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Curso de Atualização em Medicina Cardiovascular 2019
Reunião Anual Conjunta dos Grupos de Estudo de Cirurgia Cardíaca, Doenças Valvulares e Ecocardiografia da SPC
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A. Basics
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01. History of Cardiology
02. Clinical Skills
03. Imaging
04. Arrhythmias, General
05. Atrial Fibrillation
06. Supraventricular Tachycardia (non-AF)
07. Syncope and Bradycardia
08. Ventricular Arrhythmias and Sudden Cardiac Death (SCD)
09. Device Therapy
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21. Pulmonary Circulation, Pulmonary Embolism, Right Heart Failure
22. Aortic Disease
23. Peripheral Vascular and Cerebrovascular Disease
24. Stroke
25. Interventional Cardiology
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28. Risk Factors and Prevention
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30. Cardiovascular Disease in Special Populations
31. Pharmacology and Pharmacotherapy
32. Cardiovascular Nursing
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34. Public Health and Health Economics
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Complex redo aortic surgery complicated by refractory cardiogenic shock: A survivor’s tale
Session:
Sessão de Casos Clínicos - I
Speaker:
Maria Trêpa
Congress:
CPC 2019
Topic:
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Theme:
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Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Maria Trêpa; Francisca Caetano ; Susanna Price
Abstract
<p>A 43 year-old male was admitted for decompensated heart failure (HF). He had a background of congenital bicuspid aortic stenosis with aortic valve replacements in 2005 and 2015, moderate to severe LV impairment and left bundle branch block with CRT-D implanted in 2017 following ventricular fibrillation. He was previously stable in NYHA class II but had been deteriorating to NYHA III/IV in the weeks before admission. Initial studies revealed a significant decrease in functional capacity (peak MVO2 of 10.3ml/kg/min with a VE/VCO2 slope of 45.0) and transthoracic echocardiogram showed severe paravalvular aortic regurgitation, severe mitral regurgitation and worsening LV impairment. A multidisciplinary team (MDT) decision was made to perform a 3rd “Re-do” sternotomy with closure of paravalvular leak and repair of the mitral valve. Surgery went according to plan but weaning of extracorporeal circulation was difficult and an intra-aortic balloon pump (IABP) was placed. In the first 24 hours he developed refractory cardiogenic shock (CS) and recurrent ventricular tachycardia and had to be placed on peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO). He remained in CS in the subsequent days and fully dependent VA-ECMO and high doses of inotropics and vasopressors. Is ICU stay was also complicated by multiple extra-cardiac problems: need for renal replacement therapy, groin hematoma and persistent bleeding in IABP insertion site with superimposed infection (removed at day 7), CRT-D mal function and difficulty in ventilation. The patient’s status and evolution was regularly discussed at MDT meetings. Placement of a ventricular assist device as bridge to transplant was considered but the mechanical valve deemed a relative contraindication. As he deteriorated, the palliative team was involved and it was decided he was not a candidate for transplant. However, 14 days after surgery, the patient started showing signs of improvement in cardiac function and was slowly weaned off VA-ECMO that was finally removed on day 21. After 40 days, he was discharged from the ICU to a rehabilitation facility with no neurological impairment and already walking short distances.</p> <p>This case reminds us of the importance of <em>Heart Team</em> decisions, particularly in complex patients like this, and also that high risk procedures should be performed by skilled teams in centres equipped to fully support the patients in case of complications. </p>
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