AMI causing cardiogenic shock in patients with severely depressed left ventricular function

Introduction

Left ventricular function is assumed to be the main predictor of cardiogenic shock (CS), however trials and registries show that in average left ventricular function is only moderately depressed in CS after acute myocardial infarction.

Purpose

Characterize population of patients (Pts) with CS after acute myocardial infarction (AMI) and with severe left ventricular dysfunction (defined as ejection fraction (EF) <30%).

Methods

From a national multicenter registry, we evaluated 729ptswith CS after AMI.We considered 2 groups: Group 1 – pts with CS and EF <30% and Group 2 – pts with CS and EF >30%. We registered age, gender, cardiovascular and non-cardiovascular comorbidities, electrocardiographic presentation, vital signs at admission, reperfusion strategy and coronary anatomy. We also evaluated in-hospital complications, such as re-infarction, mechanical complications, high-grade atrial ventricular block, sustained ventricular tachycardia (VT), atrial fibrillation (AF) and stroke. We compared in-hospital mortality and multivariate analysis was performed to assess the impact of EF in in-hospital mortality and to identify predictors of severe left ventricular function.

Results

Severe dysfunction in Cardiogenic shock due to AMI was present in 28.9% (n=211) of pts (68% male, mean age of 72±12 years old). Group 1 had higher incidence of previous heart disease, such as AMI, previous PCI and congestive heart failure (27% vs 14%, p<0.001; 17.7% vs 9.6% p=0.002 and 16% vs 10%, p=0.022, respectively). STEMI pts were 71% (n=149), and timing from symptoms until first contact was longer (185 min (90; 437) vs 123 (60; 300), p<0.001). Undetermined location AMI was more often in group 1 (8% vs 2%, p<0.001), particularly due to left or right bundle brunch block (13% vs 4.7%, p<0.001, and 15% vs 10%, p=0.041 respectively). Anterior STEMI was also more prevalent in this groups (81% vs 46%, p<0.001). No differences were observed on coronariography rate, rate or type of reperfusion nor multivessel disease. Group 1 pts presented more with left main (LM) (25% vs 12%, p<0.001) and anterior descending (AD) (9.4% vs 2.4%, p<0.001) arteries lesions (88% vs 72.4%, p<0.001) or occlusion (65.5% vs 33.7%, p<0.001). Group 1 presented more with in-hospital VT (16% vs 10.8%, p=0.048). In-hospital mortality was also higher (56.5% vs 29.5%, p<0.001). After multivariate analysis we found that severe left ventricular dysfunction was a mortality predictor (OR 3.37; 95% CI 2.05–5.54, p<0.001). LM (OR 3.41; 95% CI 1.86–6.26, p<0.001) and AD (OR 2.74; 95% CI 1.51–4.96, p=0.001) arteries disease and previous AMI (OR 2.36; 95% CI 1.28–4.37, p=0.006) were predictors of severe LV dysfunction.

Conclusions

Severely depressed EF is a predictor of in-hospital mortality. Left main and anterior descending artery disease and previous AMI were identified as predictors of an EF <30%.

Funding Acknowledgement

Type of funding sources: None.

Cardiac magnetic resonance evaluation of takotsubo cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Takotsubo Cardiomyopathy(TCM)is a reversible pathology with clinical features practically indistinguishable from AMI.Cardiac magnetic resonance(CMR)is uniquely suited in differentiating TCM from other forms of acute ventricular dysfunction.CMR can also identify potential complications.

Purpose

The aim of this study was to characterize TCM features,as well as to evaluate diagnostic and prognostic impact of CMR in these patients.

Methods

A 7-years prospective study,which included patients of our center proposed to CMR with presumptive diagnosis of MINOCA based on acute chest pain,troponin raise and absence of angiographically significant coronary disease (luminal stenosis <50%).We analysed clinical characteristics, electrocardiograms, echo and coronariography.A presumptive diagnosis was elaborated and comparison was made with the TCM definitive one after CMR.We applied a protocol to evaluate TCM patients’ left and right ventricles(LV;RV)both anatomically and functionally, and search for late gadolinium enhancement(LGE).

Results

A total of 93 patients were evaluated,of which 16 had the final diagnosis of TCM.Takotsubo-cardiomyopathy patients were all female,with a mean age of 69 ± 14years old.At admission,75% had ST segment elevation, so emergent coronariography was performed. The median highest troponin I was 2,235[1,30-4,27]ng/mL.CMR confirmed 25%(n = 4) of presumptive diagnosis of TCM. On the other 75%initial diagnosis was changed to TCM after CMR:50%(n = 6) and 17%(n = 2)of patients had an initial presumptive diagnoses of reperfunded STEMI and NSTEMI,respectively. In 33% the initial diagnosis was myocarditis.From CMR evaluation of TCM patients, left atrial dilation was found in 31%(mean indexed area 18 ± 1,5cm2/m2).A majority (81%) presented with preserved ejection fraction(EF)(mean LV EF 59 ± 10%).Regional contractility abnormalities were described in 19%,being hypokinesia in all mid and apical segments in 2 cases, and diffuse in one.LV dysfunction was present in 13%(mean LV EF 32 ± 2%) and RV"s in 2cases (mean RV EF 42%),with only one with biventricular EF depression.Mean LV end diastolic indexed volume(EDIV)was 72 ± 23mL/m2,with only 2 with LV dilation(LV EDIV 120 ± 7mL/m2),non had dilated RV.Mild pericardial effusion was found in 38%,mild mitral regurgitation in 8patients and moderate in 1.A complication was registered:LV outflow tract protomesossystolic acceleration with mild anterior leaflet prolapse,without SAM.No LV thrombus was identified.LGE was observed in 2(13%)of patients:in one it was found on the apex,on the other one the pattern was linear intramyocardial on mid segment of inferior septum.

Conclusion

CMR provides a noninvasive and multidimensional assessment for evaluation of Takotsubo cardiomyopathy.In our population,performing CMR allowed an initial diagnosis modification in 3/4 of the cases and identification of one complication,both with therapeutic and prognostic implications.

Stage I Melanoma of the Limbs. Immediate versus Delayed Node Dissection

553 patients with stage I malignant melanoma of the limbs entered a prospective randomized clinical trial carried out by the W.H.O. Collaborating Centres for Evaluation of Methods of Diagnosis and Treatment of Melanoma from September 1967 to January 1974. 286 patients were submitted to wide excision of primary and node dissection at the time as appearance of regional lymph node metastases and 267 to wide excision and immediate node dissection. Survival was identical in the 2 groups. Different subsets of patients were evaluated to assess whether some groups of patients may benefit from immediate node dissection. As regards sex, females and a significantly higher survival rate than males (p < 0.05), but results were not improved by immediate node dissection. Maximum diameter and elevation of primary melanoma were significantly related to survival but also in these cases immediate node dissection did not achieve better results. 63 patients had an excisional biopsy of their melanoma within 4 weeks before final treatment. This procedure did not worsen survival and also in this case immediate node dissection did not improve survival. 273 cases were classified according to histologic type: survival of superficial spreading and nodular melanoma was not different at a statistically significant level after the 2 treatment modalities. 325 cases were considered classifiable according to Clark's levels, out of these 165 were submitted to immediate node dissection. Neither level III nor level IV cases showed higher survival rate after immediate node dissection. Maximum tumor thickness according to Breslow was evaluated in 338 cases: 188 were submitted to wide excision and immediate node dissection. In no clusters of thickness did the enlarged surgical procedure achieve better results. The authors conclude that there is good evidence that in stage I melanoma of the extremities delayed dissection is as effective as the immediate one in the control of the disease if the patient can be kept under strict clinical control. Immediate node dissection is advisable if the quarterly follow-up is not guaranteed, at least for melanomas thicker than 2 mm.

Intraarterial chemotherapy through carotid transposition in advanced head and neck cancer

We report results of intraarterial chemotherapy (IAC) in patients with advanced unresectable (T4, N0-3, MO) squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) of the oral cavity, oropharynx, or facial skin, given through a subcutaneously transposed external carotid artery by a fine gauge needle. Forty patients entered the study and 39 were evaluable for clinical response and toxicity. The infusion technique was done in two consecutive series of patients with the same characteristics: 17 had treatment with vincristine, bleomycin, and methotrexate (VBM), and 22 received cisplatin and bleomycin (PB) with a median number of six and five cycles, respectively. The total objective response (OR) rate was 76.9%, which included 12.8% of complete response (CR). A better percentage of OR was attained in BCC than SCC (83.3% versus 75.8%), in tumors of the skin of the face than other sites (87.5% versus 74.2%), and in the group that received PB than the group that received VBM (77.3% versus 76.5%). Our series had an overall technique-related toxicity of 18%; 10.3% with neurologic disturbances and 7.7% with skin inflammation (almost all were reversible). The most common systemic toxic side effects were generally mild and well tolerated (30.8%), whereas major toxicities (severe modifications of the cardiopulmonary function) occurred in four patients (10.3%) in the group that received VBM. After chemotherapy, 28 patients (71.8%) were deemed resectable; 23 of these patients (82.1%) agreed to surgery. Pathologic CR were obtained in 13 patients (56.5%). Our technique has significant advantages over the conventional methods of infusion, because tumor perfusion is feasible and selective, technique-related and catheter-related complications are almost completely eliminated, and fatal drug-related side effects are avoided.

Delayed regional lymph node dissection in stage I melanoma of the skin of the lower extremities

Results of a prospective randomized clinical trial conducted by the WHO Collaborating Centers for the Evaluation of Methods of Diagnosis and Treatment of Melanoma are reported. Five-hundred-fifty-three Stage I patients whose limbs were affected entered the study; 267 were submitted to wide excision and immediate node dissection and 286 had wide excision and node dissection at the time clinically positive nodes were detected. Survival curves of the two treatment groups could be superimposed. No subsets of patients benefitted from immediate node dissection. The authors conclude that delayed node dissection is as effective as the immediate dissection in Stage I melanoma of the extremities if the patient can be checked every three months. If the quarterly follow-up is not guaranteed, immediate node dissection is advisable, at least for melanomas thicker than 2 mm.

Inefficacy of immediate node dissection in stage 1 melanoma of the limbs

From September, 1967, to January, 1974, a clinical trial was carried out by the WHO Melanoma Group to evaluate the efficacy of elective lymph-node dissection in the treatment of malignant melanoma of the extremities with clinically uninvolved regional lymph nodes. Treatment was prospectively randomized: 267 patients to excision of primary melanoma and immediate regional-lymph-node dissection and 286 to excision of primary melanoma and regional-lymph-node dissection at the time of appearance of metastases. The statistical analysis showed no difference in survival between the two groups of patients, regardless of how the data were analyzed (according to sex, site of origin, maximum diameter of primary tumor or Clark's level or Breslow's thickness). Elective lymph-node dissection in malignant malanoma of the limbs does not improve the prognosis and is not recommended when patients can be followed at intervals of three months.