Cardiac intensive care unit: where we are in 2023

Cardiac intensive care has been a constantly evolving area of research and innovation since the beginning of the 21st century. The story began in 1961 with Desmond Julian's pioneering creation of a coronary intensive care unit to improve the prognosis of patients with myocardial infarction, considered the major cause of death in the world. These units have continued to progress over time, with the introduction of new therapeutic means such as fibrinolysis, invasive hemodynamic monitoring using the Swan-Ganz catheter, and mechanical circulatory assistance, with significant advances in percutaneous interventional coronary and structural procedures. Since acute cardiovascular disease is not limited to the management of acute coronary syndromes and includes other emergencies such as severe arrhythmias, acute heart failure, cardiogenic shock, high-risk pulmonary embolism, severe conduction disorders, and post-implantation monitoring of percutaneous valves, as well as other non-cardiac emergencies, such as septic shock, severe respiratory failure, severe renal failure and the management of cardiac arrest after resuscitation, the conversion of coronary intensive care units into cardiac intensive care units represented an important priority. Today, the cardiac intensive care units (CICU) concept is widely adopted by most healthcare systems, whatever the country's level of development. The main aim of these units remains to improve the overall morbidity and mortality of acute cardiovascular diseases, but also to manage other non-cardiac disorders, such as sepsis and respiratory failure. This diversity of tasks and responsibilities has enabled us to classify these CICUs according to several levels, depending on a variety of parameters, principally the level of care delivered, the staff assigned, the equipment and technologies available, the type of research projects carried out, and the type of connections and networking developed. The European Society of Cardiology (ESC) and the American College of Cardiology (ACC) have detailed this organization in guidelines published initially in 2005 and updated in 2018, with the aim of harmonizing the structure, organization, and care offered by the various CICUs. In this state-of-the-art report, we review the history of the CICUs from the creation of the very first unit in 1968 to the discussion of their current perspectives, with the main objective of knowing what the CICUs will have become by 2023

Syndrome coronaire aigu avec sus-décalage du segment ST chez un jeune à coronaires saines révélant une myocardite aigue

Les syndromes coronariens aigus peuvent parfaitement survenir chez l'adulte jeune, les étiologies non-athéromateuses peuvent en être le mécanisme. Nous rapportons le cas d'un jeune homme admis dans un tableau de coronaropathie aigue avec sus-décalage du segment ST systématisé chez qui la coronarographie était sans anomalies et l'imagerie par résonnance magnétique a confirmé une myocardite aigue ayant bien évoluée sous traitement médical

Peripartum cardiomyopathy: alluring challenge - case series and review of literature

Peripartum cardiomyopathy (PPCM) is a rare disease responsible for heart failure that usually occurs in the last month of pregnancy or within five months postpartum, without any other known cause. A case series of five PPCM patients admitted at the Department of Cardiology of the University Hospital Mohammed VI of Oujda, Morocco, between 2017 and 2019. All cases were represented by young (case 1: 35-year-old; case 2: 28-year-old; case 3: 30-year-old; case 4: 36-year-old; case 5: 34-year-old). All patients were multiparous who were admitted to our department with a severely reduced left ventricular ejection fraction. Case 1 and 4 were admitted 3 days after delivery for heart failure. Case 2 was admitted for cardiogenic shock after 3 months of delivery. Case 3 was admitted twelve days after delivery for acute heart failure with pulmonary embolism and multiple venous thrombosis. Case 5 had a history of PPCM was admitted for cardiogenic shock with a course marked by recurrent thromboembolic events. Case 1 and 2 responded to treatment at an early stage, case 4 has evolved to chronicity, the third patient died from an unclear cause, and the fifth patient died from a contraindicated pregnancy leading to the recurrence of fatal thromboembolic events. Above reported cases confirming the great heterogeneity in clinical presentation and course of peripartum cardiomyopathy and seems to confirm that a delayed diagnosis, as well thromboembolic complications are bad prognosis factors of these patients. Early diagnosis, multidisciplinary collaboration, prompt treatment of heart failure and continued monitoring are the keys to improve maternal survival

Management of hyperglycemia during and in the immediate follow-up of acute coronary syndrome

Diabetes is a serious, frequent, and insidious morbidity and mortality risk factor in patients with coronary artery disease. It has been shown that carbohydrate metabolism disorders are common in acute coronary syndromes (ACSs): 30–40% of patients have diabetes, 25–36% have an intolerance to carbohydrates, and only 30–40% have a normal carbohydrate profile. Hyperglycemia occurring either in diabetic or nondiabetic patients is strongly associated with a poor prognosis. It increases the extent of myocardial necrosis, and the risk of recurrence acute coronary syndrome and hemodynamic complications, particularly heart failure and cardiogenic shock, reflecting the importance of optimal management of glucose metabolism abnormalities. The objective of this article is to suggest a screening and management guide for carbohydrate metabolism disorders during and in the immediate follow-up of ACS in diabetic and nondiabetic patients. Screening must be systematic in any patient admitted for ACS, and based on hemoglobin A1c and oral glucose tolerance testing. Treatment of hyperglycemia in the cardiology intensive care unit is recommended in any patient admitted with hyperglycemia >1.80 g/L or postfeeding blood glucose level >1.40 g/L, and should be based on intravenous insulin with concomitant infusion of glucose solution under strict monitoring. Once the patient is no longer in intensive care, intravenous insulin therapy is no longer recommended, and the passage to a fixed insulin therapy regimen or to oral antidiabetics should be considered in consultation with diabetologists. During the rehabilitation phase, good glycemic control improves both prognosis and survival. Keywords: Diabetes, Hyperglycemia, Acute coronary syndrome, Oral antidiabetics, Intravenous insulin therap

Huge right ventricular mass revealing a testicular nonseminomatous germ cell tumor

Background: Cardiac intracavitary metastases from a testicular cancer are very unusual, and intra-cardiac metastasis is exceptionally the first expression of a noncardiac primary neoplasm. We report a case of a young patient for whom a cardiac symptom led to the diagnosis of a metastatic testicular cancer. Case presentation: Our presentation describes an unusual case of a 32 years-old male patient admitted for dyspnea, in whom full examination and tests led to the diagnosis of a huge right ventricular mass revealing a testicular malignant teratoma. As the mass was huge and obstructing the root of pulmonary artery, we had decided to opt for surgical treatment in order to remove the obstruction of the pulmonary trunk. Subsequently, the patient has received systemic adjuvant chemotherapy. Conclusions: Here, we describe the world's first reported case of intraventricular metastasis from a nonseminomatous germ cell tumor of the testis which occupies almost all the right ventricular volume and extending to the root of pulmonary artery that underwent surgical resection of the ventricular mass before chemotherapy. Keywords: Intra-cardiac metastases, Nonseminomatous germ-cell tumor of the testis, Chirurgical treatment, Palliative treatmen

Is There a Causal Link Between Acute Myocarditis and COVID-19 Vaccination: An Umbrella Review of Published Systematic Reviews and Meta-Analyses

Introduction: A few months after the beginning of the coronavirus disease of 2019 (COVID-19) vaccination, several reports of myocarditis secondary to the vaccines were published, sometimes with fulminant cases, but until today there is no proven causal link between these 2 events, but with many hypotheses proposed. Methods: A systematic review of current evidence regarding myocarditis after COVID-19 vaccination was performed by searching several databases including PubMed/Medline and Web of Science. The quality of Meta-analysis was assessed using the AMSTAR-2 tool as well as other qualitative criteria. Results: Our umbrella review appraised 4 Meta-analysis of retrospective studies (range: 5-12), The number of vaccine doses included ranged from 12 to 179 million, with the number of myocarditis cases observed ranging from 343 to 1489. All types of vaccines were evaluated, with no exclusions. The overall incidence ranged from 0.89 to 2.36 cases of myocarditis per 100 000 doses of vaccine received. Heterogeny was assessed in 3 of the Meta-analysis, and was highly significant (>75%) in all included studies, and with a significant P -value ( P  < .05). Regarding publication bias, 3 of the Meta-analysis conducted the egger and begg regression, with a significant result in only 1. Regarding the assessment of the methodology by the AMSTAR-2 scale indicating that the quality was very critical in 1, low in 2, and moderate in 1 Meta-analysis. Conclusion: The quality of current non-randomized evidence on real causality and incidence of myocarditis after COVID-19 vaccine is still low

An uncommon acute type A aortic dissection mimicking an inferior STEMI

Aortic dissection in the most common fatal disease affecting the aorta. Ascending aortic dissection can lead to coronary malperfusion causing myocardial infarction with ST elevation. The distinction between aortic dissection and a primary myocardial infarction can be difficult because both conditions can have similar presentations. Making the right diagnosis is essential because the therapies used to treat myocardial infarction can be fatal for patients with aortic dissection. Emergency transthoracic echography presents a rapid imaging procedure that provides strong hints of the coexistence of these two diseases, leading to further imaging examination and prevent inappropriate administration of treatments that could cause catastrophic outcome. We report a case of a 62-year-old man admitted to our hospital with chest pain, who was diagnosed as inferior wall myocardial infarction based on electrocardiographic findings. The diagnosis was reassessed due to a significant aortic regurgitation and an intimal tear in the ascending aorta on transthoracic echocardiography. Computed tomography angiogram of the chest and transesophageal echography fully confirmed the presence of ascending aortic dissection. Emergency surgery was successfully performed and the patient recovered well

ST-segment elevation after blunt chest trauma: myocardial contusion with normal coronary arteries or myocardial infarction following coronary lesions

Cardiac lesions secondary to blunt chest trauma vary from insignificant arrhythmias to fatal cardiac rupture. Of these, a distinction remains difficult; face to ST-segment elevation on ECG with positive cardiac biomarkers, is it a myocardial contusion or a genuine myocardial infarction (MI) secondary to coronary lesions? We report the case of a patient admitted for multiple trauma. Initial assessment showed an ST segment elevation on ECG, along with multiple fractures and abdominal injuries. We would like to discuss, through this case, the similarities and the differences between myocardial infarction due to coronary lesions and myocardial contusion in a traumatic context, but also emphasize the difficulty of striking the right balance between thrombotic and bleeding risks in this situation, and insist on the importance of a multidisciplinary and collegial reflexion so we can offer these patients the best care there is. Key words: Blunt chest trauma, myocardial contusion, myocardial infarction, coronary angiograph

Painless long-segmental aortic dissection diagnosed by echocardiography: a case report of a diagnostic conundrum with potentially poor outcome

Aortic dissection is a life-threatening condition with a higher mortality rate. Early diagnosis enhances the prognosis of this disease; however, while chest pain is the most common symptom, we can occasionally find asymptomatic patients, making diagnosis more difficult and even missed, it is an uncommon entity with few data in the literature based exclusively on reported cases. Here, we report a case of completely asymptomatic long segmental aortic dissection in a 66-year-old male, with a recent history of controlled hypertension. The diagnosis was made by noninvasive methods, and the patient was referred for surgical treatment. Aortic dissections that are painless provide a significant challenge to physicians in terms of improving prognosis for this frequently misdiagnosed yet lethal illness. The main goal of this report is to bring attention to the misdiagnosed signs and symptoms of aortic dissection

Acute myocardial infarction complicated by severe left ventricle systolic dysfunction in a young patient after Covid 19 vaccination: a case report

We report the case of a 23 years old patient who developed an acute myocardial infarction one day after his second dose of COVID-19 BIBP vaccination, complicated by severe left ventricle systolic dysfunction with an ejection fraction measured at 32%, associated with left ventricular wall motion abnormalities well evolved under treatment of heart failure with reduced EF combining :angiotensin-converting enzyme inhibitor, beta blocker, mineralocorticoid receptor antagonists and sodium-glucose cotransporter 2 inhibitors. Coronary arteries were normal at angiography suggesting initially the diagnostic of myocarditis. Therefore, a cardiac magnetic resonance imaging was performed to confirm the latter, which showed an image consistent with a recent left ventricular subendocardial infarction, remarkably prominent in the left anterior descending artery territory and the absence of signs of myocarditis. The patient had no previous past medical history or other clinical features explaining this coronary event onset. Thus, the vaccine was potentially to be implicated in the pathophysiology of the event. Overall, complications associated with COVID-19 vaccines are extremely rare, and their benefit is well established. That's why they continue to be recommended by public health experts despite of their rare side effects