Timely Use of Venous-Arterial ECMO to Treat Congenital Pediatric Junctional Ectopic Tachycardia: A Case Report

Supraventricular tachycardia is the most common tachyarrhythmia in pediatrics. Although postoperative junctional ectopic tachycardia (JET) is a known complication of congenital heart surgery that is typically transient, congenital JET is rare and requires aggressive treatment to maintain hemodynamic stability. We describe the case of a 3-month-old, previously healthy female who presented with heart failure and cardiogenic shock secondary to congenital JET for whom extracorporeal membrane oxygenation (ECMO) provided time for selection of effective therapy. Adenosine, cardioversion, and transesophageal pacing were unsuccessful, and her echocardiogram demonstrated bilateral atrial dilation and severe left ventricular systolic dysfunction. Approximately 8 hours after presentation, venous-arterial ECMO was commenced allowing for successful treatment with amiodarone. Her electrocardiogram demonstrated atrioventricular dissociation consistent with JET. She was successfully decannulated from ECMO after 6 days. Her discharge echocardiogram showed normal ventricular function, and she had no significant ECMO sequelae. This case demonstrates the value of early ECMO initiation for cardiovascular support in pediatric patients with a life-threatening arrhythmia and in cardiogenic shock. ECMO support can allow for full diagnostic and therapeutic decisions to effectively reverse the consequences of uncontrolled arrhythmias unrelated to surgical complications.

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A life-threatening reverse Takotsubo syndrome in a young breastfeeding woman: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab359 ◽

2021 ◽

Author(s):

Carla Marques Pires ◽

Sérgia Rocha ◽

Nuno Salomé ◽

Pedro Azevedo

Keyword(s):

Cardiogenic Shock ◽

Systolic Dysfunction ◽

Left Ventricular ◽

Takotsubo Syndrome ◽

Presumptive Diagnosis ◽

Lv Dysfunction ◽

St Segment ◽

Life Threatening ◽

Triggering Factor ◽

Β Blocker

Abstract Background Takotsubo syndrome (TTS) is characterized by transient left ventricular (LV) dysfunction and is usually triggered by emotional, physical or combined stress. This syndrome has been increasingly recognized, although it remains a challenging and often misdiagnosed disorder. Case Summary A 36-year-old breastfeeding woman was admitted with sudden dyspnoea and oppressive chest pain. On admission she was lethargic, hypotensive and tachycardic. The electrocardiogram showed rapid atrial fibrillation and diffuse ST-segment depression. The transthoracic echocardiogram (TTE) revealed severe LV systolic dysfunction, with midventricular and basal akinesis, compensatory apical hyperkinesia and without intraventricular gradient. Emergent coronary angiogram showed normal coronary arteries. A presumptive diagnosis of reverse TTS with cardiogenic shock was made. The patient was transferred to the Intensive Care Unit after intubation and inotropic and vasopressor support was initiated. During hospitalization, rapid clinical improvement was observed. In three days, the patient was weaned from hemodynamic support and extubated. Furthermore, β-blocker and angiotensin receptor blocker were initiated and tolerated. Cabergoline was also administered to inhibit lactation. The presumptive diagnosis was further strengthened by cardiac magnetic resonance and all triggering factors were excluded. At hospital discharge she was asymptomatic and the follow-up TTE was normal, which confirmed the diagnosis of reverse TTS. DISCUSSION We present a case of a young woman, eight months after delivery, which developed a life-threatening reverse TTS without triggering factor identified. Reverse TTS is a rare variant of TTS with different clinical features and is more likely to be complicated by pulmonary edema and cardiogenic shock.

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P1715Management and outcome in patients with non-ischemic cardiogenic shock and Impella CP use

European Heart Journal ◽

10.1093/eurheartj/ehz748.0470 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

O Maniuc ◽

T Salinger ◽

F Anders ◽

J Muentze ◽

D Liu ◽

...

Keyword(s):

Cardiogenic Shock ◽

Left Ventricular Systolic Dysfunction ◽

Systolic Dysfunction ◽

Hemodynamic Instability ◽

Serum Lactate ◽

Left Ventricular ◽

Categorical Variables ◽

Acute Ischemia ◽

Continuous Variables ◽

Significant Difference

Abstract Background and purpose From the various mechanical cardiac assist devices and indications available, use of the percutaneous intraventricular Impella CP pump is usually restricted to acute ischemic shock or prophylactic indications in high-risk interventions. In the present study, we investigated clinical usefulness of the Impella CP device in patients with non-ischemic cardiogenic shock as compared to acute ischemia. Methods In this retrospective single-center analysis, patients who received an Impella CP between 2013 and 2017 due to non-ischemic cardiogenic shock were age-matched 2:1 with patients receiving the device due to ischemic cardiogenic shock. Inclusion criteria were therapy refractory hemodynamic instability with severe left ventricular systolic dysfunction and serum lactate >2.0 mmol/l at implantation. Basic clinical data, indications for mechanical ventricular support, and outcome were obtained in all patients with non-ischemic as well as ischemic shock and compared between both groups. Continuous variables are expressed as mean ± standard deviation or median (quartiles). Categorical variables are presented as count and percent. Results 25 patients had cardiogenic shock due to non-ischemic reasons, and were compared to 50 patients with cardiogenic shock due to acute myocardial infarction. Resuscitation rates before implantation of Impella CP were high (32 vs 42%; P=0.402). At implantation, patients with non-ischemic cardiogenic shock had lower levels of HsTNT (110.65 [57.87–322.1] vs 1610 [450.8–3861.5] pg/ml; P=0.001) and LDH (377 [279–608] vs 616 [371.3–1109] U/I; P=0.007), while age (59±16 vs 61.7±11; P=0.401), GFR (43.5 [33.2–59.7] vs 48 [35.75–69] ml/min; P=0.290), CRP (5.17 [3.27–10.26] vs 10.97 [3.23–17.2] mg/dl; P=0.195), catecholamine-index (30.6 [10.6–116.9] vs 47.6 [11.7–90] μg/kg/min; P=0.663), and serum lactate (2.6 [2.2–5.8] vs 2.9 [1.3–6.6] mg/dl; P=0.424) were comparable between both groups. There was a trend for longer duration of Impella support in the non-ischemic groups (5 [2–7.5] vs 3 [2–5.25] days, P=0.211). Rates of hemodialysis (52 vs 47%; P=0.680) and transition to ECMO (13.6 vs 22.2%; P=0.521) were comparable. No significant difference was found regarding both 30-days survival (48 vs 30%; P=0.126, Figure 1) as well in-hospital mortality (66.7 vs 74%; P=0.512) although there was a trend for better survival in the non-ischemic group. 30-days survival Conclusions The current results position short-time use of the Impella CP as an alternative in the treatment of patients with cardiogenic shock due to underlying non-ischemic cardiomyopathy and/or complicating additional factors. However, additional studies are needed to test whether these findings can be confirmed in larger patient populations and which subgroups might benefit most from Impella therapy.

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Cardiogenic Shock during First Infusion of Anthracycline Chemotherapy in a Patient with Hodgkin Lymphoma: An Unusual Event

Cardiology ◽

10.1159/000480291 ◽

2017 ◽

Vol 139 (1) ◽

pp. 7-10 ◽

Cited By ~ 1

Author(s):

Giulio Binaghi ◽

Damiana Congia ◽

Stefano Cossa ◽

Stefania Massidda ◽

Daniele Pasqualucci ◽

...

Keyword(s):

Cardiogenic Shock ◽

Hodgkin Lymphoma ◽

Progressive Disease ◽

Left Ventricular Systolic Dysfunction ◽

Systolic Dysfunction ◽

Rare Event ◽

Left Ventricular ◽

Anthracycline Cardiotoxicity ◽

Unusual Event ◽

Anthracycline Chemotherapy

Introduction: Hodgkin lymphoma (HL) is one of the most common types of cancers of the lymphatic system. The currently available therapies enable a cure in approximately 80-85% of treated patients. However, the cardiotoxicity of HL treatment has become a major cause of morbidity and mortality in survivors mainly related to the use of anthracycline. Case Report: An HL, staged IIIB, was diagnosed in a 60-year-old man with no cardiovascular disease. During the first cycle of ABVD chemotherapy (Adriamycin; bleomycin; vinblastine; dacarbazine), near the end of the dacarbazine infusion, the patient presented a sudden cardiogenic shock characterized by a severe left ventricular systolic dysfunction. Laboratory and instrumental examinations performed did not suggest any specific etiology. After 15 days of medical support, the patient presented a complete cardiac function and clinical recovery. Subsequently bendamustine chemotherapy was started because of its limited extrahematological toxicity, but after 4 cycles the patient had progressive disease and died of septic shock. We concluded that a very rare hyperacute anthracycline cardiotoxicity was the most likely reason for this critical scenario. Conclusions: This rare event stresses our inability to correctly predict the risk of a patient developing cardiotoxicity and also highlights the need to improve the knowledge of underlying pathophysiological mechanisms; in fact, it suggests a possible genetic predisposition to develop cardiotoxicity due to a relatively limited dosage.

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Diagnosis and assessment of dilated cardiomyopathy: a guideline protocol from the British Society of Echocardiography

Echo Research and Practice ◽

10.1530/erp-16-0037 ◽

2017 ◽

Vol 4 (2) ◽

pp. G1-G13 ◽

Cited By ~ 16

Author(s):

Thomas Mathew ◽

Lynne Williams ◽

Govardhan Navaratnam ◽

Bushra Rana ◽

Richard Wheeler ◽

...

Keyword(s):

Dilated Cardiomyopathy ◽

Left Ventricular Systolic Dysfunction ◽

Systolic Dysfunction ◽

Left Ventricular ◽

British Society ◽

Threatening Condition ◽

Life Threatening ◽

Valve Function ◽

Artery Disease ◽

Systolic And Diastolic Function

Heart failure (HF) is a debilitating and life-threatening condition, with 5-year survival rate lower than breast or prostate cancer. It is the leading cause of hospital admission in over 65s, and these admissions are projected to rise by more than 50% over the next 25 years. Transthoracic echocardiography (TTE) is the first-line step in diagnosis in acute and chronic HF and provides immediate information on chamber volumes, ventricular systolic and diastolic function, wall thickness, valve function and the presence of pericardial effusion, while contributing to information on aetiology. Dilated cardiomyopathy (DCM) is the third most common cause of HF and is the most common cardiomyopathy. It is defined by the presence of left ventricular dilatation and left ventricular systolic dysfunction in the absence of abnormal loading conditions (hypertension and valve disease) or coronary artery disease sufficient to cause global systolic impairment. This document provides a practical approach to diagnosis and assessment of dilated cardiomyopathy that is aimed at the practising sonographer.

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The role of cardiac magnetic resonance for arrhythmic risk stratification in a patient with myocarditis

Journal of Clinical Images and Medical Case Reports ◽

10.52768/2766-7820/1008 ◽

2021 ◽

Author(s):

Giuseppe Fede ◽

◽

Giuseppe Abate ◽

Giovanni Tasca ◽

Nicoletta Guccione ◽

...

Keyword(s):

Cardiac Magnetic Resonance ◽

Magnetic Resonance ◽

Risk Stratification ◽

Left Ventricular Systolic Dysfunction ◽

Systolic Dysfunction ◽

Left Ventricular ◽

Myocardial Scar ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Life Threatening

Myocarditis is an inflammatory disease of cardiac muscle with a variable clinical presentation, ranging from asymptomatic cases to different degrees of left ventricular systolic dysfunction up to heart failure and dilated heart disease. Ventricular arrhythmias (VA) can occur in patients with myocarditis and implantable cardioverter defibrillator (ICD) may be indicated in patients with life-threatening VA who are not in the acute phase of myocarditis and who are receiving optimal medical therapy. Reduced left ventricular ejection fraction (LVEF) below 35%, which is used as the main criterion for stratifying the risk of sudden cardiac death (SCD), has low sensitivity and low specificity for arrhythmic risk stratification in patients with myocarditis. Myocardial scar is the main determinant for VA in these patients. Cardiac magnetic resonance imaging (CMR), using late gadolinium enhancement(LGE), has an excellent ability to determinate the extension and characterization of myocardial scar, indeed CMR can potentially improve SCD risk stratification and indication for ICD implantation in patients with myocarditis. We present a case of a 36 years-old male presenting to the Emergency Department with a monomorphic sustained ventricular tachycardia in whom MRI revealed myocardial-pericardial recurrent inflammatory involvement and worsening disease progression. ICD was implanted in consideration of the high risk of life-threatening arrhythmias.

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Relationship between Haemoglobin A1c and Short Term Outcome in Patients with ST-elevation Myocardial Infraction (STEMI)

Bangladesh Heart Journal ◽

10.3329/bhj.v30i1.28134 ◽

2016 ◽

Vol 30 (1) ◽

pp. 29-32

Author(s):

SM Kamrul Hasan ◽

Md Rezaul Karim ◽

Md Anisur Rahman Khan ◽

Tareq Ahmed Chowdhury ◽

Khondokar Asaduzzam ◽

...

Keyword(s):

Heart Failure ◽

Cardiac Arrest ◽

Cardiogenic Shock ◽

Hospital Stay ◽

Left Ventricular Systolic Dysfunction ◽

Systolic Dysfunction ◽

Left Ventricular ◽

Haemoglobin A1c ◽

Mechanical Complication ◽

Myocardial Infraction

Introduction: Every year, 17.1 million lives are claimed by the global burden of cardiovascular disease (CVD), 82% of which are in the developing world. Glycated hemoglobin (HbA1c), even at levels considered in the normal range, emerged as an independently significant predictor of heart-disease events, stroke, and death over more than a decade.Methodology: After applying the inclusion and exclusion criteria, 113 patients with ST segment elevation myocardial infarction were enrolled in this study after taking informed written consent from the patient or attending guardian. Follow up was done during hospital stay for mortality, arrhythmia, cardiogenic shock, cardiac arrest, congestive heart failure, mechanical complication (eg ventricular septum rupture, wall rupture), left ventricular systolic dysfunction, stroke etc.Result: The median age of patients was 53.4 years (range 22 to 85 years), patients with an HbA1c >6.5% were slightly older than those with HbA1c <6.5%(53.1 vs. 54.6),and 82% were male; and 43% had an HbA1c >6.5%. Patients with elevated HbA1c had more LVSD (54%) (p=0.022), heart failure (81%) (p= < .001). However, patients with HbA1c >6.5% were more likely to have cardiogenic shock as an outcome but it is not statistically significant (p= .528), whereas cardiac arrest, arrythmia and mechanical complication were more among HbA1c <6.5 group but it was not statistically significant. During hospital stay 16 (14%) patients died. Mortality was much higher among all STEMI patients, those with elevated hemoglobin A1c level as an outcome compared to patients with normal haemoglobin A1c level (26% vs. 5%) (p= .002).Conclusion : STEMI patients who has haemoglobin HbA1c level < 6.5 have better in hospital outcome compared to elevated (>6.5) haemoglobin A1c level.Bangladesh Heart Journal 2015; 30(1) : 29-32

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