Introduction and objectives The COVID-19 outbreak has had an unclear impact on the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to assess changes in STEMI management during the COVID-19 outbreak. Methods Using a multicenter, nationwide, retrospective, observational registry of consecutive patients who were managed in 75 specific STEMI care centers in Spain, we compared patient and procedural characteristics and in-hospital outcomes in 2 different cohorts with 30-day follow-up according to whether the patients had been treated before or after COVID-19. Results Suspected STEMI patients treated in STEMI networks decreased by 27.6% and patients with confirmed STEMI fell from 1305 to 1009 (22.7%). There were no differences in reperfusion strategy (> 94% treated with primary percutaneous coronary intervention in both cohorts). Patients treated with primary percutaneous coronary intervention during the COVID-19 outbreak had a longer ischemic time (233 [150-375] vs 200 [140-332] minutes, P < .001) but showed no differences in the time from first medical contact to reperfusion. In-hospital mortality was higher during COVID-19 (7.5% vs 5.1%; unadjusted OR, 1.50; 95%CI, 1.07-2.11; P < .001); this association remained after adjustment for confounders (risk-adjusted OR, 1.88; 95%CI, 1.12-3.14; P = .017). In the 2020 cohort, there was a 6.3% incidence of confirmed SARS-CoV-2 infection during hospitalization. Conclusions The number of STEMI patients treated during the current COVID-19 outbreak fell vs the previous year and there was an increase in the median time from symptom onset to reperfusion and a significant 2-fold increase in the rate of in-hospital mortality. No changes in reperfusion strategy were detected, with primary percutaneous coronary intervention performed for the vast majority of patients. The co-existence of STEMI and SARS-CoV-2 infection was relatively infrequent.
Myocardial necrosis, as measured by released TnT, and inflammation state evident due to circulating levels of CRP are factors that may play a major role in the development of LVR following STEMI treated with primary PCI.
Background During COVID‐19 pandemic in Spain, elective procedures were canceled or postponed, mainly due to health care systems overwhelming. Objective The objective of this study was to evaluate the consequences of interrupting invasive procedures in patients with chronic cardiac diseases due to the COVID‐19 outbreak in Spain. Methods The study population is comprised of 2,158 patients that were pending on elective cardiac invasive procedures in 37 hospitals in Spain on the 14th of March 2020, when a state of alarm and subsequent lockdown was declared in Spain due to the COVID‐19 pandemic. These patients were followed‐up until April 31th. Results Out of the 2,158 patients, 36 (1.7%) died. Mortality was significantly higher in patients pending on structural procedures (4.5% vs. 0.8%, respectively; p < .001), in those >80 year‐old (5.1% vs. 0.7%, p < .001), and in presence of diabetes (2.7% vs. 0.9%, p = .001), hypertension (2.0% vs. 0.6%, p = .014), hypercholesterolemia (2.0% vs. 0.9%, p = .026) [Correction added on December 23, 2020, after first online publication: as per Dr. Moreno's request changes in p‐values were made after original publication in Abstract.], chronic renal failure (6.0% vs. 1.2%, p < .001), NYHA > II (3.8% vs. 1.2%, p = .001), and CCS > II (4.2% vs. 1.4%, p = .013), whereas was it was significantly lower in smokers (0.5% vs. 1.9%, p = .013). Multivariable analysis identified age > 80, diabetes, renal failure and CCS > II as independent predictors for mortality. Conclusion Mortality at 45 days during COVID‐19 outbreak in patients with chronic cardiovascular diseases included in a waiting list due to cancellation of invasive elective procedures was 1.7%. Some clinical characteristics may be of help in patient selection for being promptly treated when similar situations happen in the future.
).Pancreas transplantation allows for a euglycemic state in the absence of exogenous insulin. Exocrine pancreatic drainage can be achieved via the gastrointestinal or urinary tracts. Arterio-enteric fistulas constitute an infrequently encountered but potentially fatal complication associated with failed enteric-drained pancreas transplants. Case ReportOur patient is a 58-year-old woman who is presented with hematemesis. Work up inclusive of esophagogastroduodenoscopy (EGD), colonoscopy, and capsule endoscopy did not identify any site of hemorrhage. After a 48-hour observation period with no further bleeding, the patient was discharged home. Twenty days later, she was presented to an outside hospital with a severe recurrent gastrointestinal bleed, prompting an emergent transfer to our institution for further diagnosis and treatment.Her past medical and surgical histories were significant for type 1 diabetes mellitus and renal failure, for which she had undergone an isolated living donor-related kidney transplant 5 years before presentation. She underwent a cadaveric pancreas after kidney transplant, 2 years later. The methods of pancreas transplantation utilized were enteric exocrine drainage and systemic venous drainage. The pancreatic allograft functioned well initially, and the patient maintained euglycemia for 2 years. At that point, 1 year before presentation, the pancreatic allograft had failed because of chronic rejection. Her kidney allograft was still functioning normally. Her immunosuppressive regimen consisted of the following: mycophenolate mofetil 250 mg oral, twice a day; tacrolimus 3 mg oral, twice a day; and prednisone 5 mg oral, once a day.The patient was admitted to our intensive care unit and transfused 6 units of packed red blood cells and 2 units of fresh-frozen plasma with an adequate hemodynamic response. A bedside EGD showed large amounts of blood in the stomach and duodenum with no apparent source. On the basis of these findings, it was decided to proceed with an emergency angiogram to identify the source of bleeding and control it, possibly by endovascular approach. While in the radiology department, as the procedure was about to be Keywords ► arterio-enteric fistula ► enteric-drained pancreas transplant ► gastrointestinal bleeding ► endovascular stenting ► allograft pancreatectomy AbstractEnteric drainage is the preferred method of exocrine diversion in simultaneous kidneypancreas transplantation. Because of improvements in immunosuppression, enteric drainage has become the preferred method of pancreas transplantation in general.Although associated with less potential complications than bladder-drained pancreas, potentially lethal arterio-enteric fistulas in the setting of nonfunctioning allografts represent a constant threat. We herein present a case report, a review of the literature, and a call for caution.
A double-chambered right ventricle is a relatively uncommon congenital cardiac defect characterized by the presence of anomalous muscle bundles dividing the right ventricle into a high-pressure proximal chamber and a low-pressure distal chamber. This pathology is often wrongly diagnosed in adult patients. We report the first case of a patient with double-chambered right ventricle associated with a mural and pulmonic valve endocarditis caused by Streptococcus parasanguis diagnosed with two-dimensional echocardiography. During the course of treatment, the patient suffered from a septic pulmonary embolism, and subsequently required surgical intervention, which confirmed the echocardiographic findings.
Wound infections are a major cause of postoperative morbidity in patients undergoing kidney transplantation. These patients can then be at risk for graft loss and mortality as well.1 Beyond the routine risk of surgical site infections for standard procedures, kidney transplantation bears the added risk caused by its obligate medication regimented immunosuppression. Immunosuppressive agents inhibit the inflammatory cytokines that are responsible for transplant rejection. These cytokines are also responsible for the initial inflammatory phase of wound healing.2 Furthermore, many patients with end-stage renal disease have concomitant diabetes or obesity which are additional independent risk factors for surgical site infection. The risk of infection is greater in the first year after transplantation.3 Reports of wound infections range from AbstractWound infections are a major cause of morbidity after kidney transplantation. The purpose of our study was to evaluate an improved technique of wound closure. Data corresponding to 104 consecutive live donor kidney recipients were prospectively collected and analyzed. Our routine standard technique involved closure of the abdominal wall muscle and fascia in one layer with interrupted nonabsorbable full thickness sutures. No drains were used. The skin was closed with interrupted 2-0 nylon sutures 4 to 5 cm apart, leaving the skin and subcutaneous tissue in between partially open. Patients were allowed to shower starting on the first postoperative day. Examination of the wounds was continued for at least 1 month postoperatively, and then routinely as needed. All patients were thoroughly informed preoperatively of our technique. There were no immediate postoperative wound infections. There were no instances of dehiscence, evisceration, or need for revision. All patients were able to continue with their routine daily activities. Cosmetic results were satisfactory in all cases. We did not experience any patient complaints with respect to our technique. Patient satisfaction scores conducted by Press Ganey and Associates ranked in the 99 percentile with respect to peers undergoing kidney transplantation. Three patients returned six months postoperatively with suture granulomas which were treated nonoperatively. Partial closure of the skin wound with no associated drains is an effective and cosmetically desirable way to decrease the incidence of postoperative infections in kidney transplantation.
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