Syndrome of Reversible Cardiogenic Shock and Left Ventricular Ballooning in Obstructive Hypertrophic Cardiomyopathy

Background Cardiogenic shock from most causes has unfavorable prognosis. Hypertrophic cardiomyopathy (HCM) can uncommonly present with apical ballooning and shock in association with sudden development of severe and unrelenting left ventricular (LV) outflow obstruction. Typical HCM phenotypic features of mild septal thickening, outflow gradients, and distinctive mitral abnormalities differentiate these patients from others with Takotsubo syndrome, who have normal mitral valves and no outflow obstruction. Methods and Results We analyzed 8 patients from our 4 HCM centers with obstructive HCM and abrupt presentation of cardiogenic shock with LV ballooning, and 6 cases reported in literature. Of 14 patients, 10 (71%) were women, aged 66±9 years, presenting with acute symptoms: LV ballooning; depressed ejection fraction (25±5%); refractory systemic hypotension; marked LV outflow tract obstruction (peak gradient, 94±28 mm Hg); and elevated troponin, but absence of atherosclerotic coronary disease. Shock was managed with intravenous administration of phenylephrine (n=6), norepinephrine (n=6), β‐blocker (n=7), and vasopressin (n=1). Mechanical circulatory support was required in 8, including intra‐aortic balloon pump (n=4), venoarterial extracorporeal membrane oxygenation (n=3), and Impella and Tandem Heart in 1 each. In refractory shock, urgent relief of obstruction by myectomy was performed in 5, and alcohol ablation in 1. All patients survived their critical illness, with full recovery of systolic function. Conclusions When cardiogenic shock and LV ballooning occur in obstructive HCM, they are marked by distinctive anatomic and physiologic features. Relief of obstruction with targeted pharmacotherapy, mechanical circulatory support, and myectomy, when necessary for refractory shock, may lead to survival and normalization of systolic function.

Agreements between mean arterial pressure from radial and femoral artery measurements in refractory shock patients

Radial and femoral artery catheterization is the most common procedure for monitoring patients with shock. However, a disagreement in mean arterial pressure (MAP) between the two sites has been reported. Hence, the aim of this study was to compare the MAP from the radial artery (MAPradial) with that of the femoral artery (MAPfemoral) in patients with refractory shock. A prospective study was conducted in the medical intensive care unit. The radial and femoral were simultaneously measured MAP in the patients every hour, for 24 hours. In total, 706 paired data points were obtained from 32 patients. MAPradial strongly correlated with MAPfemoral (r = 0.89, p <0.0001). However, overall MAPradial was significantly lower than MAPfemoral 7.6 mmHg. The bias between MAPradial and MAPfemoral was -7.6 mmHg (95% limits of agreement (LOA), -24.1 to 8.9). In the subgroup of patients with MAPradial < 65 mmHg, MAPradial moderately correlated with MAPfemoral (r = 0.63) and the bias was increased to -13.0 mmHg (95% LOA, -28.8 to 2.9). There were 414 (58.6%) measurements in which the MAP gradient between the two sites was > 5 mmHg. In conclusion, the radial artery significantly underestimated MAP compared with the femoral artery in patients with refractory shock.

Blocking vicious cycle of cardiac dysfunction by external cardiopulmonary resuscitation is the key to rescue acute aluminium phosphide poisoning

Aluminium phosphide (ALP) and aluminium zinc phosphide (ZnP), the two main ingredients of fumigation drugs, are commonly used to kill insects or rodents in grain. When exposed to water, highly toxic phosphine gas is released and absorbed through the respiratory or digestive tract. Phosphine gas could non-selectively block cytochrome oxidase, inhibit electron transfer and suppress oxidative phosphorylation, leading to cellular hypoxia and organ dysfunction. The characteristic clinical manifestations are refractory shock and metabolic acidosis with high mortality. However, patients with ALP poisoning have a chance to be cured. Here, we report a case of oral ALP poisoning that was successfully treated by extracorporeal membrane oxygenation (ECMO) combined with continuous renal replacement therapy (CRRT) during frequent ventricular fibrillation and cardiac dysfunction.

Acoustic Pulse Thrombolysis Complemented by ECMO Improved Survival in Patients with High-Risk Pulmonary Embolism

Background: The optimal treatment of high-risk PE with cardiac arrest is still controversial although various treatment approaches have been developed and improved. Here, we present a serie of patients with high-risk PE showing hemodynamic collapse, who were successfully treated with extracorporeal membrane oxygenation (ECMO) as an adjunct to EKOS™ acoustic pulse thrombolysis. Method: From April 2016 to June 2020, 29 patients with high-risk PE with cardiac arrest were retrospectively included. The mean age was 55.3 ± 9.2 years. Twelve (41.3%) patients were female. All patients had cardiac arrest, either as an initial presentation or in-hospital after the presentation. All patients exhibited acute symptoms, computed tomography (CT) evidence of large thrombus burden, and severe right ventricular dysfunction. Primary outcome was all-cause 30-day mortality. Results: Twenty-two patients survived to hospital discharge, with a mean ICU stay of 9.9 ± 1.6 days (range, 7 to 22 days) and mean length of hospital stay of 23.7 ± 8.5 days (range, 11 to 44 days). Six patients died from refractory shock. Ninety-day mortality was 24.1% (7/29). The Mean ECMO duration was 3.5 ± 1.1 days and the mean RV/LV ratio decreased from 1.31 ± 0.17 to 0.92 ± 0.11 in patients who survived to discharge. The mean tissue plasminogen activator (tPA) dose for survivor patients was 20.5 ± 1.6 mg. Conclusion: Patients with high-risk pulmonary embolism who suffer a cardiac arrest have high morbidity and mortality. APT complemented by ECMO could be a successful treatment option for patients who have high-risk PE with circulatory collapse.

Hypothyroxinaemia in refractory shock: a clue to diagnose hypopituitarism

The rarity of congenital hypopituitarism (CHP) makes it essential for clinicians to be aware of its varying clinical manifestations. We report a neonate with one such unique presentation. A preterm girl baby was managed for respiratory distress. Diffuse cutis marmorata was present since birth; septic screens were positive with placental histopathology showing chorioamnionitis. Newborn screening showed low free thyroxine and normal TSH. Transient hypothyroxinaemia of prematurity was considered. Her respiratory status worsened on day 9, followed by refractory shock. She was treated for sepsis. Further evaluation for absent heart rate variability in response to vasopressor resistant shock led to the detection of hypocortisolism. Low cortisol along with hypothyroxinaemia made hypopituitarism the working diagnosis. Owing to the variable clinical spectrum of CHP, diagnosis is challenging. We highlight a few clinical and laboratory features, which would help in earlier diagnosis of CHP.

Refractory Septic Shock (Part 2)

Refractory shock is the shock that does not respond to vasopressor therapy. Refractory shock with a short-term mortality rate of more than 50% is diagnosed in 6-7% of critically ill patients. There is an objective need to Investigate methods of intensive therapy for refractory septic shock.The objective of the study: to analyze literature data on the intensive care of refractory septic shock.Results. The second part of the article analyzes 37 studies, both Russian and foreign ones devoted to the intensive care of refractory shock. At present, based on the analysis of the publication, it is impossible to draw reasonable conclusions about the advantage of one or another method of intensive therapy for refractory shock (veno-venous hemofiltration, the use of angiotensin II and vasopressin, as well as methylene blue, vitamin B12, ECMO) over basic therapy.