This case report describes the successful treatment of severe accidental hypothermia with cardiopulmonary bypass (CPB). A known intravenous drug misuser aged 22 years was found to be unresponsive at his home (winter evening) with a Glasgow coma scale of 3/15. In the ambulance, the patient went into cardiac arrest, cardiopulmonary resuscitation being started. On arrival to the emergency department, he had a core body temperature of 27°C which was refractory to conservative management. He underwent femoro-femoral CPB, which was successful in rewarming the patient slowly. The patient was discharged home with no neurological deficit 10 days later.
Introduction
Sarcoidosis is a systemic inflammatory disorder associated with ventricular arrhythmias (VAs) and sudden death in the context of cardiac involvement. Guidelines advocate implantable cardioverter‐defibrillator (ICD) implantation in specific subcohorts, but there is a paucity of data on outcomes.
Methods and Results
A systematic review was performed to assess outcomes in patients with definite or probable cardiac sarcoidosis (CS) treated with ICD. Observational studies were identified from multiple databases from inception to 21st May 2021. Outcomes of interest included appropriate and inappropriate ICD therapies in addition to all‐cause mortality. Study quality was assessed individually using the Newcastle Ottawa Scale (NOS).
Eight studies were identified comprising 530 patients, with follow‐up period of 24–66 months (weighted average 40 months). Mean age was 53.9 years with ejection fraction of 41.3%. Overall incidence of appropriate therapy was 38.1% during follow‐up. Left ventricular systolic dysfunction (LVSD) with ejection fraction <40% was a predictor of appropriate therapy in the majority of studies, as were sustained VAs during electrophysiological testing (EP) in one study. There was no interaction with device indication (i.e. primary or secondary). Where documented, inappropriate therapy was primarily driven by atrial arrhythmias. All‐cause mortality was 6.0% over a median follow‐up period of 42 months. Only three studies achieved good quality in the comparability domain of NOS.
Conclusions
Appropriate ICD therapy in patients with CS is commonly associated with LVSD, which can act as a surrogate for scar burden. The utility of EP testing in this setting remains unclear.
DESCRIPTIONA 43-year-old man was referred to a specialised liver unit with progressive abdominal distension and sarcopoenia. He had a background of moderate-to-high alcohol intake. His exercise tolerance was appropriate for his age, and he denied having had exertional dyspnoea or orthopnoea. On examination, there was shifting-dullness of his abdomen, bilateral pitting oedema, an elevated jugular venous pressure and sarcopenia. Other than having clinical ascites, there were no stigmata of liver disease. His observations were stable, and urine output acceptable.His blood tests revealed an acute derangement in his transaminases. A full liver screen was unremarkable in revealing a possible aetiology for this derangement. An abdominal ultrasound scan showed a large amount of ascites, in the presence of a normal liver morphology and patent hepatic vessels. His chest X-ray and ECG (figure 1) were unremarkable. Ascitic fluid demonstrated a transudative picture with a high serum-ascites albumin gradient; samples were negative for tuberculosis or malignancy.To establish cardiac ventricular function, a transthoracic echocardiogram (TTE) was performed. This showed normal right ventricular dimensions with good systolic function, a mildly dilated right atrium and left ventricular ejection fraction (LVEF) of 57±5%. A subsequent CT Thorax (figure 2) and cardiac-MRI revealed features in keeping with constrictive pericarditis (figure 3) (video 1). Invasive haemodynamic evaluation during cardiac catheterisation confirmed this diagnosis.An uneventful surgical pericardiectomy was performed, with no postoperative complications. A repeated TTE 2 weeks postoperatively demonstrated good biventricular function; LVEF was 85%. Histology demonstrated end stage, chronic fibrosing ('obliterative') pericarditis with no Figure 1 ECG initially seemed unremarkable-on retrospect, non-specific signs of constriction can be noted on the rhythm strip shown, including low-voltage notched P-waves and flattened T-waves.
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