Chest
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Pericarditis with hemodynamic compromise is a rare manifestation of infection with Nocardia asteroides. To our knowledge, only six cases have been reported previously. In contrast to other cases of pericardial disease due to Nocardia, culture of the pericardial fluid in our case was negative while culture of pericardial tissue led to the diagnosis. Surgical intervention and appropriate antibiotic therapy are essential in the treatment of Nocardia pericarditis.
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We report a patient who received a right single lung transplant (SLT) for progressive lymphangioleiomyomatosis and required reintubation for postoperative respiratory distress. She developed hemodynamic instability due to mediastinal shift from unilateral auto-PEEP with hyperinflation of the native lung. Placement of a double lumen endotracheal tube (DLET) and institution of differential lung ventilation restored equal lung inflation and hemodynamic stability.
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The survival of subjects with postmyocardial infarction cardiogenic shock treated with intra-aortic balloon pumping (IABP) differs significantly among various reports. Differences in the criteria for IABP application and in the timing of its initiation have been considered as the main reasons for variations in survival. This study examines whether the way patients in cardiogenic shock are treated prior to IABP may affect their survival. Fifty-five patients in severe postmyocardial infarction cardiogenic shock were classified into three groups according to the rate of dobutamine infusion prior to IABP: the "nondobutamine" (group A, n = 31), the "high-dose dobutamine" (8 to 20 micrograms.kg-1.min-1, group B, n = 17), and the "low-dose dobutamine" (up to 7 micrograms.kg-1.min-1, group C, n = 7). All subjects seen from 1978 to 1983 were recruited for group A, from 1986 to 1990 for group B, and in years 1984, 1985, and 1991 for group C, without using any other classification criteria. It was shown a posteriori that the three groups did not differ in the features of the subjects, in the severity of shock, and in the time length between onset of shock and pumping initiation. None of the 17 subjects of group B could survive under pumping, while 10 of the 31 subjects in group A and 4 of the 7 subjects in group C were weaned off pumping. ⋯ A protracted, high-dose pre-IABP administration of dobutamine may adversely affect the survival of patients with postmyocardial infarction cardiogenic shock.
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To assess the prevalence and severity of Doppler-detected valvular regurgitation, as assessed by multiple Doppler modalities, in patients with structurally normal hearts, we analyzed Doppler echocardiograms in a consecutive sample of 206 referred patients who were found to have completely normal M-mode and two-dimensional echocardiograms. Valvular regurgitation was detected by Doppler in 94 percent, and 56 percent had regurgitation in at least two valves (mitral, tricuspid, and/or aortic). Mitral, tricuspid, and aortic regurgitation was detected in 73 percent, 68 percent, and 12 percent, respectively, with moderate regurgitation occurring in 6 percent, 5 percent, and 2 percent, respectively. ⋯ Estimated right atrial pressure was > 10 mm Hg in only 7 percent, and only 13 percent had estimated pulmonary artery systolic pressure > or = 40 mm Hg. These data indicate a very high prevalence of trivial and mild mitral and tricuspid regurgitation in patients with otherwise "normal" hearts, suggesting that these findings are physiologically normal. These data should be considered when addressing management in patients with Doppler-detected valvular regurgitation in order to prevent "iatrogenic heart disease."