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Clinical Case: Hemodynamic apocalypses!



chacon-lozsan-francisco.jpg

 Dr. Chacón-Lozsán Francisco - ACCA Young National Ambassador
Critical Care Medicine - Acute Cardiac Care
Universidad Central de Venezuela
Medical Director CICU AngiOs Cardiovascular Center

Considerations before start…

  • Hospital based in low income country
  • NO Hemodynamic Lab
  • No MRI
  • No X-Rays
  • No advanced hemodynamic monitors
  • Limited drugs
  • Limited Lab

ICU Admission

Jan 2017

Patient: Female, 33yo.

ICU Admission cause: Post mitral valve replacement after rheumatic severe double mitral injury (severe stenosis, severe insufficiency).

Medical Record:

  • None.
  • No coronary lesions previous surgery.

Physical examination:

  • Hemodynamic stable.
  • Residual sedation.
  • Mechanical ventilated.
  • Normal blood drain in chest tubes.
  • Normal labs results.
  • Normal ECG.

Looks like a normal C-ICU day…

After 3hrs…

Hemodynamics

  • HR: 50dpm.
  • BP: 80/48(59)mmHg.
  • PP 32mmHg.
  • CI: 1,8L/min/m2.
  • SVRi 2335dynes/sec/m3.
  • PPV 26%.

Gases

Metabolic acidosis with anion gap and pH 7,3.

 ECG

 Sinus rhythm with T wave inversion V1-V6, non-Q or J point changes.

Example from the e-journal of the ESC Council for Cardiology Practice Vol. 13, N° 7 - 01 Dec 2014

What’s next?

What will you do?

 what's next.png

 

 

 

 

 

 

  

What we did?

Management

  • Crystalloid fluid therapy was given guided by PPV.
  • Blood test were taken included cardiac biomarkers.
  • TTE.
  • No PCI Lab in the institution.

Results

Blood test

Test Hb CK CKMB TnI
Result 9,5 1140 62 4

ETT

  • Reduced contractility in various segments of the LV hyperkinetic basal segments and EF 26%.
  • Not pericardial effusion.
  • Valve is working good.

After fluid treatment

Hemodynamics

  • HR: 60dpm.
  • BP: 88/59(69)mmHg.
  • PP 29mmHg.
  • CI: 1,7L/min/m2.
  • SVRi 2983dynes/sec/m3.
  • PPV 12%.

Gases

Metabolic acidosis with anion gap with pH 7,36.

What we have:

what we have.png

  • Low CI.
  • Low EF.
  • Stunning LV.
  • Low ACS probability.
  • Normal Hb.
  • No Bleeding.
  • Normal valve function.

Get into the guidelines

cardiogenic-septic-shock.jpgACCA Scientific poster on Definitions and Treatment - Cardiogenic and Septic Shock

What we did?

Management

  • Dobutamine infusion was started (No Levosimendan in the Hospital).
  • TTE close monitoring.
  • Continuous hemodynamic monitoring.
  • Serial blood laboratory and gases.

Control US

What’s this shape?

  • Improved EF to 40%.
  • Apical hypokinemia, basal hyperkinemia.
  • Valve working good, no pericardial effusion

Echo 1 Control US.png

Echo 2 Control US.png 

 And during the US control 

Atrial fibrillation with rapid ventricular response in shock patient

What will you do?

Atrial fibrillation with rapid ventricular response in shock patient.png

  

Get into the guidelines 

Direct current cardioversion of AF

Management

  • Cardioversion was performed.
  • Sinus rhythm obtained but still low EF and same contractility problem.
  • Probable Catecholamine induced arrhythmia in a patient with stunned ventricle, low EF with ballooning shape in LV.
  • No coronary disease and Cardiac biomarkers going down.
  • No signs of infection, biomarkers negative.
  • Patient’s family found Levosimendan in private clinic and was started.

 

CK CKMB TnI
1140 62 4
876 39 2,65
587 24 2,08

management cardioversion.png

Get into the guidelines 

Criteria Clinical Observation
Clinical Presentation Hypotension ans Shock
Bloodwork Moderate elevation of cardiac biomarkers
ECG changes T wave inversion
Echocardiography TRANSIENT LV ballooning shape. Hypokinesis
Coronary angiography Not available, health coronary arteries previous
SIgns of myocarditis None

 

Tako -tsubo 2.png

Additional information

Patient’s TEFR was 11,1 at the moment of decompensation.

"TEFR value <60 low probability of MI"

ROC curve of TEFR value ≤ 60 is the cut-off to discriminate between TC and AMI with a sensitivity of 96,23% and a specificity of 84,91%; AUC 0.97 (95% confidence internal [CI] 0.914-0.993)

 

Management of takotsubo syndrome - European Heart Journal, Volume 39, Issue 22, 07 June 2018

 

“(2) In patients with life-threatening acute HF, before coronary angiography becomes possible,   echocardiography including also STE can identify a highly probable acute phase of TTS and in such patients, if absolutely necessary, any administration of catecholamines should be continuously monitored by echocardiography and immediately stopped if the signs for TTS become more evident

 

Avoid Inotropes as :

  • Adrenaline
  • Noradrenaline
  • Dobutamine
  • Milrinone
  • Isoprotenerol

Timeline

timeline.png

At the end… Full recovery…

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