Search

Extracorporeal life support (ECLS) is generally considered to be the treatment of choice for bridging to heart transplantation (HTx) patients with cardiogenic shock; however, alternative mechanical circulatory support (MCS) devices have been proposed with satisfactory results and, among those, paracorporeal systems have demonstrated to be safe and effective. This technology has been used for decades as bridge to transplant, especially in patients with advanced right ventricular dysfunction or evidence of multiorgan failure (MOF), which could be difficult to manage with an isolated left ventricular support. Paracorporeal systems are defined by having the pump located outside of the body, with inflow and outflow cannulas that traverse the skin connecting the pump with the heart and great vessels. They can be utilised in a uni- or bi-ventricular configuration and can provide pulsatile or continuous flow, depending on the device technology (pneumatic vs. centrifugal). In particular, pneumatic devices allow for patient mobilization and hospital discharge, improving rehabilitation and organ recovery while bridging to transplant. In our institution at the University Hospital of Udine, 34 pneumatic paracorporeal ventricular assist devices (VADs) have been implanted since 1998: in most cases (32 pts), as biventricular support for patients in INTERMACS class I–II. After a median support time of 34 (range, 0–385) days, with 19 patients (56%) supported for more than 1 month, 23 patients (68%) underwent HTx and 3 (9%) were successfully weaned to hospital discharge, resulting in an overall combined 76% survival to HTx or weaning. After transplant, the survival rate was similar to the one of the patients not bridged with MCS. In conclusion, pneumatic VADs can effectively assist patients with severe biventricular failure, especially those with contraindications to ECLS or expected long waiting times for HTx. Moreover, they can potentially result in hospital discharge, optimal organ and patient recovery and donor-recipient matching, resulting in a satisfactory transplant outcome.

Background: Aspirin therapy improves saphenous vein graft (SVG) patency in patients undergoing coronary artery bypass graft (CABG), however, its use in the pre-operative period remains controversial. Therefore, we conducted a systematic review and meta-analysis of randomized-controlled trials (RCTs) to update the evidence about risk and benefits of pre-operative aspirin therapy in patients undergoing CABG. Methods: Electronic databases (Medline, Embase, PubMed, Cochrane Library, and Scopus) were searched to identify RCTs evaluating the effect of aspirin versus placebo/control before CABG. Two investigators independently and in duplicate screened citations and extracted data and rated the risk of bias. The strength of evidence was appraised using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Meta-analysis was performed using a random-effects model. The main outcomes of interest were 30-day mortality, peri-operative myocardial infarction (MI), chest tube drainage and SVG occlusion. Results: A total of 13 RCTs involving 4,377 participants (2,266/2,111 pre-operative aspirin/control) met the inclusion criteria. Pre-operative aspirin reduced the risk of SVG occlusion [risk ratio (RR): 0.69, 95% confidence interval (CI): 0.49–0.97, P=0.03, I 2 =16%], but no differences in mortality (RR: 1.41, 95% Cl: 0.73–2.74, I 2 =0%) and MI (RR: 0.84, 95% CI: 0.69–1.03, I 2 =0%) were found. However, pre-operative aspirin increased chest tube drainage (MD: 100.40 mL, 95% CI: 24.32–176.47 mL, P=0.01, I 2 =84%) and surgical re-exploration (RR: 1.52, 95% CI: 1.02–2.27, P=0.04, I 2 =8%), with no significant difference in RBC transfusion (RR: 1.06, 95% CI: 0.90–1.25, I 2 =35%). Conclusions: Based on trials where the rated body of evidence was of low to very-low quality, pre-operative aspirin improves SVG patency but increases chest tube drainage and need for surgical re-exploration.

Uniportal subxiphoid video assisted bilateral segmentectomy is a minimally invasive option for the treatment of synchronous bilateral lung lesions. Its advantages over conventional multiportal or uniportal video assisted thoracoscopic surgery include avoidance of damage to the intercostal neurovascular bundle and allowance of bilateral lesion resection as a combined procedure via a single incision. This article presents a case from our centre to describe our surgical technique for this procedure.