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Venous thromboembolism (VTE), including pulmonary embolism and deep venous thrombosis, is the third most common cause of cardiovascular death. The management of the acute phase of VTE has already been described in several guidelines. However, the management of the follow-up (FU) of these patients has been poorly defined. This consensus document, created by the Italian cardiologists, wants to clarify this issue using the currently available evidence in VTE. Clinical and instrumental data acquired during the acute phase of the disease are the cornerstone for planning the FU. Acquired or congenital thrombophilic disorders could be identified in apparently unprovoked VTE during the FU. In other cases, an occult cancer could be discovered after a VTE. The main targets of the post-acute management are to prevent recurrence of VTE and to identify the patients who can develop a chronic thromboembolic pulmonary hypertension. Knowledge of pathophysiology and therapeutic approaches is fundamental to decide the most appropriate long-term treatment. Moreover, prognostic stratification during the FU should be constantly updated on the basis of the new evidence acquired. Currently, the cornerstone of VTE treatment is represented by both the oral and the parenteral anticoagulation. Novel oral anticoagulants should be an interesting alternative in the long-term treatment.

Objectives: Lung transplantation (LTx) is the only effective treatment for end-stage lung disease. In rapidly deteriorating patients awaiting transplant, supportive strategies for lung function allow only a short period of support and lung transplantation remains the definitive therapy. An urgent transplant programme may reduce the waiting time, allowing lung transplantation in these patients., Methods: Since November 2010 a nation-wide urgent lung transplant programme has been established in Italy and patients on the waiting list dependent on mechanical ventilation and/or extracorporeal lung support (ECLS) can be transplanted on an emergency basis with the first available graft in the country. Results of the first 14 months of this programme are analysed here., Results: From November 2010 to December 2011, 28 patients (14 males, mean age 33.6 ± 14.4 years) were considered for urgent LTx. Rapidly deteriorating lung function was supported with mechanical ventilation alone in 4 patients (14.3%), ECLS in 13 patients (46.4%) and mechanical ventilation plus ECLS in the remaining 11 patients (39.3%). Three patients (10.7%) were excluded because of worsening conditions, 3 patients (10.7%) while on the urgent listed and 22 patients (78.6%) underwent transplantation after 9.8 ± 6.2 days of being on the urgent list. The 30-day mortality rate after LTx was 18%, and the 1-year survival rate was 71.4%., Conclusions: The urgent lung transplant programme allowed transplantation in a significant percentage of prioritized patients with acceptable 30-day and 1-year mortality rates. An accurate selection of recipients may further improve the clinical impact of this programme, reducing the ethical concerns about transplantation in high-risk patients., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

We present postoperative and midterm (3 years) angiographic changes after removal of five (of six) occluded stents from the left anterior descending (LAD) coronary artery and its reconstruction with a 9-cm-long on-lay patching done with the left internal mammary artery., (Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Re-do mitral valve procedures performed through median sternotomy carry substantial mortality and morbidity. To avoid complications of sternal re-entry and to provide adequate mitral valve exposure, antero-lateral thoracotomy has been suggested by some authors., Methods: From October 1997 to January 2007, 677 mitral valve operations have been performed in our centre using port-access video-assisted right mini-thoracotomy. Among these, 241 (35.6%) were performed on patients who had undergone one or more previous cardiac surgery procedures., Results: Mean cardio-pulmonary bypass time and endo-clamp time were 117+/-46 min and 71+/-31 min, respectively. Arterial cannulation was performed either on the ascending aorta, with the endo-direct cannula (112 patients, 46.5%), or peripherally with a femoral artery approach (129 patients, 53.5%). Conversion to median sternotomy was necessary in only two patients (0.8%) due to aortic dissection (one case) and left ventricle free wall rupture (one case). Median intensive care unit stay was 24h, median mechanical ventilation time was 12h; median hospital stay was 8 days. Bleeding requiring surgical revision occurred in 12 patients (4.9%). Hospital mortality was 4.9% (12/241 patients)., Conclusions: Port-access video-assisted right mini-thoracotomy allows good results in a difficult subset of patients; it allows minimal adhesion dissection, short ICU and hospital stay. In our practice, this technique has become the treatment of choice for mitral valve re-do surgery., (Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objectives: Antiphospholipid (a-PL) antibodies, especially IgG isotype, have been associated with a variety of neurological manifestations related to thrombotic mechanism and reactivity against nervous tissues. Furthermore, high titre of a-PL antibodies has been also correlated to chronic thromboembolic pulmonary hypertension (CTEPH) and, therefore, is frequently reported in patients undergoing pulmonary endarterectomy (PEA). The impact of a-PL antibodies in postoperative outcome following PEA, however, has not been clearly evaluated yet. In this paper, we investigated the impact of a high a-PL IgG titre (HAPT) on postoperative outcome following PEA., Methods: From April 1994 to October 2008, out of 204 patients undergoing PEA at our centre, 184 were prospectively screened for a-PL antibodies. According to the preoperative IgG titre, patients were divided into two groups: Group A (high a-PL antibodies titre - HAPT) with a-PL IgG titre >10 U/ml and Group B (low a-PL antibodies titre - LAPT) with a-PL IgG titre

Intra aortic balloon pump (IABP) is the mechanical assist device most frequently used in cardiac surgery. Recent demonstration of better outcome following preoperative IABP insertion in high-risk patients has further extended its indication. However, due to an increasing complexity of patients currently referred for cardiac surgery, several patients with potential indication for preoperative and/or postoperative IABP present severe peripheral vascular disease which usually contraindicates IABP insertion. Here we present an alternative technique for IABP insertion in patients with severe peripheral vessel disease.

Axillary artery has been proposed as a safe and effective alternative for arterial cannulation in surgical procedures involving ascending aorta and/or aortic arch, and is nowadays the site of choice in many centres. Advantages of axillary artery cannulation include antegrade flow and the possibility of selective mono-hemispherical brain perfusion during circulatory arrest. Experiences with the axillary vein cannulation, however, are scarce. Here we report our preliminary experience with axillo-axillary cardiopulmonary bypass, through both axillary artery and vein cannulation (using echo-guided Seldinger technique) at deltoido-pectoralis groove. We have used such an approach in 5 cases of redo surgery on ascending aorta and we have not had any inconvenience during cardiopulmonary bypass. Full flow was maintained in all patients (in 2 with vacuum assisted drainage) including 2 cases with deep hypothermic circulatory arrest. In conclusion such an approach seems to be feasible and effective and can be safely performed providing that accurate TE echo monitoring is provided.

Video-assisted minimally invasive cardiac surgery (VAMICS) is currently performed with various indications. However, despite the increasing evidence of its effectiveness, new approaches have to be defined to simplify this procedure, minimize its potential complications and limit its costs, for a wider use in the surgical community. The limited access to the aorta is a key point in VAMICS and mandates specific clamping modalities with their own limitations, costs and drawbacks. The Portaclamp (Cardio Life Research SA, Louvain la Neuve, Belgium), a new autoguided extravascular aortic cross-clamping system, has been recently proposed to facilitate VAMICS. Herein, we describe the Portaclamp approach and report our indications and preliminary clinical experience so to define its role in VAMICS.

Objectives: Mandatory use of prolonged immunosuppression in organ transplantation is complicated by an increased incidence of cancer. The current study represents a retrospective analysis of the incidence of neoplasms in our heart transplantation program., Methods: Four-hundred and seventy-four patients (403 male and 71 female; mean age, 48.6+/-12.1 years), with at least 30 days of follow-up, were enrolled in this study. Patients received triple immunosuppression with cyclosporin A, azathioprine and steroids. Moreover, as a prophylactic anti-lymphocyte therapy, 388 patients (82%) were administered RATG, 67 patients (14%) received ALG and 19 patients (4%) OKT3. The mean follow-up time was 71.1+/-43.0 months., Results: Fifty-five patients (11.6%) developed malignant neoplasms. The cancer frequencies were: solid tumors, 55%; non-Hodgkin lymphomas (NHL), 20%; Kaposi's sarcomas, 11%; skin cancers, 9%; undifferentiated sarcomas and myelomas, 5%. Solid tumors mainly affected the lung (39%), bowel (16%), stomach (6.5%), liver (6.5%), pancreas (6.5%) and oral cavity (6.5%). The times to the onset of cancer from transplantation were: Kaposi's sarcoma, 12.7+/-16.8 months; skin cancers, 34.5+/-23.8 months; solid tumors, 54.3+/-38.7 months; NHL, 60.1+/-36.4 months; undifferentiated sarcomas and myelomas, 90.0+/-15.6 months. As determined by univariate and multivariate analyses, sex, number of treated rejections, previous history of tumor, average dose of cyclosporine and prednisone and cyclosporine blood levels did not increase the incidence of malignancies. Univariate analysis suggests a significant correlation between the type of prophylactic immunoglobulins and the average dose of azathioprine with the incidence of neoplasms. Both univariate and multivariate analyses demonstrated a significant correlation between patient's age at the time of transplantation and risk of cancer occurrence (risk increased by 1.074/year; P=0.0056 with multivariate Cox regression)., Conclusions: Cancer is a strong limitation for long-term survival after heart transplantation. The only risk factor recognized is the patient's age at the time of transplant. Furthermore, the type of prophylactic globulins used for induction therapy and some specific immunosuppressant agent (azathioprine) may play a significant role in the development of malignancies after transplantation.

Objective: To see whether degree of pulmonary hypertension or severity of cardiac failure affect the success of pulmonary thromboendarterectomy (PTE) in chronic thromboembolic pulmonary hypertension., Methods: From May 1996 to June 1999, 33 patients, all in New York Heart Association (NYHA) class 3 or 4 were treated with PTE. Preoperative hemodynamic values were: central venous pressure (CVP) 8+/-6 (1-23), mean pulmonary artery pressure (mPAP) 50+/-10 (30-69), cardiac output (CO) 3.3+/-0.9 (1.8-5.2), pulmonary vascular resistance (PVR) 1056+/-344 (523-1659), and right ventricle ejection fraction (RVEF) 12+/-5 (5-21). To establish whether some hemodynamic or cardiac variables correlate with surgical failure (early death or functional non-success), these patients were divided into a low risk or a high risk group for each variable: CVP (<9 or > or =9), mPAP (<50 or > or =50), CO (> or =3.5 or <3.5), PVR (> or =1100 or <1100), and RVEF (> or = 10 or <10). The duration of 3-4 NYHA class period (<24 or > or = 24 months) was also included in the study., Results: Three patients (9. 1%) died in hospital, one (3.0%) underwent lung transplant shortly after PTE, and in five cases (15.2%) mPAP and PVR at the 3-month follow-up examination corresponded with our definition of functional nonsuccess (mPAP and PVR decreased by less than 40% of preoperative values). One of the five functional nonsuccess patients underwent lung transplant 3 months after the operation and another died 17 months after the operation from a non-related cause. Thus PTE was successful in 24 patients and unsuccessful in nine. None of the hemodynamic variables considered was found to be associated with the disparate outcomes. At the 3-month examination, all surviving patients were in NYHA class 1 or 2 except for three in NYHA class 3. At 2 years, hemodynamic values were: CVP 2+/-2 (0-4), mPAP 16+/-3 (12-21), CO 5.0+/-1.0 (3.4-6.5), PVR 182+/-51 (112-282), and RVEF 35+/-5 (26-40). All differences were significant with respect to baseline values (P<0.001). Preoperative mPAP and RVEF values had a strict linear correlation (R=0.45; P=0.014)., Conclusions: None of the variables considered was correlated with early death or functional nonsuccess. Neither preoperative severity of pulmonary hypertension nor degree of cardiac failure influenced the outcome of the operation. PTE leads to hemodynamic recovery even in very compromised patients.

Objective: Non-heart beating donors could be an important source of lungs for transplantation. In prior experiments, trypan blue exclusion was used to assess the percentage of viable lung cells after different intervals following circulatory arrest. In this study, we assessed the importance of the trypan blue perfusate pH because in liver preservation studies, pH of the perfusate appears to be very important with the presence of a 'pH paradox'., Methods: Forty Sprague-Dawley rats (n = 5 each group) were sacrificed, left at room temperature, and ventilated with 100% O2 (tidal volume 0.01 cc/g, rate 30/min) for 4 or 8 h after death. Lungs were then flushed with 150 cc of trypan blue in Krebs-Heinseleit buffer via the pulmonary artery, then with 150 cc of fixative (2%) paraformaldehyde + 2% gluteraldehyde). The pH of the trypan blue solution was varied from 6.5 to 7.8. Lungs were sectioned, and cell viability was quantified based on exclusion of trypan blue., Results: Longer cadaver time was associated with less viability, but pH had no effect on viability. The results were similar in groups ventilated for the same period of time and then flushed with solutions at different pH (4 h, viability 80-84%; 8 h, viability 68-72%). Over the range investigated, the pH of the trypan blue solution had no impact on lung viability in non-heart beating donors and the lungs did not show the 'pH paradox'., Conclusion: Lung tissue is not susceptible to the 'pH paradox' observed in liver preservation studies. Because more than 80% of lung cells are still viable 4 h after death if the lungs are ventilated with 100% O2 during the cadaveric period, retrieval and transplantation of cadaveric lungs may be feasible and might alleviate the paucity of lung donors.