Selecting Children for Mechanical Circulatory Support

Mechanical circulatory support (MCS) has become a critical tool for managing children with impending respiratory and cardiac failure. Although extracorporeal membrane oxygenation was classically the only form of support available for children, ventricular assist devices (VADs) are increasingly used in children. Common indications for MCS include an inability to oxygenate or ventilate that progresses to respiratory failure and cardiac failure secondary to anatomic abnormalities or primary myocardial failure. The most common contraindication for MCS is death in the near future. This contraindication may include patients with other fatal systemic diseases, patients at high risk of bleeding, or extreme prematurity. Important recent advances in VAD technology include the introduction of the Berlin Heart EXCOR device, as well as the successful use of devices for adults (e.g., the Heartmate and Heartware VADs) in larger children. Although outcomes of VAD support in children have been promising, further studies of smaller and clinically more complex children are required.

Neurohumoral Pathway in Heart Failure

Heart Failure is now considered as one of the leading cause for mortality and morbidity. It is affecting several organs and cause organ damages due to the myocardial failure to pump inadequate oxygenated blood to the body including metabolites, to end organs and peripheral tissues. Heart failure results from multifactorial mechanism including neurohumoral activations including increased activity of the sympathetic nervous system, renin-angiotensin aldosteron system, vasopression and the atrial natriuretic peptide. This neurohumoral pathway has significant contribution to the development of myocardial dysfunction that lead to clinical manifestation of heart failure. Some of the markers in these pathways have now been considered as an independent predictors of prognosis in heart failure patient.

REVERSIBLE MYOCARDIAL FAILURE IN A CAT: A CASE REPORT

A three-year-old neutered male mixed-breed cat was referred for tachypnea, decreased appetite, and lethargy due to a pleural effusion secondary to myocardial failure. Severe left atrial (LA) and left ventricular (LV) dilation, extremely decreased fractional shortening of the LV, and spontaneous echocardiographic contrast in the LA appendage were noted on an echocardiogram. Medical treatments included furosemide, pimobendan, benazepril, clopidogrel, and taurine supplementation. During follow-up visits, tachypnea was not observed, and his activities and appetite returned to normal. Echocardiography showed normal LA and LV chambers and increased LV fractional shortening. The point-of-care test result for N-terminal pro-brain natriuretic peptide (NT-proBNP) was abnormal during the first two visits (day 1 and day 16), and the concentration of plasma NT-proBNP was 1500[Formula: see text]pmol/L and 349[Formula: see text]pmol/L, respectively. On the third and fourth visits (day 35 and day 70), the point-of-care test result for NT-proBNP was normal and corresponded with normal echocardiography findings.

Metabolic Profiles of Propofol and Fospropofol: Clinical and Forensic Interpretative Aspects

Propofol is an intravenous short-acting anesthetic widely used to induce and maintain general anesthesia and to provide procedural sedation. The potential for propofol dependency and abuse has been recognized, and several cases of accidental overdose and suicide have emerged, mostly among the health professionals. Different studies have demonstrated an unpredictable interindividual variability of propofol pharmacokinetics and pharmacodynamics with forensic and clinical adverse relevant outcomes (e.g., pronounced respiratory and cardiac depression), namely, due to polymorphisms in the UDP-glucuronosyltransferase and cytochrome P450 isoforms and drugs administered concurrently. In this work the pharmacokinetics of propofol and fospropofol with particular focus on metabolic pathways is fully reviewed. It is concluded that knowing the metabolism of propofol may lead to the development of new clues to help further toxicological and clinical interpretations and to reduce serious adverse reactions such as respiratory failure, metabolic acidosis, rhabdomyolysis, cardiac bradyarrhythmias, hypotension and myocardial failure, anaphylaxis, hypertriglyceridemia, renal failure, hepatomegaly, hepatic steatosis, acute pancreatitis, abuse, and death. Particularly, further studies aiming to characterize polymorphic enzymes involved in the metabolic pathway, the development of additional routine forensic toxicological analysis, and the relatively new field of ‘‘omics’’ technology, namely, metabolomics, can offer more in explaining the unpredictable interindividual variability.

Fulminant Myocarditis Managed by Extracorporeal Life Support (Impella® CP): A Rare Case

Background. Treating myocarditis can be difficult, as clear criteria for diagnosis and management are lacking for heterogeneous clinical presentations. Case Description. We report a case of a 49-year-old female who presented with cardiogenic shock and subsequent cardiac arrest. Extracorporeal life support was instituted, and after eight days with Impella CP the patient recovered and at six months presented with normal cardiac function. Conclusion. Fulminant myocarditis remains a challenging disease in daily clinical practice, not only for diagnosis, but also for treatment. With this report we emphasize that myocardial failure due to fulminant myocarditis may be reversible if treated with extracorporeal life support, which thus plays an important and life-saving role.