Two cases of patients that developed right ventricular failure (RVF) after cardiac valve surgery are presented with a narrative revision of the literature. RVF involves a great challenge due to the severity of this condition; it has a low incidence among non-congenital cardiac surgery patients, is more likely associated with cardiovascular and pulmonary complications related to cardiopulmonary bypass (CPB), and is a cause of acute graft failure and of a higher early mortality in cardiac transplant. The morphologic and hemodynamic characteristics of the right ventricle and some specific factors that breed pulmonary hypertension after cardiac surgery are in favor of the onset of RVF. Due to the possibility of complications after cardiac valve repair or replacement, measures as appropriate hemodynamic monitoring, to manage oxygenation, ventilation, sedation, acid base equilibrium and perfusion goals are a requirement, as well as a normal circulating volume, and the prevention of a disproportionate rise in the afterload, to preserve the free wall of the right ventricle (RV) and the septum’s contribution to the right ventricular global function and geometry. If there is no response to these basic measures, the use of advanced therapy with inotropics, intravenous or inhaled pulmonary vasodilation agents is recommended; the use of mechanical ventricular assistance stands as a last resource.

Objectives. The study aims to describe characteristics and clinical outcome of patients with SARS-CoV-2 infection that received siltuximab according to a protocol that aimed to early block the activity of IL-6 to avoid the progression of the inflammatory flare. Patients and methods. Retrospective review of the first 31 patients with SARS-CoV-2 treated with siltuximab, in Hospital Clinic of Barcelona or Hospital Universitario Salamanca, from March to April 2020 with positive polymerase-chain reaction (PCR) from a nasopharyngeal swab. Results. The cohort included 31 cases that received siltuximab with a median (IQR) age of 62 (56-71) and 71% were males. The most frequent comorbidity was hypertension (48%). The median dose of siltuximab was 800 mg ranging between 785 and 900 mg. 7 patients received siltuximab as a salvage therapy after one dose of tocilizumab. At the end of the study, a total of 26 (83.9) patients had been discharged alive and the mortality rate was 16.1% but only 1 out of 24 that received siltuximab as a first line option (4%). Conclusions. Siltuximab is a well-tolerated alternative to tocilizumab when administered as a first line option in patients with COVID-19 pneumonia within the first 10 days from symptoms onset and high C-reactive protein.

Idiopathic peripartum cardiomyopathy presenting with heart failure is a true diagnostic and treatment challenge. Goal oriented clinical management aims at the relapse of left ventricular systolic dysfunction. A 35-year-old patient on her 12th day post-delivery presents progressive signs of heart failure. Transthoracic echocardiography showed severe mitral insufficiency, mild left ventricular dysfunction, mild tricuspid insufficiency, severe pulmonary hypertension, and right atrial enlargement. With wet and cold heart failure signs, the patient was a candidate for inodilator cardiovascular support and volume depletion therapy. As the patient presented a persistent tachycardia at rest, levosimendan was chosen over dobutamine. Levosimendan was administered at a dose of 0.2 µg/kg/min during a period of 24 hours. After inodilator therapy, the patient’s signs and symptoms of heart failure began to decrease, showing improvement of dyspnea, mitral murmur grade went from IV/IV to II/IV, filling pressures and systemic and pulmonary resistance indexes decreased, arterial blood gases improved, and an echocardiography performed 72 h later showed non-dilated cardiomyopathy, mild cardiac contractile dysfunction, mild mitral insufficiency, type I diastolic dysfunction and improvement of pulmonary hypertension. Cardiovascular function in peripartum cardiomyopathy tends to go back to normality in 23-41% of the cases, but in a large group of patients, severe ventricle dysfunction remains months after initial symptoms. This article describes the diagnostic process of a patient with peripartum cardiomyopathy and a successful reversion of a severe case of mitral insufficiency using levosimendan as a new therapeutic strategy in this clinical context.

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Background: D-dimer is a fibrin degradation product present in the blood after infection, thrombosis, or pregnancy. Covid-19 is a prothrombotic inflammatory condition, where D-dimer is often detectable showing higher levels in severe COVID-19 cases. The usefulness of D-dimer for the diagnosis of pulmonary embolism (PE) in SARS CoV2 has not been determined.Aim: To determine the operational characteristics of D-dimer as a diagnostic method for PE in patients with COVID-19 treated at a university hospital in Bogotá, Colombia.Methods: Diagnostic test study that included data from patients with COVID-19 with suspected PE who were screened with the index test (D-dimer measured by turbidimetric immunoassay technique) and reference test (Angiotomography of pulmonary arteries). Results: Among the 209 patients analyzed, the prevalence of PE was 14.4%, D-dimer levels were significantly higher in the group of PE cases (2888 vs. 1114 ng/Dl; p=0.002). 80% of PE cases were submassive and 53% segmental. The operating characteristics for the reference cut-off point of the technique (>499ng/mL) were Sensitivity: 93.9%, Specificity: 8.9%, Positive predictive value: 14.7%, Negative predictive value: 8.9%, proportion of false positives: 91.1%, a Youden J- index of 0.02. The area under the receiving operating curve was 0.684. The coordinates of the curve showed a Youden J- index of 0.367 for a value of 2.281 ng/mL (4.5 times the reference value), using this cut-off point, we obtained a sensitivity of 60%, a specificity of 76%, PPV of 30%, NPV of 92%, and a proportion of false Negatives of 40%.Conclusion: D-dimer does not have appropriate characteristics to be used alone for the diagnosis PE in patients with severe COVID-19. It can be used as part of a rational diagnostic process, being just as specific as the patient’s signs and symptoms.