Coronavirus Disease-2019 (COVID-19) has been associated with potentially life threatening cardiovascular complications, including fulminant myocarditis and cardiac tamponade. Optimal management strategies are still unclear, including the role of immunomodulatory therapies and extracorporeal membrane oxygenation (ECMO) in the context of cardiogenic shock. We report a case of a middle-aged female with COVID-19 who developed respiratory distress and hemodynamic deterioration with elevated troponin levels on the seventh day of symptoms. Echocardiography demonstrated pericardial effusion with diastolic restriction of the right ventricle. Cardiac arrest developed during pericardiocentesis, resulting in emergency thoracotomy and pericardial drainage. Venoarterial ECMO was subsequently initiated due to refractory cardiogenic shock. Tocilizumab, immunoglobulin, methylprednisolone and convalescent plasma were added to supportive care, with progressive recovery of cardiac function and successful weaning from mechanical ventilation. This case highlights the potential role of ECMO, convalescent plasma and immunomodulatory therapies in the management of cardiogenic shock associated with COVID-19 myopericarditis.
OBJECTIVE: Hydroxychloroquine and Ivermectin are advocated as potential treatments for coronavirus disease 2019 (COVID-19) despite the lack of supportive clinical evidence. In this study, outcomes associated with Hydroxychloroquine and/or Ivermectin were determined in a series of patients with confirmed COVID-19 from a single institution in Brazil. METHODS: Consecutive patients admitted between March and July 2020 were retrospectively analyzed and divided into four treatment categories: no treatment (Group 0), Ivermectin only (Group I), Hydroxychloroquine only (Group II), and Hydroxychloroquine and Ivermectin (Group III). Intensive care unit admission, mechanical ventilation, and death were compared between the Groups.RESULTS: A total of 230 patients were included, with the following treatment distribution: 35.2% (0), 9.1% (I), 48.3% (II), and 7.4% (III). Groups I, II, and III had the higher rates of Intensive care unit admission, mechanical ventilation, or death (0: 23.5% versus I: 38.1% versus II: 37.8% versus III: 70.6%, p=0.002), and the greatest mortality was found in Group III (0 versus III: 13.6% versus 35.3%, p=0.03).In the multivariate analysis, Hydroxychloroquine remained significantly associated with death (OR 3.3, 95%CI 1.1-9.6, p=0.03).
CONCLUSION:In a series of consecutive hospitalized patients with COVID-19, Ivermectin was not associated with improved outcomes and Hydroxychloroquine may have resulted in a harmful effect.
Contrast-induced thrombocytopenia is a rare complication distinguished by acute and severe platelet consumption, with spontaneous recovery within days. We describe a case of acute thrombocytopenia 6 hours after coronary angioplasty in a patient with a negative antiplatelet factor 4 test. The count reached 1 × 10/µL, but improved spontaneously to 210 × 10/µL after 8 days. In conclusion, physicians should be aware of this complication, particularly when dual antiplatelet therapy is being considered.
Aim: Pulmonary disease burden and biomarkers are possible predictors of outcomes in patients with COVID-19 and provide complementary information. In this study, the prognostic value of adding quantitative chest computed tomography (CT) to a multiple biomarker approach was evaluated among 148 hospitalized patients with confirmed COVID-19. Materials & methods: Patients admitted between March and July 2020 who were submitted to chest CT and biomarker measurement (troponin I, D-dimer and C-reactive protein) were retrospectively analyzed. Biomarker and tomographic data were compared and associated with death and intensive care unit admission. Results: The number of elevated biomarkers was significantly associated with greater opacification percentages, lower lung volumes and higher death and intensive care unit admission rates. Total lung volume <3.0 l provided further stratification for mortality when combined with biomarker evaluation. Conclusion: Adding automated CT data to a multiple biomarker approach may provide a simple strategy for enhancing risk stratification of patients with COVID-19.
Fat embolism syndrome (FES) is a known clinical situation, especially secondary to long bone trauma conditions. Bone marrow embolism for pulmonary circulation may cause changes in pulmonary function and right ventricular dysfunction, either through the release of chemical mediators from fracture locations, which change blood lipid solubility, causing coalition and subsequent pulmonary embolization, or through direct access of fat to venous circulation and, then, to lungs. A 72-year old female patient was submitted to an orthopedic surgery for femur fracture correction with placement of intramedullary rod. As the patient was aged, with coronary artery disease history and without possibility of a proper preoperative stratification, as it was an urgent surgery, she was submitted to preoperative monitoring with transesophageal echocardiogram for global and segmental ventricular function assessment. During intrabone preparation for rod receiving (milling), a great amount of hyperecogenic ( fig. 1), often forming small pieces ( fig. 2), was seen entering through the right heart and reaching out pulmonary circulation. As the interatrial septum was complete, an exuberant contrast difference could be seen between right and left atrial content. There was no change of pulmonary, cardiac or hemodynamic function after procedure completion, and the patient had good postoperative evolution, being discharged afterwards. Fig. 1 -During intramedullary milling procedure, a great amount of hyperecogenic material fills out the whole right atrium Fig. 2 -Marrow material coalescing in small pieces (arrow) were also seen passing through right heart
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