Igor Medved

Successful treatment of fulminant Lyme myocarditis with mechanical circulatory support in a young male adult: a case report

We describe the case of fulminant myocarditis due to Lyme disease and use of mechanical circulatory support (MCS) for the treatment of the Lyme carditis associated with refractory cardiogenic shock. Fulminant Lyme myocarditis in young adult male patient led to a sudden onset of acute, severe biventricular heart failure with progressive cardiogenic shock, and multiorgan failure immediately after admission. The previously healthy 28-year-old man was admitted to hospital with dyspnea, atrial flutter with 160/min ventricles rate, normotension, cardiomegaly, and incipient cardiogenic pulmonary edema on chest x-ray. Within the next 24 hours, the acute heart failure (AHF) progressed to the refractory cardiogenic shock with severe systemic hypotension, respiratory distress, anuria, liver congestion, and laboratory evidence of extremely high level of the anaerobic metabolism in the arterial blood (pH 7.16; HCO3 12.3 mmol/L; BE -14.6; lactates level 17 mmol/L). The transesophageal echo imaging showed severe dilatation and global biventricular akinesis, with left ventricular ejection fraction of 5%. The diagnosis of acute fulminant myocarditis of unknown etiology was reached. Since the patient did not respond rapidly to vasoactive and supportive therapy, MCS was immediately inserted. Broad differential diagnosis of fulminant myocarditis was considered and disseminated Borrelia infection was serologically confirmed and appropriate antimicrobial therapy was started from the fifth day after admission. MCS used over the next 26 days was successfully integrated with pharmacologic support and artificial ventilation in therapy. The patient was discharged from hospital after 65 days with a complete restoration of bilateral heart ejection fraction. This case shows that the clinical course of the Lyme carditis can present uncommonly with profound cardiovascular collapse and the MSC implementation should be considered in the early stage of drug resistant hemodynamic instability. Rapid transfer to the cardiac center where the MCS is available for all patients with signs and symptoms of AHF due to confirmed or suspected Lyme carditis would be recommended, as this treatment could be the only life-saving method.

Muscle strength differ between patients with diabetes and controls following heart surgery

BACKGROUND The aim of our study was to analyze muscle strength in patients with recent surgical treatment for ischemic and combined ischemic-valvular heart disease, based on existence of diabetes mellitus. Connections existing between muscle strength and patient characteristics or conventional diagnostic tests were analyzed as well. METHODS Study prospectively included consecutive patients scheduled for cardiovascular rehabilitation 0-3months after heart surgery. Diagnostics covered drug utilization, anthropometrics, demographics, echocardiography, conventional laboratory, echocardiography, bioelectrical impedance analysis (BIA), and hand grip test (HGT). HGT was analyzed for dominant hand. RESULTS Patients with diabetes had significantly weaker muscle strength on HGT than controls; 29.4±12.2kg vs. 38.2±14.7kg (p=0.029), respectively. ROC analysis for HGT and existence of diabetes mellitus were significant; ≤40kg had sensitivity of 89.7% (95%CI: 72.6-97.8), specificity 43.7% (31.9-56.0); AUC 0.669 (0.568-0.760); p=0.002. HGT significantly correlated with hematocrit (Rho CC=0.247; p=0.013), whilst other laboratory or echocardiographic parameters were insignificant (all p>0.05). HGT also correlated with body weight (Rho CC=0.510; p<0.001); height (Rho CC=0.632; p<0.001); waist circumference (Rho CC=0.388; p<0.001); waist-to-hip ratio (Rho CC=0.274; p=0.006) and BIA (Rho CC=-0.412; p<0.001). CONCLUSIONS In postoperative recovery of patients with diabetes, muscle strength assessed by HGT is decreased and in relation with nutritional status. Clinically resourceful connections of HGT were also found to hematocrit and utilization of loop diuretics.

Acute respiratory distress syndrome in an 11-month-old girl leading to extracorporeal membrane oxygenation

Acute respiratory distress syndrome (ARDS) is a condition recognised for almost fifty years, and is related to high morbidity and mortality in children. From its recognition, medical experts tried to make joint efforts to make recommendations and optimize treatment in children and adult population. The new definition of ARDS suggests treatment by introducing three levels of severity, according to PaO2/ FiO2 and positive end-expiratory pressure. Lung-protective ventilation remains crucial in achieving better outcome in paediatric acute respiratory distress syndrome (PARDS), but promising therapies based on paediatric studies include non-invasive ventilation, endotracheal surfactant, highfrequency oscillatory ventilation (HFOV), and use of ECMO as „rescue“ therapy. Nevertheless, PARDS is a real challenge for the paediatric critical care provider, and even if current state-of-the-art treatment methods are delivered, this disease often leads to fatal outcome. We report the case of an 11-month-old female infant who developed ARDS, was treated by current up-to-date treatment methods, including ECMO, and despite this, succumbed to her illness. With this case report we would like once more to bring to consideration the current knowledge on etiology, epidemiology, diagnosis and treatment of ARDS in children, and emphasize the high morbidity and mortality related to this syndrome.

Case report of undiagnosed retrosternal goitre – an unpleasant finding during complex cardiac surgery procedure

An 84-years old patient was scheduled for elective, combined procedure of aortic valve replacement and coronary artery bypass grafting. After median sternotomy was done, there was a finding of unusual retrosternal mass. Concurrently, otherwise routine procedure, changed it course. During surgical manipulation, patient started to show signs of thyreotoxic crisis. Patient was initially stabilised with intravenous metoprolol and amiodarone, blood was taken for analysis and we decided to continue with planned procedure. Bioprosthesis and vein graft on PD were implanted. During operation , blood analysis came through and revealed high levels of FT4 – free thyroxin : 44,10 pmol/L (with normal values of 11,5 – 22,7 pmol/L). After CPB termination and adequate hemostasis, with help of general surgeon, partial thyreoidectomy was done. In early postoperative course, patient recived some inotropic support and was extubated on 4th postoperative day. Except for some minor restlessness, recovery went uneventfull and 84 years old patient was released in good health, on 18th postoperative day. Upon release, patient was reffered to endocrinologist for further treatment.