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.

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.

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.

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Background: Takotsubo syndrome (TTS) is an acquired form of cardiomyopathy. National Brazilian data on this condition are scarce. The Takotsubo Multicenter Registry (REMUTA) is the first to include multicenter data on this condition in Brazil. Objective: To describe the clinical characteristics, prognosis, in-hospital treatment, in-hospital mortality, and mortality during 1 year of follow-up. Methods: This is an observational, retrospective registry study including patients admitted to the hospital with diagnosis of TTS and patients admitted for other reasons who developed this condition. Evaluated outcomes included triggering factor, analysis of exams, use of medications, complications, in-hospital mortality, and mortality during 1 year of follow-up. A significance level of 5% was adopted. Results: The registry included 169 patients from 12 centers in the state of Rio de Janeiro, Brazil. Mean age was 70.9 ± 14.1 years, and 90.5% of patients were female; 63% of cases were primary TTS, and 37% were secondary. Troponin I was positive in 92.5% of patients, and median BNP was 395 (176.5; 1725). ST-segment elevation was present in 28% of patients. Median left ventricular ejection fraction was 40 (35; 48)%. We observed invasive mechanical ventilation in 25.7% of cases and shock in 17.4%. Mechanical circulatory support was used in 7.7%. In-hospital mortality was 10.6%, and mortality at 1 year of follow-up was 16.5%. Secondary TTS and cardiogenic shock were independent predictors of mortality. Conclusion: The results of the REMUTA show that TTS is not a benign pathology, as was once thought, especially regarding the secondary TTS group, which has a high rate of complications and mortality.

Os primeiros relatos de infecções pela síndrome respiratória aguda grave coronavírus 2 (SARS-CoV-2) ocorreram em dezembro de 2019 em Wuhan, China. 1,2 A doença (denominada doença coronavírus-2019, Covid-19) se espalhou rapidamente pelo mundo e, em 11 de março de 2020, a Organização Mundial da Saúde (OMS) declarou estado de pandemia. 1,2 O "Lockdown" era uma recomendação comum em países afetados. 3

Introdução: As infecções de dispositivos cardíacos podem acometer a loja da unidade geradora, o sistema endovascular ou ambos. Embora a retirada de todo o sistema é fundamental para um sucesso terapêutico, o procedimento pode cursar com um alto risco de complicações, quando então a antibioticoterapia supressora deve ser considerada. Caso: Homem, 90 anos, portador de demência, diabetes, fibrilação atrial e insuficiência cardíaca isquêmica, submetido a implante de cardiodesfibrilador há 9 anos, sem história de choques. Procurou atendimento após extrusão da unidade geradora, com sinais inflamatórios locais. Indicada a retirada de todo o sistema, mas por dificuldades técnicas e fragilidade clínica subjacente, foi removida apenas a unidade geradora, com lavagem extensa do local, coleta de material para cultura e proposta de antibioticoterapia supressora contínua. Três dias depois houve crescimento de Proteus mirabilis, além de queda do estado geral, sem febre. Iniciado ceftriaxone e coletadas hemoculturas que revelaram a mesma bactéria. Após 6 semanas de antibiótico venoso houve resposta adequada e negativação das culturas, sendo mantido cefuroxime oral para uso domiciliar. Após 1 mês, houve recidiva dos sintomas com reinternação e nova identificação de P. mirabilis em múltiplas hemoculturas. Submetido a FDG-PET/TC que confirmou atividade inflamatória no cabo sepultado (Figura – setas). Além do novo curso de ceftriaxone, foi indicada a retirada do cabo sepultado, apesar dos riscos inerentes ao procedimento. O mesmo foi realizado sem intercorrências, e o paciente apresentou evolução satisfatória após completar o período de antibiótico. Conclusão: Nas infecções de dispositivos cardíacos, a antibioticoterapia isolada sem a retirada do sistema deve ser reservada para situações restritas, por estar associada a maiores taxas de falha terapêutica e morte. Mesmo em pacientes frágeis e com múltiplas comorbidades, a remoção do dispositivo deve ser almejada para a resolução do quadro infeccioso, independente da bactéria envolvida.