete revascularization.

Conclusion

Successful total revascularization by early PCI improve IMR degree.

It is an extremely rare to find an Acute ST Elevation Myocardial Infarction after the chest trauma. My case was complicated advent of the chest trauma. Acute myocardial infarction had happened post sever punch to front of the chest. The case was presented with atypical symptoms like syncope, dizziness and burning pain in the chest.

Background

Since description of continuous renal replacement therapy (CRRT), these therapies provided improvement in hemodynamic parameters while reducing need for vasopressors in shock. Our aim is to determine whether hemodynamic improvement after 24 h of CRRT is a strong predictor of short term survival.

Methods

In a prospective observational study we enrolled 30 patients admitted to the intensive care unit (ICU)with acute kidney injury (AKI)and hemodynamic instability. AKI defined according to KDIGO criteria. All patients were subjected to continuous renal replacement therapy (CRRT). Based on the hemodynamic response 24 h after CRRT, patients were classified into responders (defined as having a 20% reduction in norepinephrine dosage or a 20% rise in MAP with no increase in norepinephrine), compared with nonresponders . All patients were followed up for 15 days after withdrawal of CRRT. Results of the 30 patients studied, 12 (40%) were responders and 18 (60%) were nonresponders. Responders showed higher mean arterial pressure and urine output during CRRT. SOFA score tended to increase significantly in nonresponders on day 3 (SOFA3) and day 4 (SOFA4) compared to nonresponders (P = 0.01, P = 0.001; respectively). During a 15 days follow-up period, the mortality rate among non responders was 100%, compared to 25% among responders (18 versus 3; P = 0.001).

Conclusion

Early hemodynamic improvement after CRRT is strong predictor of short term mortality. Of all scoring systems , post CRRT SOFA score is the most accurate prognostic indicator for mortality.

Biventricular resynchronization therapy is recommended for patients presenting with left ventricular (LV) dysfunction and ventricular dyssynchrony. Implantation of a left ventricular (LV) lead fails in 5%–10% of patients in whom cardiac resynchronization therapy (CRT) is attempted. Conventional approach is not feasible due to anatomic abnormalities in coronary sinus (CS) and its branches or due to high pacing thresholds or phrenic nerve stimulation. We present a case of a 62 year old male in which, LV lead implantation through CS was failed and LV lead implantation was done via transseptal approach. We described that LV endocardial pacing is an alternative to CS pacing and needs a long-term follow up.

As there are no large scale Egyptian surveys estimating the prevalence of cardiac disease and the incidence of SCD in a non-selected population, the purpose of this report was to assess the relation between family history of SCD and the presence of CAD or coronary risk factors in first degree relatives of SCD victims searching for potential victims.

A questionnaire screening CAD risk factors and cardiac problems as indicators for SCD was developed, Data were collected from 8786 candidates by means of a questionnaire only protocol (random samples (8117)) and questionnaire plus clinical examination, ECG and laboratory investigations during medical convoys (random samples (669)). Data were coded and verified according to presence and absence of CAD risk factors, IHD and other risk factors in order that a triage could be performed in the general population to detect adults at risk of SCD.

Family history of CAD, DM and HTN head the list of risk factors more frequently associated with family history of SCD clearly pointing the role played by those comorbidities in pointing to potential victims of SCD.

Compared to those with no family history of SCD, those with positive family history of SCD were 8.7 times more associated with family history of DM, 12 times more associated with family history of CAD, 7 times more associated with family history of HTN.

This study underscores the importance of searching for positive family history of sudden cardiac death as a warning marker a red flag that makes familial evaluation strongly recommended.

Quadrigeminy means a cardiac arrhythmia in which every fourth beat is a premature ventricular contraction (extrasystole) or three sinus beats between extrasystoles. Premature ventricular contractions is one of the manifestations of sympathetic over activity due to anxiety. However, anxiety might induce electrocardiographic (ECG) changes in normal person with normal heart, as in this documented case. Patient re-assurance is a therapeutic option, without need for any other pharmacological interventions.

The landscape of the CCU today, however, has changed vastly from that of the 1960s. It is no longer simply an observation unit for patients with acute MI, but rather it has become a dynamic and diverse arena of patient care. Dedicated CCU's that were developed in the 1960's have been transformed into combined units including CCU and ICU or CCU and cardiology ward with very few dedicated CCUs remaining.

The CCU has changed dramatically since its initial inception, and with it has changed the required skill set of the CCU cardiologist. It is no longer acceptable to assume that all cardiologists trained in acute cardiac care can also manage the critically ill cardiac patient. Similarly critical care medicine extended its scope to handle critically ill multi organ failure patients including emergency interventions.

As a result, now more than ever before, the distinctions between our CCUs and traditional medical ICUs have become increasingly blurred. The cardiologist is being called on to care, at the onset, for patients with multiple critical care issues.

Therefore CCU cardiologists must now be trained in the management of acute lung injury, prolonged ventilation/weaning, delirium, renal replacement therapy, gastrointestinal hemorrhage, ICU polyneuropathy, and septic shock, etc. which are skills mastered by ICU specialists.

Given the remarkable diversity of critically ill patient now seen in our CCUs, we should anticipate an imminent challenge to the general cardiologists that currently staff these units and call for dedicated intensivists to assume care for these complex patients.