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Objectives: Left ventricular free wall rupture (LVFWR) is a catastrophic complication following acute myocardial infarction with an estimated incidence of 0.2-7.6% and mortality can be as high as 60%. This study aimed to identify the risk factors for morbidity and mortality in patients affected by LVFWR., Methods: This is a retrospective study of 35 patients who underwent surgery for LVFWR between January 2000 and December 2016 at our institution., Results: The mean age of patients was 68.3 years. The in-hospital survival was 65.7% (n = 23), and 13% of survived patients presented with cardiac arrest. The following characteristics were associated with in-hospital mortality at univariable analysis: pre-existing hypertension (P = 0.02), need for inotropes (P = 0.02) and cardiac arrest (P < 0.0001) at presentation, cardiopulmonary resuscitation (P = 0.004), preoperative extracorporeal membrane oxygenation (P = 0.004), technique of LVFWR repair (P = 0.013), operation on extracorporeal membrane oxygenation (P = 0.005) and postoperative extracorporeal membrane oxygenation (P = 0.001). In the multivariable analysis, cardiac arrest at presentation was an independent predictor of in-hospital mortality (odds ratio 11.7, 95% confidence interval 2.352-59.063; P = 0.003). The overall mean postoperative follow-up was 8.3 ± 1.3 years. Overall survival rates at 5 and 10 years were 53.2 ± 8.6% and 49.1 ± 8.9%, respectively. Among the survivors, only 6 (26.1%) patients died during follow-up with a 5-year and 10-year overall survival rate of 80.9 ± 8.7% and 74.7 ± 10%, respectively., Conclusions: These data suggest a trend towards long-term benefit in patients surviving high-risk surgery for LVFWR repair. Considering the high lethality of LVFWR, the urgency and complexity of the primary surgical intervention early diagnosis and prompt surgery play a key role in the management of this complication., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Abstract: Disorders of consciousness may follow brain injury, due to impairments of wakefulness and/or awareness. Polysomnography can identify elements that may be ascribed to impairments of specific neuroanatomical areas. Recognizing which impairments affect each patient is crucial for diagnosis, prognosis, and to select an appropriate therapy. We present a pediatric case of insufficient wakefulness in a patient with severe disability following a pilocytic astrocytoma. Polysomnography was crucial for diagnosis, as it detected a well-structured pattern with daytime sleep initiations in the REM sleep phase. Treatment with modafinil was successful, as confirmed by polysomnography, leading to partial recovery of the patient's consciousness and communication ability. We suggest that polysomnography is a useful diagnostic tool to direct the pharmacotherapy and rehabilitation of states of reduced consciousness., (© 2017 American Academy of Sleep Medicine)

Objective: Weaning from veno-arterial extracorporeal life support is challenging. The objective of this trial was to investigate the endothelial and hemodynamic effects of levosimendan in cardiogenic shock patients supported with veno-arterial extracorporeal life support., Design: This was a prospective observational trial., Setting: Cardiovascular intensive care unit of a large tertiary care university hospital in Monza, Italy., Participants and Interventions: Flow-mediated dilatation of the brachial artery and hemodynamic parameters were assessed in 10 cardiogenic shock patients supported with veno-arterial extracorporeal life support, before and after the infusion of levosimendan., Measurements and Results: Flow-mediated dilatation increased both as absolute value and as a percentage after levosimendan, from 0.10±0.12 to 0.61±0.21 mm (p<0.001) and from 3.2±4.2% to 17.8±10.4% (p<0.001), respectively. Cardiac index increased from 1.93±0.83 to 2.64±0.97 L/min/m 2 (p = 0.008) while mixed venous oxygen saturation increased from 66.0% to 71.5% (p = 0.006) and arterial lactate levels decreased from 1.25 to 1.05 mmol/L (p = 0.004) without significant variations in arterial oxygen saturation or hemoglobin levels. This made it possible for clinicians to reduce extracorporeal membrane oxygenation blood flow from 1.92±0.65 to 1.12±0.49 L/min/m 2 (p<0.001)., Conclusion: In conclusion, in the authors' study population of adult cardiogenic shock patients supported with veno-arterial extracorporeal life support, their observations supported the use of levosimendan to improve endothelial function and hemodynamics and facilitate weaning from the extracorporeal support., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Myocardial failure is generally considered to be a progressive, irreversible medical condition with characteristic ventricular enlargement, spatial alteration of the heart chambers, diminished cardiac inotropy and resultant dysfunctional, mechanically inefficient heart.The Jarvik 2000®, similar to the mechanical pump, is an electrically powered, axial-flow left ventricular assist device (LVAD) designed to enhance the function of the chronically failing heart and, consequently, normalize the cardiac output for a long period of time.We report the case of 70-year-old man with congestive dilated cardiomyopathy and bioprosthetic mitral valve who underwent surgical implantation of the Jarvik 2000® LVAD, using the miniaturized extracorporeal circulation (MECC) system.The LVAD was implanted through a left thoracotomy and the MECC system was used to avoid intraoperative spontaneous hemodynamic instability and/or malignant ventricular arrhythmia. The circulatory support with the MECC system was optimal and no complication in terms of hemodynamic instability and perioperative bleeding was recorded. The MECC system obliterated the adverse effects associated with conventional extracorporeal circulation, which are often fatal in critically-ill patients., (© The Author(s) 2016.)

Study Objective: Sleep patterns of pediatric patients in unresponsive wakefulness syndrome (UWS) have been poorly investigated, and the prognostic potential of polysomnography (PSG) in these subjects is still uncertain. The goal of the study was to identify quantitative PSG indices to be applied as possible prognostic markers in pediatric UWS., Methods: We performed PSG in 27 children and adolescents with UWS due to acquired brain damage in the subacute phase. Patients underwent neurological examination and clinical assessment with standardized scales. Outcome was assessed after 36 mo. PSG tracks were scored for sleep stages and digitally filtered. The spectral difference between sleep and wake was computed, as the percent difference at specific spectral frequencies. We computed (1) the ratio between percent power in the delta and alpha frequency bands, (2) the ratio between alpha and theta frequency bands, and (3) the power ratio index, during wake and sleep, as proposed in previous literature. The predictive role of several clinical and PSG measures was tested by logistic regression., Results: Correlation was found between the differential measures of electroencephalographic activity during sleep and wake in several frequency bands and the clinical scales (Glasgow Outcome Score, Level of Cognitive Functioning Assessment Scale, and Disability Rating Scale) at follow-up; the Sleep Patterns for Pediatric Unresponsive Wakefulness Syndrome (SPPUWS) scores correlated with the differential measures, and allowed outcome prediction with 96.3% of accuracy., Conclusions: The differential measure of electroencephalographic activity during sleep and wake in the beta band and, more incisively, SPPUWS can help in determining the capability to recover from pediatric UWS well before the confirmation provided by suitable clinical scales., (© 2016 American Academy of Sleep Medicine.)

Background: After traumatic brain injury, epilepsy affects up to 20 % of children. It is a risk factor, for both clinical recovery and cognitive performance; therefore pharmacological therapy is advisable. Current guidelines recommend prophylaxis to be initiated as soon as possible and tapered 1 week after trauma. However, no guideline exists for paediatric patients and the clinical practice is heterogeneous., Objective: In our institute, prophylaxis was routinely tapered 6 months after trauma. Therefore we investigated whether this prophylaxis or its tapering influenced the development of post-traumatic epilepsy, together with several clinical-demographic factors., Methods: The study population comprised all patients with post-traumatic brain injury referred to this institute between 2002 and 2009 who consented to participate. Clinical, epileptological and pharmacological data were collected. The role of prophylaxis and several other predictors on occurrence of post-traumatic epilepsy was analysed through logistic regressions., Results: Two hundred and three patients (145 paediatric) were followed for 57 months on average. Risk factors for epilepsy were past neurosurgery [odds ratio (OR) = 2.61, 95 % confidence interval (CI) 1.15-5.96], presence of epileptiform anomalies (OR = 6.92, 95 % CI 3.02-15.86) and the presence of prophylaxis (OR = 2.49, 95 % CI 1.12-5.52), while higher intelligence quotient (IQ) was protective (OR = 0.96, 95 % CI 0.95-0.98). While evaluating possible different effects within and after 6 months (tapering, for those under prophylaxis), we found that epileptiform anomalies (OR = 7.61, 95 % CI 2.33-24.93, and OR = 8.21, 95 % CI 3.00-22.44) and IQ (OR = 0.96, 95 % CI 0.94-0.98, and OR = 0.97, 95 % CI 0.95-0.98) were always significant predictors of epilepsy, while neurosurgery (OR = 4.38, 95 % CI 1.10-17.45) was significant only within 6 months from trauma, and prophylaxis (OR = 3.98, 95 % CI 1.62-9.75) only afterwards., Conclusions: These results suggest that prophylaxis was irrelevant when present; furthermore its tapering increased the risk of epilepsy. Since the presence of epileptiform anomalies was the main predictor of post-traumatic epilepsy, such anomalies may be useful to better direct the choice of prophylaxis.

Background: Extracorporeal membrane oxygenation (VA ECMO) demonstrated an advantage in survival and neurological outcome in patients with cardiogenic shock and, in selected population, in victims of refractory cardiac arrest. The incidence of vascular complications ranges in recent series from 10 to 70% including both early and late complications. The aim of the present study was to determine the incidence of early vascular complications and the effectiveness of the prevention of limb ischemia by the insertion of a catheter for distal perfusion., Methods: Data from our registry of 100 patients treated with VA ECMO implanted via percutaneous femoral approach for cardiogenic shock or refractory cardiac arrest were analyzed. If the leg perfusion was inadequate, an additional 7-9 Fr percutaneous catheter distal to the ECMO arterial cannula was placed into the femoral artery to prevent limb ischemia., Results: Thirty-five patients had early vascular complications. Thirty patients with early ischemia were cannulated with a small reperfusion cannula to obtain antegrade perfusion of the limb. Twenty-six had an effective reperfusion. Seven patients developed a compartment syndrome of the leg requiring urgent fasciotomy that led to clinical improvement and recovery in five, while the other two patients progressed to irreversible ischemia requiring amputation of the limb., Conclusion: The majority of ischemic episodes were resolved with the insertion of a distal perfusion catheter. We did not observe any mortal vascular complication, nor any of the observed complications was related to increased mortality.

Coronary artery spasm (CAS) refers to the spontaneous or stimuli-induced transient, often localized and intense subtotal or total constriction/occlusion of the epicardial coronary artery, usually concomitant with angina pectoris with associated elevation of the ST segment on electrocardiogram (ECG). In this article, we present a literature review on post-valvular surgery CAS and report the clinical case of a 77 year-old man who experienced severe early post-aortic surgery chest pain and hemodynamic instability. Emergent coronary angiography revealed severe occlusion of multiple branches of both coronary arteries. The CAS was alleviated with intracoronary infusion of nitroglycerin.

Objectives: We aimed (i) to search for qualitative sleep patterns for pediatric unresponsive wakefulness syndrome (SPPUWS) in prolonged polysomnographic (PSG) recordings in children and adolescents with subacute severe disorders of consciousness due to an acquired brain damage; (ii) to investigate the clinical relevance of SPPUWS and of possible neurophysiological markers (rapid eye movement sleep and sleep spindles) in PSG recordings of pediatric patients with unresponsive wakefulness syndrome (UWS)., Methods: We performed a PSG study in 27 children with UWS due to acquired brain damage in the subacute phase. Patients received a full neurological examination and a clinical assessment with standardized scales. In addition, outcome was assessed after 36 months., Results: We identified 6 PSG patterns (SPPUWS) corresponding to increasing neuroelectrical complexity. The presence of an organized sleep pattern, as well as rapid eye movement sleep and sleep spindles, in the subacute stage appeared highly predictive of a more favorable outcome. Correlation was found between SPPUWS and recovery, as assessed by several clinical and rehabilitation scales., Conclusions: Polysomnography can be used as a prognostic tool, as it can help determine the capability to recover from a pediatric UWS and predict outcome well before the confirmation provided by suitable clinical scales.

To evaluate the feasibility of a fully objective rehabilitative and assessment process of the gait abilities in children suffering from Acquired Hemiplegia (AH), we studied the combined employment of robotic-aided gait training (RAGT) and 3D-Gait Analysis (GA). A group of 12 patients with AH underwent 20 sessions of RAGT in addition to traditional manual physical therapy (PT). All the patients were evaluated before and after the training by using the Gross Motor Function Measures (GMFM), the Functional Assessment Questionnaire (FAQ), and the 6 Minutes Walk Test. They also received GA before and after RAGT+PT. Finally, results were compared with those obtained from a control group of 3 AH children who underwent PT only. After the training, the GMFM and FAQ showed significant improvement in patients receiving RAGT+PT. GA highlighted significant improvement in stance symmetry and step length of the affected limb. Moreover, pelvic tilt increased, and hip kinematics on the sagittal plane revealed statistically significant increase in the range of motion during the hip flex-extension. Our data suggest that the combined program RAGT+PT induces improvements in functional activities and gait pattern in children with AH, and it demonstrates that the combined employment of RAGT and 3D-GA ensures a fully objective rehabilitative program.

Objective: Cardiopulmonary bypass (CPB) exerts several deleterious effects on inflammatory pathways. Most of these can be related to an endothelial insult leading to endothelial dysfunction. To date, the degree of endothelial damage only has been evaluated on a cellular and molecular level, but no studies exist looking at the functional effects of CPB on the endothelium., Design: Previous studies hypothesized a negative effect of continuous flow as opposed to the physiologic pulsatile flow. The aim of the present retrospective study was to investigate how different perfusion modalities during CPB (ie, continuous v pulsatile flow) or its avoidance differently impact endothelial function., Setting: Cardiovascular operating room and intensive care unit of a large tertiary University Hospital in Monza, Italy., Participants: Flow-mediated dilatation (FMD) of the brachial artery was assessed in 29 patients undergoing elective myocardial revascularization. Ten patients receiving continuous-flow CPB, 10 receiving pulsatile-flow CPB, and 9 scheduled for beating-heart revascularization were studied., Interventions: Patients were studied at baseline (after induction of general anesthesia), after CPB upon intensive care unit (ICU) admission after surgery, and on the first postoperative day before discharge from the ICU (on average, 24 hours after CPB discontinuation)., Measurements and Main Results: The continuous-flow CPB group demonstrated a significant reduction in FMD after CPB, (12.8% ± 9.7% v 1.6% ± 1.5%, p<0.01), which lasted up to the first postoperative day (5.9% ± 4.1%). On the other hand, FMD did not change in the pulsatile-flow group (12.5% ± 10.5%, 11.0% ± 7.2%, and 16.6% ± 11.7%, respectively). FMD also was unaffected in the beating-heart group, thus suggesting a direct effect of CPB itself on endothelial function., Conclusions: In conclusion, in this study population of adult patients undergoing elective coronary revascularization, continuous-flow CPB markedly impaired endothelial function, although this was not the case with pulsatile-flow CPB. This study posed the rationale for further investigations on the potential value of FMD to predict cardiovascular events in these patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

We present the case of a woman assisted with veno-arterial extracorporeal membrane oxygenation (v-a ECMO) for postischemic cardiogenic shock, who developed left ventricular thrombosis despite systemic anticoagulation and left ventricular apical venting. We successfully achieved local thrombolysis with tenecteplase administered through the venting cannula to obtain local thrombolysis while reducing systemic effects to a minimum. The procedure was effective with mild systemic bleeding and the patient was successfully weaned off the extracorporeal support a few days thereafter., (© 2015 Wiley Periodicals, Inc.)

To provide an estimate of the occurrence of misdiagnosis in paroxysmal events in institutionalized children with severe disabilities and refractory epilepsy. A multi-step diagnostic survey, from observational to long-term video-EEG monitoring was performed in 46 severe disabled children. Multirater Kappa statistic was used to assess agreement between investigators and to individualize children who remained with dubious events. Subsequently, prolonged EEG-video monitoring analysis was performed in selected children to define phenomena due to seizures. A total of 128 video records were performed, 64 routine video-EEG and 27 long-monitoring video-EEG data were screened for detailed analysis. Thirty (21 female, 9 male) children (65%) with dubious seizures were identified by video records (concordance K=0.63). Of these, in 18 children (39%) seizures were excluded by routine video-EEG monitoring (K=0.86). Twelve children (26%) required accurate investigations with long-term video-EEG. In 5 children (11%), 3 symptomatic and 2 cryptogenic, very short and subtle seizures were confirmed by investigators concordance (K=0.83). Distinguishing paroxysmal phenomena is a challenge in children with severe disabilities; its most remarkable consequence is inappropriate pharmacological treatment and social costs. Our data suggest that the frequency of misdiagnosis could have been underestimated. The clinicians who manage children with severe disabilities and refractory epilepsy must remain alert to risk of an incorrect treatment., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary artery defect leading to sudden cardiac death. Diagnosis is made after the onset of symptoms, mainly in the pediatric population. We describe an uncommon presentation of ALCAPA and rheumatic mitral valve regurgitation, diagnosed by a coronary 64-CT scan performed before a planned mitral valve repair operation.

In this case report, we report the application of frozen-and-thawed allogeneic platelet gel (PLT-gel) to treat a late driveline exit site infection in a 56-year old patient supported by a Heartware-HVAD left ventricular assist device. The treatment duration was 4 weeks and at the follow-up the skin around the exit site was free from further infection. PLT-gel can be used to treat local infection of the driveline exit site and to prevent further high-risk infections., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

CD26 is a widely expressed transmembrane glycoprotein with peptidase activity in its extracellular domain and which regulates multiple biological processes. It acts mainly as catabolic enzyme for a number of circulating proteins involved in common pathological conditions such as diabetes and cardiovascular disease and may represent a target to modulate bioavailability of crucial substrates. The aim of the present review is to summarize data regarding CD26-based pharmacological interventions. Four main subtopics were identified:1) CD26 as the target of pharmacological inhibitors to increase bioavailability of glucagon-like petide-1 (GLP-1) and hence to enhance GLP-1 glucose-lowering activity in diabetic patients; 2) role of CD26 in the physiology and pathology of the cardiovascular system; 3) the adverse prognostic value of CD26 expression on cancer cells; 4) CD26 down-regulation on lymphocytes as a mechanism of TGF-beta immunomodulation.

Introduction: Recent advances in surgical and anesthesiology techniques allow simultaneous thoracic and abdominal operations to be performed for severe heart disease and benignant or malignant abdominal diseases., Case Report: The simultaneous surgical management in a 75-year-old patient suffering from severe double coronary artery disease and a renal cell carcinoma with extended intravascular growth into the inferior vena cava is reported., Conclusion: The postoperative course was uneventful. Simultaneous surgery proved to be beneficial and safe, showing optimal results in our patient.

Inflammatory response and hemodilution are the main drawbacks of extracorporeal circulation. We hypothesize that the use of miniaturized extracorporeal circulation (MECC) might lower the systemic and myocardial inflammatory patterns compared with a standard system (SECC) and off-pump coronary artery bypass grafting (OPCABG). Sixty-one patients undergoing isolated coronary artery bypass graft were prospectively randomized to MECC (n = 19), SECC (n = 20), or OPCABG (n = 22). Blood samples were collected from radial artery and coronary sinus to analyze blood lactate, hemodilution, and markers for inflammation and endothelial activation such as tumor necrosis factor (TNF)-α, interleukin-6, monocyte chemotactic protein-1, and E-selectin. No differences were observed in early clinical outcome. Interleukin -6 levels increased in every group during and after cardiac surgery, whereas TNF-α values grew in the SECC group (p = 0.05). E-selectin systemic values decreased during and after operation (p = 0.001) in every group. Monocyte chemotactic protein-1 systemic and cardiac levels raised only in SECC group (p = 0.014). In conclusion, MECC is comparable to SECC and OPCABG in the clinical outcome of low-risk patients, and it might be extensively used with no additional intraoperative risk. The analysis of the inflammatory patterns of endothelial activation shows MECC as effective as OPCABG, suggesting further studies to clarify MECC recommendation in high-risk patients.

A 77-year-old man, with a recent history of an acute inferior myocardial infarction, was referred to our hospital with echocardiographic and clinical signs of left ventricular free wall rupture (LVFWR). The intraoperative finding demonstrated a huge double LVFWR. The inferoposterior wall was dramatically destroyed without any possibility to repair.

Objective: Persistent post-injury cognitive, academic and behavioural deficits have been documented in children who sustained severe TBI during the school-age years. The major aim of this study was to examine and follow-up for 2 years the cognitive profile of a sample of post-injured patients (aged 6-16.11), in order to verify to what extent they recovered their intellectual functions after rehabilitation., Method: Twenty-six patients who received a specific neuropsychological treatment and three cognitive evaluations with WISC-III were selected from a pool of 77., Results: This group of patients showed a mild cognitive deficit at baseline, which improved over the 2 years to a borderline level. Despite the improvement in intellectual quotients and single sub-test scores achieved through rehabilitation, different recovery times were seen according to the function under study. The most common deficits are in processing speed, inferential and lexical-semantic skills., Conclusions: Detailed analysis of the WISC-III sub-tests allows for an accurate description of single cognitive functions after TBI. This allows one to make differential diagnoses between functional profiles and plan individualized rehabilitation treatments. Post-injured school-aged patients should receive rehabilitation for a period of at least 2 years, which is the time necessary for an at-least partial reorganization of basic cognitive functions.

Objective: Extracorporeal membrane oxygenation (ECMO) support has been suggested to improve the survival rate in patients with refractory in- and out-of-hospital cardiac arrest (IHCA and OHCA). The aim of our study is to report our experience with ECMO in these patients., Design: Retrospective, single-centre, observational study., Patients: From January 2006 to February 2011 we studied 42 patients (31 males) with refractory cardiac arrest., Measurement and Main Results: ECMO implantation was successful in 38 (90%) of the 42 patients. ECMO support was positioned: three times (8%) in the operating room, six (16%) in the cardiac surgery intensive care unit, 21 (55%) in the emergency room, five (13%) in the catheterisation laboratory and three (8%) in the general ward. A total of 14 IHCA (58%) and three OHCA (16%) patients were weaned from ECMO (p<0.05). Eleven IHCA (46%) and one OHCA (5%, p<0.05) patients were discharged from intensive care unit (ICU). Among IHCA patients, 10 were alive at 6 months, nine of whom (38%) with good neurological outcome. Among OHCA patients weaned from ECMO, one was alive at 6 months with good neurological outcome (5%, p<0.05 vs. IHCA)., Conclusions: ECMO support should be considered as a resuscitation alternative in selected patients. More specifically, patients with witnessed IHCA benefit more from ECMO treatment compared to those who experience an out-of-hospital cardiac arrest., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: The present study was aimed at determining the impact of type 2 diabetes mellitus (DM) on postoperative bioprosthetic structural valve degeneration., Methods and Results: Twelve Italian centers participated in the study. Patient data refer to bioprosthetic implantations performed from November 1988 to December 2009, which resulted in 6184 patients (mean age 71.3±5.4 years, 60.1% male) being enrolled. Of these patients, 1731 (27.9%) had type 2 DM. The propensity score-matching algorithm successfully matched 1113 patients with type 2 DM with the same number of no-DM patients. The postmatching standard differences were less than 0.1 for each of the covariates, and 64.2% of DM patients were matched. The early (30 days) mortality rate was 7.8% (n=87) versus 2.9% (n=33) in patients with or without type 2 DM (P<0.001), respectively. Seven-year freedom from valve deterioration was significantly lower in patients with DM (73.2% [95% confidence interval, 61.6-85.5] versus 95.4% [95% confidence interval, 83.9-100], P<0.001). In Cox regression models with robust SEs that accounted for the clustering of matched pairs, DM was the strongest predictor of structural valve degeneration (hazard ratio 2.39 [95% confidence interval 2.28-3.52]). When we allowed for interaction between type 2 DM and other key risk factors, DM remained a significant predictor beyond any potentially associated variable., Conclusions: Patients with type 2 DM undergoing bioprosthetic valve implantation are at high risk of early and long-term mortality, as well as of structural valve degeneration.

Extracorporeal membrane oxygenation (ECMO) is often applied for acute cardiorespiratory failure. Left ventricular distension can compromise recovery of the failing heart. To overcome this complication, we describe a new technique to decompress the left heart through the insertion of a venting cannula in the pulmonary artery. A 43-year-old woman was connected to ECMO for refractory cardiogenic shock after left pneumonia and severe sepsis. Transesophageal echocardiography (TEE) revealed a large intraventricular clot. A 15F venous cannula was placed percutaneously in the pulmonary artery and connected to the venous limb of the ECMO circuit to decompress the left heart, and to prevent left ventricular ejection and potential embolization. After myocardial recovery, when the thrombus was judged as stable, the patient was weaned, and ECMO was removed on day 16. The patient was discharged from the cardiac surgery intensive care unit on day 30 and subsequently had an uneventful recovery. This new percutaneous approach represent a feasible and effective method to vent the left heart during ECMO, when it becomes necessary to reduce wall tension or to prevent ejection.

Adult patients supported on extracorporeal membrane oxygenation (ECMO) are very sick and many complications are often present in each single patient; therefore, it is not always easy to find some risk factors that can predict the early outcome. This retrospective study reports our experience in ECMO support treatment in adult cardiac patients suffering from cardiac failure (CF) in which one or more predictive factors of 30-day mortality were analyzed. Between January 2002 and August 2009, 42 consecutive adult cardiac patients with cardiogenic shock (mean age 64.3+/-11.3 years) were supported on ECMO for >2 days. They were divided into patients who had a survival <30 days (n=20) and patients who survived >30 days (n=22). Twenty-nine patients (69%) survived on ECMO. Sixteen patients were discharged with a survival rate of 38.1%. The overall mean ECMO duration was 7.9+/-5.3 days. The following variables were significantly different between the two groups: number of platelets and packed red blood cells (PRBCs) transfused per day during ECMO (P=0.002 and P=0.003), blood lactate levels 48 h and 72 h after the initiation of ECMO (P=0.01 and P=0.04), indexed blood flow after 48 h and 72 h (P=0.01 and P<0.0001), liver failure (P=0.001) and multiorgan failure (P=0.002). Stepwise logistic regression identified that blood lactate levels at 48 h and number of PRBCs transfused were associated with 30-day mortality [P=0.019, odds ratio (OR) =2.16; 95% confidence interval (CI)=1.13-4.14 and P=0.008, OR=1.08; 95% CI=1.02-1.14, respectively]. The predicted probability of mortality would be 52% when blood lactate levels are >3 mmol/l after 48 h. The blood lactate level at 48 h and PRBCs transfused per day can be considered as important parameters to predict the mortality in adult cardiac patients supported by ECMO for CF., (2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.)

Extra-axial cerebellopontine angle (CPA) tumors account for approximately 10% of all brain neoplasms in adults. Vestibular schwannomas are the most common, followed by meningiomas. Gliomas in the CPA are rare and quite often are the exophytic extension of primary brain stem or cerebellar tumors. We describe a pilocytic astrocytoma of the CPA that was found to arise from the proximal portion of trigeminal nerve without any anatomic continuity with the brain stem and the cerebellum. Pre-operative MRI suggested a schwannoma. The proposed origin of this extremely rare tumor is the root entry zone of the involved nerve. The tumor was completely resected via a suboccipital retrosigmoid approach.

It is known that L-arginine treatment can ameliorate endothelial dysfunction and insulin sensitivity in type 2 diabetes mellitus patients, but little is known on L-arginine effects on these variables in nondiabetic patients with stable cardiovascular disease (coronary artery disease). We evaluated the effects of long-term oral L-arginine treatment on endothelial dysfunction, inflammation, adipokine levels, glucose tolerance, and insulin sensitivity in these patients. Sixty-four patients with cardiovascular disease previously submitted to an aortocoronary bypass and not known for type 2 diabetes mellitus had an oral glucose load to define their glucose tolerance. Thirty-two patients with nondiabetic response were eligible to receive, in a double-blind randomized parallel order, L-arginine (6.4 g/d) or placebo for 6 months. An evaluation of insulin sensitivity index during the oral glucose load, markers of systemic nitric oxide bioavailability and inflammation, and blood flow was performed before and at the end of the treatment in both groups. Compared with placebo, L-arginine decreased asymmetric dimethylarginine levels (P < .01), indices of endothelial dysfunction, and increased cyclic guanosine monophosphate (P < .01), L-arginine to asymmetric dimethylarginine ratio (P < .0001), and reactive hyperemia (P < .05). Finally, L-arginine increased insulin sensitivity index (P < .05) and adiponectin (P < .01) and decreased interleukin-6 and monocyte chemoattractant protein-1 levels. In conclusion, insulin resistance, endothelial dysfunction, and inflammation are important cardiovascular risk factors in coronary artery disease patients; and L-arginine seems to have anti-inflammatory and metabolic advantages in these patients.

Objective: This prospective randomized study sought to verify the systemic inflammatory response, inflammatory myocardial damage, and early clinical outcome in coronary surgery with the miniaturized extracorporeal circulation system or on the beating heart., Methods: Sixty consecutive patients were randomized to miniaturized extracorporeal circulation (n = 30) or off-pump coronary revascularization (off-pump coronary artery bypass grafting, n = 30). Intraoperative and postoperative data were recorded. Plasma levels of interleukin-6 and tumor necrosis factor-alpha were measured from systemic blood intraoperatively, at the end of operation, and 24 and 48 hours thereafter. Levels of the same markers and blood lactate were measured from coronary sinus blood intraoperatively to evaluate myocardial inflammation. Markers of myocardial damage were also analyzed., Results: One patient died in the off-pump coronary artery bypass grafting group. There was no statistical difference in early clinical outcome in both groups. Release of interleukin-6 was higher in the off-pump coronary artery bypass grafting group 24 hours after the operation (P = .03), whereas levels of tumor necrosis factor-alpha were not different in both groups. Cardiac release of interleukin-6, tumor necrosis factor-alpha, and blood lactate were not different in both groups. Release of troponin T was not significantly different in both groups. Levels of creatine kinase mass were statistically higher in the miniaturized extracorporeal circulation group than in the off-pump coronary artery bypass grafting group, but only at the end of the operation (P < .0001). Hemoglobin levels were significantly higher in the miniaturized extracorporeal circulation group than in the off-pump coronary artery bypass grafting group after 24 hours (P = .01)., Conclusion: Miniaturized extracorporeal circulation can be considered similar to off-pump surgery in terms of systemic inflammatory response, myocardial inflammation and damage, and early outcome.

Primary Objective: This study aimed at investigating the long-term effects of the combination of severity of injury and time of injury in a 6-year-old bilingual Arabic-Italian child who sustained a severe left traumatic brain injury at the age of 7 months., Methods and Procedures: Standard neurological, cognitive and neuropsychological assessments were administered at 40 days after surgery and again at 18, 31, 62 and 73 months., Main Outcomes and Results: The child presented with developmental arrest at 18 and 31 months. Later on, right hemiparetic and oculomotor signs gradually improved to a significant extent, as well as dysexecutive, visuospatial and praxic deficits. At present, persistent language disorders in a fluent speech characterize the child's profile to a similar extent and type in both languages, suggesting common underlying learning strategies which are ineffective for procedurally acquiring language., Conclusions: This case confirms that children who sustain severe left hemisphere traumatic brain injury in infancy present with increased vulnerability to linguistic deficits. Left frontotemporal, cortical-subcortical lesions which occur during very early language development may permanently disrupt the procedural language acquisition network required for first language acquisition.

Although microporous polypropylene hollow fiber oxygenators are standard devices used for extracorporeal membrane oxygenation (ECMO), they have limitations such as development of plasma leakage. Poly-methylpentene (PMP) is a new material used for the last generation of oxygenators. We reviewed our experience with a new PMP oxygenator (Quadrox D) and a centrifugal pump (RotaFlow) used to support adult patients with refractory cardiogenic shock. Between January 2000 and April 2007, 25 patients required ECMO for primary or postcardiotomy cardiogenic shock. Eighteen patients were analyzed [mean age 60.2 years; 11 (61%) men; 7 (39%) women]. Nine patients (50%) suffered primary cardiogenic shock. Cardiopulmonary resuscitation was applied in 11 patients (61%) with a mean duration time of 31.5 minutes. Mean ECMO duration time was 7.1 +/- 6.3 days (range, 1-27 days). Intra-aortic balloon pump was used in 13 patients (72.2%) with a mean duration time of 7.7 +/- 5 (range, 2-17 days). Twelve patients (66.7%) survived on ECMO and five patients (27.8%) were discharged. Our results indicate the PMP oxygenator and the centrifugal pump provided acceptable results in terms of surviving on ECMO and discharge. Patients with an initial catastrophic hemodynamic status could benefit by means of a rapid institution of ECMO with PMP oxygenators.

Objective: A trigone-to-trigone semirigid annuloplasty band (C-G Future Band, Medtronic, Inc., Minneapolis, Minnesota, USA) was introduced in 2001 for mitral valve repair. We report our early clinical and echocardiographic results with this new device to correct ischemic mitral regurgitation., Methods: Between January 2002 and December 2004, among 216 patients operated on for mitral regurgitation, 107 patients had a C-G Future Band annuloplasty and 85 consecutive patients (72.6% male; mean age 66.9 +/- 8.6 years) received this annuloplasty band to correct ischemic mitral regurgitation. Mean follow-up was 14.3 +/- 9.8 months (range 0.2-37 months). Clinical and echocardiographic assessment was accomplished preoperatively, postoperatively, at 6 and 12 months, and at two years., Results: Perioperative mortality was 3.7% (three in-hospital deaths), whereas overall survival at two years was 88.7 +/- 4.2%. Immediately after repair, echocardiographic mitral regurgitation was dramatically reduced (2.5 +/- 0.6 vs. 0.9 +/- 0.6; P < 0.0001); ejection fraction increased from 43.8 +/- 11% preoperatively to 44.8 +/- 12% postoperatively (P = 0.007). At the time of follow-up, New York Heart Association (NYHA) functional class was significantly improved (mean preoperative NYHA class 2.04 +/- 0.9 vs. mean postoperative NYHA class 1.25 +/- 0.6; P < 0.0001). No patient experienced thromboembolic events and no late mitral valve reoperation occurred., Conclusions: Early and mid-term mitral valve function is satisfactory with trigone-to-trigone semirigid band annuloplasty, with excellent repair durability immediately after the operation and at two years. Moreover, after annuloplasty repair, an improvement in clinical functional status is obtained. A wider use of this semirigid annuloplasty band can be recommended.

Objective: The importance of echocardiography in the perioperative management of cardiac surgical patients is widely appreciated. A modified mediastinal drain has been developed, which allows the introduction of a standard TEE probe in a closed-ended sleeve coupled with the drain to permit epicardial echocardiographic imaging after chest closure (substernal epicardial echocardiography [SEE]). The aim of the present study was to develop a standardized and comprehensive SEE examination sequence to allow repeatable examinations with a single movement of the TEE probe inside the drain., Design: Prospective observational protocol., Setting: Tertiary care university hospital., Participants: Ten adult patients undergoing elective cardiac surgery., Interventions: Twenty-three SEE examinations in 10 patients undergoing elective myocardial revascularization to develop a standard examination sequence., Measurements and Main Results: The examination sequence includes 11 views with all the structures relevant for postoperative monitoring. The entire sequence is performed with a single in-out movement of the transesophageal probe to minimize discomfort to patients and the risk of damaging the tube., Conclusions: This new approach to the perioperative monitoring of cardiac surgical patients represents an option for patients in whom TEE is contraindicated or multiple examinations are anticipated because SEE examinations can be performed without the need for sedation in awake patients.

Early postoperative seizures are defined as those that appear within the first week after surgery and are a well-known and feared complication in patients with supratentorial brain tumors. Few studies have investigated the value of pharmacological prophylaxis in the prevention of postoperative seizures in these patients and their outcome has not been consistent. Furthermore, the efficacy of the new generation of antiepileptic agents in the prophylaxis of perioperative seizures has not been assessed so far. We analyzed the data related to 150 patients harboring supratentorial brain gliomas with the aim to assess the efficacy of oxcarbazepine in preventing the occurrence or the recurrence of early postoperative seizures and its tolerability when it is rapidly titrated. Only four patients (2.7%) experienced seizures within the first week after surgery. Patients did not report disturbances during the titration phase. Regarding adverse events in the first week, six patients (4%) showed minor skin rash. Persistent symptomatic hyponatremia never occurred. Our data showed that oxcarbazepine can be a good alternative to traditional antiepileptic agents in the prevention of perioperative seizures being efficacy, ease of use (rapid titration in 3 days, not requiring close plasma concentration monitoring) and good tolerability (no major side effects during titration and during the first postoperative week) the key factors. Moreover, oxcarbazepine can be a valid choice when long-term therapy is required because of the low interaction with other drugs and the low hematological side effects.

Background and Aim: We present our experience in the use of right gastroepiploic artery (rGEA). Long-term clinical results are reported., Methods: From April 1994 to June 2005, 271 patients (257 males, mean age 56.2 +/- 7.1) underwent coronary artery bypass grafting with the use of rGEA. Preoperative, perioperative, and postoperative data were retrospectively collected and clinical results and survival were examined. The end points of follow-up were death and recurrence of cardiac events such as angina and myocardial infarction (MI). The mean follow-up was 8.2 +/- 2.9 years., Results: Left ventricular ejection fraction ranged from 0.20 to 0.68 (mean 0.55 +/- 0.7). The mean cardiopulmonary bypass time was 96.8 +/- 15.8 minutes and the mean cross-clamping time was 69.7 +/- 14.2 minutes. The mean number of distal anastomosis was 3.3 +/- 0.7 (range 2 to 5). Early mortality was 2.6% and postoperative MI occurred in three patients. There were 21 (7.9%) late deaths and three of them (1.2%) were cardiac related. Actuarial 10-year-survival of all deaths, including in-hospital death, was 70.8%+/- 9.9%. No abdominal complications occurred during or after rGEA harvesting. Seven patients have been suffering of recurrence of angina. Angiography was performed only on those patients with recurrent angina., Conclusion: The rGEA can be considered as a valid arterial conduit, relatively easy to harvest, safe to use with low perioperative risks, and good mid- and long-term results. The low early and late rate mortality and the satisfactory clinical results are good reasons for using routinely this conduit in selected patients.

Background: Recently, L-arginine has been added to cardioplegia to limit myocardial ischemic damage. The mechanism of action is related to the production of nitric oxide, with vasodilatation and reduction of endothelial dysfunction. Our prospective randomized study on coronary artery bypass patients investigates the effect of L-arginine on myocardial stress as expressed by myocardial cytokines release and myocardial ischemia in terms of troponin T concentration., Methods: Coronary artery surgery patients were randomly assigned to receive 7.5 g L-arginine in 500 mL of cardioplegic solution (group A). Group B was used as control. Cold blood 4:1 anterograde and retrograde cardioplegia with warm induction was administered. Blood samples were collected from the retrograde coronary sinus catheter to determine interleukin-2 receptor, interleukin-6, and tumor necrosis factor levels. Serum samples at different time points were also analyzed to measure myocardial ischemia markers. Hemodynamic and echocardiographic evaluations were obtained perioperatively., Results: Sixty-five patients were enrolled (group A, treated with L-arginine, n = 33; group B, control, n = 32). Wedge pressure and intensive care unit stay were significantly reduced in group A (p = 0.023 and p = 0.03, respectively). Cytokines levels were lower in group A, with a significance for interleukin-6 (p = 0.026); troponin T was reduced in treated patients (0.33 versus 0.57 ng/mL at 18 hours: p = 0.009)., Conclusions: Coronary artery surgery patients benefit from L-arginine cardioplegia supplementation in terms of reduced inflammatory reaction, limitation of myocardial ischemia, and better hemodynamic performance. Moreover, a clinical advantage is evident in terms of a shorter intensive care unit stay in patients treated with L-arginine.

Background: Arterial spasm is described as an event occurring after left internal thoracic artery (LITA) harvesting. Many vasodilators have been used to treat or prevent LITA spasm. The aim of this study is to compare the effects between glyceril-trinitrate/verapamil (GV) solution and papaverine to treat LITA spasm and to determine the best delivery method., Methods: One hundred consecutive ischemic patients were randomly assigned to three groups: group GV (n = 34, GV solution), group P (n = 33, papaverine), or group C (n = 33, normal saline). In each patient, pedicled LITA was harvested, thereafter sprayed with the randomized solution, and covered with a sponge. Fifteen minutes after heparin administration, LITA was distally divided; flow per minute was calculated after measuring the free flow for over 15 seconds; this is named "topical free flow." Then, the vasodilator was injected intraluminally and free flow per minute was measured; this is called "intraluminal free flow.", Results: Analysis of variance was applied to detect differences among groups; paired-sample t test was used for LITA topical free flow versus intraluminal free flow within single groups. Mean LITA free flows were as follows: group GV, topical free flow = 38.6 +/- 25.2 mL/min versus intraluminal free flow = 58.8 +/- 29 mL/min (p < 0.0001); group P, topical free flow = 45.4 +/- 38.9 mL/min versus intraluminal free flow mL/min (p < 0.0001); group C, topical free flow = 31.6 +/- 19.9 mL/min versus intraluminal free flow = 34 +/- 19.8 mL/min (p = 0.14). Topical free flow difference among the three groups was not statistically significant (p = 0.1); intraluminal free flow difference was statistically significant (p = 0.001). Intraluminal free flow in group GV and in group P were higher than intraluminal free flow in group C (p = 0.004 and 0.001, respectively). Intraluminal free flow of group P was higher than that of group GV; this difference did not reach statistical significance (p = 1.00)., Conclusions: Glyceril-trinitrate/verapamil solution and papaverine are able to treat the spasm and increase the flow of the LITA, when they are used intraluminally. When used topically, these vasodilator agents do not ensure an optimal free flow.

We report a case of a 68-year-old woman with a large left atrial myxoma occluding the mitral valve. The tumor was diagnosed by preoperative echocardiogram. During the operation and after the myxoma resection, a severe mitral valve regurgitation, which was not observed during the preoperative echocardiogram, was noticed. Mitral valve defect was corrected by an annuloplasty ring, and the patient had an uneventful recovery. Careful evaluation of the mitral valve during a myxoma resection operation is recommended.

Background: Many studies confirm that beating heart surgery is an alternative to on-pump myocardial revascularization. However, the clinical conditions of patients are currently considered as a major landmark in the indication for beating heart surgery. This retrospective non-randomized study was carried out to evaluate the efficacy and the advantages of this surgical technique when anatomical criteria are used to choose the surgical strategy., Methods: From February to December 2003, 222 consecutive patients underwent isolated myocardial revascularization: 76 (34%) with an off-pump coronary artery bypass (OPCAB) and 146 (66%) with an on-pump coronary artery bypass (ONCAB) procedure. Selection for surgical treatment was based on coronary anatomy. All patients were stratified for mortality risk class according to the EuroSCORE system. Operative and postoperative data were analyzed., Results: Morbidity and mortality did not differ significantly between the two groups but the release of creatine kinase-MB fraction was significantly higher in the ONCAB group (48.7 +/- 55.3 vs 20.8 +/- 16.6 U/ml, p < 0.001). Patients at high surgical risk were dealt with a more complicated clinical outcome; logistic regression analysis showed that this class was an independent risk factor for postoperative complications in both groups., Conclusions: We did not find any statistical difference in hospital mortality and morbidity either using ONCAB or OPCAB; however a lower release of creatine kinase-MB in beating heart revascularization group suggests that OPCAB reduces myocardial injury and preserves cardiac function when anatomical criteria are considered for patient selection.

Left ventricular free wall rupture (LVFWR) is still an uncommon catastrophic complication after acute myocardial infarction (MI), and it is one of the most frequent causes of sudden cardiac death. Immediate surgical repair is the treatment of choice. When LVFWR presents acutely with tamponade and cardiogenic shock in emergency department, salvage with a good outcome is still possible by timely pericardiocentesis and extracorporeal membrane oxygenation (ECMO) support. We report a case of cardiac rupture with tamponade and cardiogenic shock in which cardiopulmonary support with portable ECMO was used to rescue the patient before the operation.

Quadricuspid aortic valves (QAVs) constitute a rare congenital malformation, with an incidence ranging from 0.008 to 0.048%. We report a case of severe aortic regurgitation associated with a QAV, which was diagnosed intraoperatively using transesophageal echocardiography. Since the first case described in 1862, 186 QAVs have been reported. In most cases, QAVs are associated with valve regurgitation, with a concurrent stenosis in some patients, while only a small number of QAVs are functionally normal. Once the diagnosis has been made, echocardiographic follow-up is recommended, as progression to severe valve regurgitation is common. Antibiotic prophylaxis is advisable for dental, and "dirty" surgical procedures, to minimize the risk of infective endocarditis.