Search

The intra-aortic balloon pump (IABP) is the most widely available mechanical support device, but its use has been disputed in recent decades. Although several efforts have been made to reduce the associated complication rate, contemporary data on this matter is lacking. The present study aims to evaluate the differences in vascular complications between the sheathless and the sheathed IABP implantation technique in cardiac surgery patients. A retrospective multi-center cohort, consisting of patients treated in 8 cardiac surgical centers, was evaluated. Patients who underwent cardiac surgery with peri-operative IABP support were included. Primary outcome was a composite end point of vascular complications. Propensity score matching (PSM) was performed, and a multivariable regression model was applied to evaluate predictors of vascular complications. The unmatched cohort consisted of 2,615 patients (sheathless n = 1,414, 54%, sheathed n = 1,201, 46%). A total of 878 patients were matched (n = 439 for both groups). The composite vascular complication end point occurred in 3% of patients in the sheathless group, compared with 8% in the sheathed group (p

BackgroundDeep hypothermic circulatory arrest (DHCA) at

The high incidence of out-of-hospital cardiac arrest refractory to standard resuscitation protocols, despite precompetitive screening, demonstrated the need for a prehospital team to provide an effective system for life support and resuscitation at the Volleyball Men’s World Championship. The evolution of mechanical circulatory support suggests that current advanced cardiovascular life support protocols no longer represent the highest standard of care at competitive sporting events with large spectator numbers. Extracorporeal life support (ECLS) improves resuscitation strategies and offers a rescue therapy for refractory cardiac arrest that can no longer be ignored. We present our operational experience of an out-of-hospital ECLS cardiopulmonary resuscitation team at an international sporting event.

Papillary fibroelastoma (PFE) represents only 16% of the benign cardiac tumor and approximately 15% of these are located on the tricuspid valve.Over a period of 22 years (1999-2021) we observed 75 pts with cardiac tumors at our Center over 9650 pts operated on but only one case of a tricuspid valve PFE in a 69-year-old patient. Trans-thoracic echocardiography demonstrated a mobile mass (20 × 10 mm), adhering to the atrial side of the septal leaflet of the tricuspid valve of unknown origin. In consideration of the mobility of the mass and the consequent high embolic risk, surgical removal was made. The patient underwent surgery through a median sternotomy on CPBP. A 'gelatinous' mass adhering to the tricuspid leaflet was found and completely removed. The postoperative course was uneventful. The pathological diagnosis was PFE.PFEs of the tricuspid valve are rare entities being in most cases found incidentally. In our experience, the incidence of this tumor in this location is 1/10,000 cases of cardiac surgery. Although most patients are asymptomatic, surgical treatment is nevertheless recommended in consideration of the high embolic risk.

The natural history of secondary mitral regurgitation (MR) is unfavorable. Nevertheless, there are no evidence that its correction can improve the outcome. If from one side the original cause of secondary MR can be such to limit the possibilities of improvement, from the other side it is possible that the surgical technique widely applied to repair, restrictive mitral annuloplasty, is not adequate to correct the regurgitation. The addition of valvular and/or subvalvular techniques has been considered a possible technical solution. However, we do not know the prevalence of each technique, how many times mitral replacement is used to correct secondary MR. This aspect is of particular importance, as we know that a successful mitral repair causes a better left ventricular systolic remodeling than a unsuccessful repair or replacement. This study is a prospective, observational registry, conceived to understand what is done in the real world. Any surgeon will use the technique he thinks the most suitable for the patient. Every year, for 5 years, patients will have a clinical and echocardiographic follow-up, to evaluate the risk factors for a worse result (death, rehospitalization for heart failure, reoperation for MR return, moderate, or more MR return). This knowledge will give us the possibility to understand which is the technique, or the strategy, more efficient to treat this disease and the real efficacy of the surgical treatment.

AIMS: To compare early and late mortality of acute isolated tricuspid valve infective endocarditis (TVIE) treated with valve repair or replacement.METHODS: Patients who were surgically treated for TVIE from 1983 to 2018 were retrieved from the Italian Registry for Surgical Treatment of Valve and Prosthesis Infective Endocarditis. All the patients were followed up by means of phone interview or calling patient referral physicians or cardiologists. Kaplan-Meier method was used to assess late survival and survival free from TVIE recurrence with log-rank test for univariate comparison. The primary end points were early mortality (30 days after surgery) and long-term survival free from TVIE recurrence.RESULTS: A total of 4084 patients were included in the registry. Among them, 149 patients were included in the study. Overall, 77 (51.7%) underwent TV repair and 72 (48.3%) TV replacement. Early mortality was 9% (13 patients). Expected early mortality according to EndoSCORE was 12%. The TV repair showed lower mortality and major complication rate (7% and 16%), compared with TV replacement (11% and 25%), but statistical significance was not reached. Median follow-up was 19.1 years (14.3-23.8). Late deaths were 30 and IE recurrences were 5. No difference in cardiac survival free from IE was found between the two groups after 20 years (80 ± 6% Repair Group vs 59 ± 13% Replacement Group, P = 0.3).CONCLUSIONS: Overall results indicate that once surgically addressed, TVIE has a low recurrence rate and excellent survival, apparently regardless of the type of surgery used to treat it.

OBJECTIVES Although the intra-aortic balloon pump (IABP) has been the most widely adopted temporary mechanical support device in cardiac surgical patients, its use has declined. The current study aimed to evaluate the occurrence and predictors of early mortality and complication rates in contemporary cardiac surgery patients supported by an IABP. METHODS A multicentre, retrospective analysis was performed of all consecutive cardiac surgical patients receiving perioperative balloon pump support in 8 centres between January 2010 to December 2019. The primary outcome was early mortality, and secondary outcomes were balloon-associated complications. A multivariable binary logistic regression model was applied to evaluate predictors of the primary outcome. RESULTS The study cohort consisted of 2615 consecutive patients. The median age was 68 years [25th percentile 61, 75th percentile 75 years], with the majority being male (76.9%), and a mean calculated 30-day mortality risk of 10.0%. Early mortality was 12.7% (n = 333), due to cardiac causes (n = 266), neurological causes (=22), balloon-related causes (n = 5) and other causes (n = 40). A composite end point of all vascular complications occurred in 7.2% of patients, and leg ischaemia was observed in 1.3% of patients. The most important predictors of early mortality were peripheral vascular disease [odds ratio (OR) 1.63], postoperative dialysis requirement (OR 10.40) and vascular complications (OR 2.57). CONCLUSIONS The use of the perioperative IABP proved to be safe and demonstrated relatively low complication rates, particularly for leg ischaemia. As such, we believe that specialists should not be held back to use this widely available treatment in high-risk cardiac surgical patients when indicated.

Background: To assess early and late mortality in patients with isolated acute tricuspid valve infective endocarditis (TVIE) using data from a multicenter registry.Methods: From 1983 to 2018, isolated acute TVIE was surgically treated in 157 (3.8%) patients [mean age 47 +/- 16 years (range 15-86 years), 25% females]. Of these, 142 (90%) had native tricuspid regurgitation, 7 (5%) native tricuspid valve (TV) steno-regurgitation, and 8 (5%) prosthetic TVIE. Intravenous drug use (IVDU) was recorded in 38% of patients, infection involved cardiac implantable electronic device leads in 21%, and vascular catheters for dialysis in 1%; in the remaining cases, the cause was unknown. The primary endpoint was in-hospital outcome, long-term freedom from recurrence and overall survival.Results: Overall, 77 (49%) patients underwent TV repair, 72 (46%) TV replacement, and 8 (5%) prosthetic TV replacement. Early mortality was 11% (n = 17). Expected early mortality according to EndoSCORE was 12%, with age (odds ratio 1.06) and redo (odds ratio 6.64) as risk factors. Late deaths occurred in 31 patients and TVIE recurrences in 4. Survival rates at 10, 20, and 25 years were 66%, 60%, and 44%, respectively. Risk factors were age [hazard ratio (HR) 1.06], mycotic TVIE (HR 4.2), IVDU (HR 4.90), infected prosthesis replacement (HR 4.4), and presence of cardiac implantable electronic device leads (HR 3.0). No significant difference was found in valve repair vs. replacement and in IVDUs vs. non-IVDUs.Conclusions: Patients with isolated acute TVIE undergoing surgical treatment show acceptable early and late outcomes. TVIE recurrence was low, and repair of the affected valve does not seem to confer any advantage either at early or long term up to 25 years. (C) 2019 Elsevier B.V. All rights reserved.

Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.

Objectives The aim of this prospective study was to validate an echocardiographic protocol derived from 5 HeartWare left ventricular assist device (HVAD) patients for the noninvasive evaluation of right atrial pressure (RAP) and left atrial pressure (LAP) in HVAD patients. Background Echocardiography is an invaluable tool to optimize medical treatment and pump settings and also for troubleshooting residual heart failure. Little is known about the echocardiographic evaluation of hemodynamic status in HVAD patients. Methods Right heart catheterization and Doppler echocardiography were performed in 35 HVAD patients. Echocardiography-estimated RAP (eRAP) was assessed using inferior vena cava diameter, hepatic venous flow analysis, and tricuspid E/e′ ratio. Echocardiography-estimated LAP was assessed using E/A ratio, mitral E/e′ ratio, and deceleration time. Results eRAP and estimated LAP significantly correlated with invasive RAP and LAP (respectively, r = 0.839, p Conclusions Doppler echocardiography accurately estimated hemodynamic status in HVAD patients. This algorithm reliably detected high RAP and LAP. Notably, high RAP was associated with high wedge pressure and adverse outcome. The benefit of noninvasive estimation of hemodynamic status in the clinical management of patients with left ventricular assist devices needs further evaluation.

Background previous studies evaluating external stents for saphenous vein grafts (SVG) in CABG were limited to on-pump isolated CABG and single grafting technique with one external stent per patient. The objective of this prospective study was to evaluate the safety and the short-term performance of external stents in a heterogeneous group of patients who underwent on- and off-pump CABG, single and sequential grafting. Methods 102 patients undergoing CABG were enrolled in two centers. All patients received internal mammary artery to the left anterior descending artery and additional arterial and/or venous grafts. In each patient, at least one SVG was supported with an external stent. Grafts’ patency and SVG lumen uniformity were assessed using CT angiography at a pre-defined time window of 6–12 months post procedure. All patients were prospectively followed-up via phone call and/or visit every 6 months for Major Adverse Cardiac and Cerebrovascular Events. Results 51 patients (50%) underwent off-pump CABG and 23 patients (23%) were grafted with bilateral internal mammary arteries. Each patient received one or more SVG grafted in a sequential technique (44%) or as a single graft (56%). All SVG were externally stented in 84% of patients and in 16% (n = 16) one SVG was stented and one remained unsupported. At 6–12 months, patency rates of LIMA, RIMA, externally stented SVG and none-stented SVG were 100, 100, 98 and 87.5% respectively. 90% of the externally stented SVG had uniform lumen compared to 37% of the non-stented SVG. Clinical follow-up was completed for all patients with a mean duration of 20 months (range 6–54 months). During follow up period, one patient experienced myocardial infarction due to occlusion of the LIMA-LAD graft and one patient experienced a transient ischemic attack. Conclusions External stenting of SVG is feasible and safe in CABG setting which includes off pump CABG and sequential SVG grafting and associated with acceptable early patency rates. Trial registration Study was registered at ClinicalTrials.gov. NCT01860274 (initial release 20.05.2013).

OBJECTIVES Endocarditis after the Bentall procedure is a severe disease often complicated by a pseudoaneurysm or mediastinitis. Reoperation is challenging but conservative therapy is not effective. The aim of this study was to assess short- and midterm outcomes of patients reoperated on for Bentall-related endocarditis. METHODS Seventy-three patients with Bentall procedure-related endocarditis were recorded in the Italian registry. The mean age was 57 ± 14 years and 92% were men; preoperative comorbidities included hypertension (45%), diabetes (12%) and renal failure (11%). The logistic EuroSCORE was 25%; the EuroSCORE II was 8%. RESULTS Preoperatively, 12% of the patients were in septic shock; left ventricular-aortic discontinuity was present in 63% and mitral valve involvement occurred in 12%. The most common pathogens were Staphylococcus aureus (22%) and Streptococci (14%). Reoperations after a median interval of 30 months (1–221 months) included a repeat Bentall with a bioconduit (41%), a composite mechanical (33%) or biological valved conduit (19%) and a homograft (6%). In 1 patient, a heart transplant was required (1%); in 12%, a mitral valve procedure was needed. The hospital mortality rate was 15%. The postoperative course was complicated by renal failure (19%), major bleeding (14%), pulmonary failure (14%), sepsis (11%) and multiorgan failure (8%). At multivariate analysis, urgent surgery was a risk factor for early death [hazard ratio 20.5 (1.9–219)]. Survival at 5 and 8 years was 75 ± 6% and 71 ± 7%, with 3 cases of endocarditis relapse. CONCLUSIONS Surgery is effective in treating endocarditis following the Bentall procedure although it is associated with high perioperative mortality and morbidity rates. Endocarditis relapse seems to be uncommon.

BACKGROUND: Patients with liver cirrhosis (LC) undergoing cardiac surgery (CS) face perioperative high mortality and morbidity, but extensive studies on this topic are lacking.METHODS: All adult patients with LC undergoing a CS procedure between 2000 and 2017 at 10 Italian Institutions were included in this retrospective cohort study. LC was classified according to preoperative Child-Turcotte-Pugh (CTP) score and Model for End-Stage Liver Disease (MELD) score. Early-term and medium-term outcomes analysis was performed in the overall population and according to CTP classes.RESULTS: The study population included 144 patients (mean age 66 ± 9 years, 69% male). Ninety-eight, 20, and 26 patients were in CTP class A, in early CTP class B (MELD score 12), respectively. The main LC etiologies were viral (43%) and alcoholic (36%). Liver-related clinical presentation (ascites, esophageal varices, and encephalopathy) and laboratory values (estimated glomerular filtration rate, serum albumin, and bilirubin, platelet count) significantly worsened across the CTP classes (P= .001). Coronary artery bypass grafting or valve surgery (87% bioprosthesis) were performed in 36% and 50%, respectively. Postoperative complications (especially acute kidney injury, liver complication, and length of stay) significantly worsened in advanced CTP class B (P= .001). Notably, observed mortality was 3-fold or 4-fold higher than the EuroSCORE (European System for Cardiac Operative Risk Evaluation) II-predicted mortality, in the overall population, and in the subgroups. At Kaplan-Meier analysis, 1-year and 5-year cumulative survival in the overall population was 82% ± 3% and 77% ± 4%, respectively. The 5-year survival in CTP class A, early CTP class B, and advanced CTP class B was 72% ± 5%, 68% ± 11%, and 61% ± 10%, respectively (P= .238).CONCLUSIONS: CS outcomes in patients with LC are significantly affected in relation to the extent of preoperative liver dysfunction, but in early CTP classes, medium-term survival is acceptable. Further analysis are needed to better estimate the preoperative risk stratification of these patients.

With advancements in mechanical circulatory support technology, and limitations in donor supply for heart transplantation, the use of left ventricular assist devices (LVADs) has increased significantly in recent years. Multiple studies have shown that minimally invasive cardiac surgery can improve outcomes, with shorter hospital stays, decreased morbidity, faster recovery and ambulation, and lower total hospital costs. The current generation of centrifugal continuous-flow pumps is miniaturized and makes minimally invasive approaches increasingly practicable. Lateral surgical access to the ventricle allows off-pump implantation with minimal risk of blood loss, reducing the risk of air embolism and difficult de-airing. Off-pump implantation reduces hemodilution, systemic inflammatory response syndrome due to extracorporeal circulation, and the negative effects of pulmonary hypertension and right ventricular dysfunction in the perioperative period. Minimally invasive lateral access is encouraged in cases of bridge-to-transplant to avoid the risks associated with resternotomy. We describe the surgical technique for minimally invasive implantation of the HeartMate 3 (Abbott, USA) left ventricular assist device (LVAD), avoiding sternotomy and cardiopulmonary bypass. Our surgical approach was based on a left minithoracotomy for the LVAD implantation and a right thoracotomy for the outflow graft anastomosis to the ascending aorta.

Background Neurologic injury is still a frequent cause of mortality, morbidity, and long-lasting disability in patients undergoing an aortic arch operation with hypothermic circulatory arrest. The aim of this analysis was to evaluate short- and long-term outcomes in neurologic and cognitive functions in this group of high-risk patients. Methods A total of 333 patients undergoing an aortic arch operation between February 2004 and June 2010 were retrospectively reviewed. Cerebral protection was obtained with deep hypothermic circulatory arrest in 220 patients (66%) or with moderate hypothermic circulatory arrest in 113 cases (34%). Straight deep hypothermic circulatory arrest was adopted in 35 cases (11%), while the association with antegrade cerebral perfusion was adopted in 271 cases (81%) and with retrograde cerebral perfusion in 27 cases (8%). Seventy-eight patients were enrolled in a case control prospective study (mean follow-up time = 42 months) and underwent neuropsychologic evaluations; data were compared with those of a matched-control group of hypertensive patients without history of cardiac operations. Results Forty-one out of 333 patients experienced permanent neurologic dysfunction (12%) and 83 experienced temporary neurologic dysfunctions (25%). Acute aortic dissection and deep hypothermic circulatory arrest were significant predictors of mortality and permanent neurologic dysfunction. Acute aortic dissection and hypothermic circulatory arrest duration >30 minutes were significant predictors of temporary neurologic dysfunction, while antegrade cerebral perfusion was protective on mortality. Neuropsychologic evaluations showed no significant differences between the groups. The operative group showed worse verbal and working memory (P = .003), worse semantic fluency (P = .036), higher degree of alexithymia (P = .004), and a lower quality of life (P = .007). Conclusion Although moderate hypothermic circulatory arrest with antegrade cerebral perfusion demonstrated a lower mortality compared with deep hypothermic arrest, neurocognitive testing demonstrated no difference between the groups. Additionally, patients undergoing an aortic arch operation demonstrated long-term cognitive deficits and psychological dysfunction when compared to a matched cohort of nonoperative patients.

The aim of this prospective study was to validate an echocardiographic protocol derived from 5 HeartWare left ventricular assist device (HVAD) patients for the noninvasive evaluation of right atrial pressure (RAP) and left atrial pressure (LAP) in HVAD patients.Echocardiography is an invaluable tool to optimize medical treatment and pump settings and also for troubleshooting residual heart failure. Little is known about the echocardiographic evaluation of hemodynamic status in HVAD patients.Right heart catheterization and Doppler echocardiography were performed in 35 HVAD patients. Echocardiography-estimated RAP (eRAP) was assessed using inferior vena cava diameter, hepatic venous flow analysis, and tricuspid E/e' ratio. Echocardiography-estimated LAP was assessed using E/A ratio, mitral E/e' ratio, and deceleration time.eRAP and estimated LAP significantly correlated with invasive RAP and LAP (respectively, r = 0.839, p 0.001, and r = 0.889, p 0.001) and accurately detected high RAP and high LAP (respectively, area under the curve 0.94, p 0.001, and area under the curve 0.91, p 0.001). High eRAP was associated with high LAP (area under the curve 0.92, p 0.001) and correlated with death or hospitalization at 180 days (odds ratio: 8.2; 95% confidence interval: 1.1 to 21.0; p = 0.04). According to estimated LAP and eRAP, patients were categorized into 4 hemodynamic profiles. Fifteen patients (43%) showed the optimal unloading profile (normal eRAP and normal wedge pressure). This profile showed a trend toward a lower risk for adverse cardiac events at follow-up (odds ratio: 0.2; 95% confidence interval: 0.1 to 1.0; p = 0.05) compared with other hemodynamic profiles.Doppler echocardiography accurately estimated hemodynamic status in HVAD patients. This algorithm reliably detected high RAP and LAP. Notably, high RAP was associated with high wedge pressure and adverse outcome. The benefit of noninvasive estimation of hemodynamic status in the clinical management of patients with left ventricular assist devices needs further evaluation.

Left ventricular assist devices are currently implanted using three different techniques [1]: Median sternotomy with cardiopulmonary bypass (CPB). Left posterolateral thoracotomy with the outflow graft connected to the descending aorta with or without CPB. This approach is more frequently used in case of reoperations to avoid re-sternotomy. Minimally invasive left mini-thoracotomy (with or without CPB).

Background Continuous flow left ventricular assistance devices (CF-LVADs) have revolutionized the treatment of advanced heart failure. Pump replacement for thrombosis is a high-risk procedure with a high perioperative mortality rate with possible recurrence. We aim to summarize our experience using a conservative approach with medical therapy. Methods We retrospectively reviewed records of patients who experienced pump thrombosis after LVAD implantation with HeartWare HVAD at our institution, from November 2010 to March 2016. Device thrombosis (DT) was divided into suspected (SDT) and confirmed (CDT). A conservative approach using thrombolysis and heparin was used in all patients. Results A total of 32 HeartWare HVAD pumps were implanted. Mean age was 59 ± 10 years and the mean time on mechanical support was 19.29 months (± 14.06). Pump thrombosis occurred in 7 patients (0.14 patients/year) after a mean time of 733 (231–1,606) days after LVAD implantation. Three out of 7 cases had thrombosis recurrence (43%). Overall 19 episodes were recorded (0.38 event per patient/year). Eighteen out of 19 thrombolytic treatments were successful (94.7%). No patient required LVAD replacement or transfusion of blood products. There was no significant difference in terms of survival between patients who experienced thrombotic events and patients who did not. No major complications related to thrombolysis were recorded. Conclusions Systemic thrombolysis plus heparin was an excellent therapeutic option. Early intervention in clinically stable patients without signs of heart failure but with indirect signs of device thrombosis has led to better outcomes.

BackgroundIn continuous-flow left ventricular assist device (LVAD) recipients, little is known about the relative pump- and left ventricle-generated blood flow (PBF and LVBF, respectively) contribution to peak systemic perfusion during incremental exercise and about how PBF/LVBF interplay and exercise capacity may be affected by pump speed increase.MethodsTwenty-two LVAD recipients underwent ramp cardiopulmonary exercise tests at fixed and increasing pump speed (+ 1.5% of baseline speed/10 W workload increase), echocardiography and NT-proBNP dosage. Peak systemic perfusion was peak VO2/estimated peak arterio-venous O2 difference, and LVBF was systemic perfusion minus PBF provided by LVAD controller. A change of peak percentage of predicted VO2max (Δpeak%VO2) ≥ 3 in increasing- vs. fixed-speed test was considered significant.ResultsTricuspid annular plane systolic excursion (TAPSE) and NT-proBNP were significantly lower and higher, respectively, in Δpeak%VO2 < 3 than ≥ 3. A LVBF contribution to systemic perfusion significantly larger than that of PBF was observed in Δpeak%VO2 ≥ 3 vs. < 3 in fixed-speed test, which was further amplified in increasing-speed test (2.4 ± 1.7 l/min vs. 2.0 ± 1.5 l/min and 0.8 ± 2.2 l/min vs. 1.3 ± 2.3 l/min, respectively, p for trend < 0.0005). Among several clinical-instrumental parameters, logistic regression selected only TAPSE > 13 mm as a predictor of Δpeak%VO2 ≥ 3.ConclusionsA significant LVBF contribution to peak systemic perfusion and pump speed increase-induced peak VO2 improvement was detectable only in patients with a more preserved right ventricular systolic function and stable hemodynamic picture. These findings should be taken into consideration when designing LVAD controllers aiming to increase pump speed according to increasing exercise demands.

Treatment of acute coronary syndrome secondary to septic coronary embolism during valvular endocarditis is controversial. Urgent coronary angiography and stent implantation or surgical intervention have been proposed. We present the case of a patient presented at the emergency department with chest pain and cardiogenic shock. The coronary angiography showed a large filling defect in the left main due to a septic coronary embolism.

Background Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period. Method From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access. Results Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation. Conclusions Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.

OBJECTIVES: Driveline infections are one of the most common and important complications in patients with left ventricular assist device (LVAD). One of the causes favouring the development of this complication is the traumatism of the exit site, which occurs in response to movement of the driveline. In this work, we present a simple and feasible method to immobilize the driveline at the level of the exit site. METHODS: From April 2013 until November 2013, 6 patients underwent implantation of HeartWare LVAD (HVAD) for an end-stage heart failure. When the patient has begun to mobilize after the implantation of the device, we have combined the use of two components with the aim of securing the driveline to the patient’s skin: a StatLock system and a silicone suture. RESULTS: No case of local traumatism and no case of local infection at the driveline were observed during the follow-up. No patient reported pain or swelling at the driveline exit site. All patients were satisfied with their quality-of-life and they do not report any limitations in their daily activities. CONCLUSIONS: One of the major long-term complications in patients with LVAD is the development of infections of the exit site of the driveline. The trauma of this skin region promotes the onset and maintenance of an inflammatory process and local infectious. Avoiding excessive mobilization of the driveline is likely to reduce the incidence of infections of the exit site and improve the quality-of-life.

Background Left ventricular assist device (LVAD) implantation improves survival and quality of life in patients with advanced heart failure (HF). Despite these advantages, LVADs are not free from risks. Among all adverse events (AE), pump thrombosis and bleeding, especially of the gastrointestinal (GI) tract, have been reported to occur with increasing frequency in some CF-LVADs. The INCOR LVAD system is a third-generation, continuous flow, axial pump with active magnetic levitation, avoiding the potential downsides of mechanical bearings. Methods The aim of this retrospective study was to review the Italian clinical experience with the INCOR LVAD and to determine the prevalence of GI bleeding and pump thrombosis. All patients implanted between January 2006 and May 2012 were considered eligible. Results The total population consisted of 42 patients. LVAD indication was BTT in 36 (86%) and DT in 6 (14%) patients; 31 patients (74%) were INTERMACS class 1 or 2. Mean support time was 525 ± 570 days. The 1-year and 2-year survival rates were 74% and 60%, respectively. The most frequent AE was driveline infection (0.33 events PPY) followed by stroke with consequence (0.17 events PPY), sepsis (0.07 events PPY), and right HF (0.05 events PPY). No episodes of pump thrombosis or GI bleeding were observed. Conclusions In this cohort of high-risk, advanced HF patients, the INCOR LVAD provided effective support with improved survival. Moreover, the absence of GI bleeding and pump thrombosis demonstrates a favorable characteristic of this device. Further prospective studies are needed to confirm these data.

We present our technique for the implantation of the Jarvik 2000 left ventricular assist device (Jarvik Heart, Inc, New York, NY) without cardiopulmonary bypass by the induction of rapid pacing that allows the insertion of the apical device into the left ventricle, minimizing blood loss and surgical complications. Although the off-pump implantation of left ventricular assist devices is not new, our experience of rapid pacing has not been previously reported to our knowledge.

The internal mammary artery (IMA) has been already used in some pioneering experiences since the middle of last century but it became the graft of choice only in the 1980s, after widespread angiographic and clinical demonstration of its superiority over the saphenous vein graft (SVG). The use of both mammary arteries was then explored in order to achieve better long-term results when compared to single IMA and SVG. The IMA can be harvested pedicled or skeletonized and used as an in situ graft or as a source for composite graft (Y-graft, lengthened graft). When the bilateral internal mammary artery (BIMA) is grafted in situ, the left internal mammary artery (LIMA) is generally used for the left descending artery (LAD) and the RIMA for the right coronary artery (RCA), or for the lateral wall, usually going through the transverse sinus. In the case of Y-graft, the left coronary system is more frequently chosen as the target site of revascularization. Our experience shows that: (1) The use of IMA provides better 15-year clinical results when compared to SVG. (2) The use of BIMA in patients younger than 75 years can produce higher 10-year freedom from cardiac-related events than the single one, even in diabetic patients.

Background . Between March 1980 and September 1997, 91 patients underwent evaluation and treatment for primary cardiac neoplasms. Methods . Tumors were grouped into three categories: atrial myxomas, benign nonmyxomas, and malignant tumors. Survivors were contacted; no one was lost to follow-up. The mean follow-up for this series is 7 ± 5 years. Results . Eighty-three patients were diagnosed with atrial myxomas (Male/Female: 29/54), average age 55 ± 13 years. The hospital mortality was 3.6% (3/83), the late mortality was 6.5% (5/80). No recurrent myxomas have been identified clinically or by echocardiography in any patient. Three patients were diagnosed with benign nonmyxoma tumors. (Male/Female: 2/1), average age 64 ± 8 years. There were no perioperative deaths and 1 patient died 4 years postoperatively from fibroma, with no linked causes. No recurrent tumors have been identified. Five patients were diagnosed with malignant tumors. (M/F: 1/4), average age 53 ± 16 years. The hospital mortality was 20% (1/5); in 3 patients a redo-operation was necessary after 8, 11, and 12 months because of tumor recurrence. All patients died within 3 years of the first operation (mean 13 ± 14 months). Conclusions . Surgical resection, when possible, is the treatment of choice for all primary cardiac tumors. Patients with benign tumors are probably cured by resection and in our experience there was no known tumor recurrence. Effective palliation is possible with resection of malignant tumors, but more effective adjuvant therapy will be necessary to improve long-term prognosis.

The main limitation to long-term survival for allogeneic heart transplant recipients is the onset of “accelerated allograft coronary artery disease” (ACAD). Over the years, different treatment options for the management of ACAD-induced critical ischemia have been taken into consideration. The use of percutaneous transluminal coronary angioplasty (PTCA) is still controversial, performed mostly for Type B/C and Type A lesions measuring 2.5 mm. According to Musci et al, there is no difference between PTCA-treated and non–PTCAtreated patients with ACAD. Myocardial re-vascularization surgery is burdened with high peri-operative mortality and poor long-term results. Transmyocardial laser re-vascularization initially provided encouraging short-term results, but these were not borne out by long-term outcome. In consideration of the increasing number of potential heart transplant recipients and the limited donors pool, which is not increasing proportionally, re-transplantation does not appear to be an ethically sufficient option, because a second transplantation entails a far higher short-term mortality than a first transplantation and is accompanied by a high probability of coronary artery disease (CAD) recurrence. The good outcome reported in the literature and our own experience since 1986 in the management of refractory angina with spinal cord stimulation (SCS) has led us to use this technique in posttransplantation CAD as well. To our knowledge SCS treatment for cardiac transplant recipients has not been reported to date. The Brussels Consensus Statement on SCS in 1998 stated that “to be accepted for SCS treatment, angina pectoris must be refractory both to drug therapy (beta-blockers, calcium channel antagonists, long action nitrates, aspirin) and revascularization methods.” We report a 32-year-old man (weight 58 kg, height 168 cm) who underwent orthotopic cardiac transplantation in February 1992 because of dilated cardiomyopathy, which was diagnosed 2 years earlier and probably had a viral etiology. Post-transplantation follow-up revealed hyperlipoproteinemia, hyperuricemia with sporadic episodes of gout, and obesity. During the 4 years after surgery the patient’s tolerance to the allograft was good. Following the onset of diastolic hypertension and atypical chest pain, left cardiac catheterization with coronary angiography was performed in July 1996. Hemodynamic study showed lesion-free coronary arteries. In January 2000 the patient’s weight increased to 97 kg. Also, he complained of chest pain, typical of exercise-induced angina. The pain was “band-like,” retrosternal, with short duration, and decreased at rest (CCS Functional Class II to III). One month From the Divisions of Pain Therapy and Palliative Care, and Cardiac Surgery, University of Turin, Turin, Italy. Submitted June 11, 2002; revised February 13, 2003; accepted February 13, 2003. Reprint requests: Paolo Centofanti, MD, Divisione di Cardiochirurgia, Ospedale Molinette, C.so A.M. Dogliotti 14, 10126 Turin, Italy. E-mail: paolocentofanti@tiscalinet.it Copyright © 2004 by the International Society for Heart and Lung Transplantation. 1053-2498/04/$–see front matter doi:10.1016/S1053-2498(03)00151-7

© S Z ency department because of inguinal pain. After manual eduction of the long-standing inguinal hernia, ankle dema, thrombocytopenia and elevated liver enzymes ere noticed. Abdominal echography discovered a mass nto the inferior vena cava and the subsequent transthoacic echocardiographic study showed a huge right atrial ass (95 mm × 42 mm) extending in the right ventricle, bstructing the tricuspid valve orifice, with caudal extenion into the inferior vena cava (Fig. 1A). Urgent surgical excision of the cardiac mass was perormed through a standard median sternotomy and via a tochemistry confirms hepatic origin of the mass staining tumoral cells with Hepatocyte Antigen (DAKO, OCH1E5) (Fig. 1C). Moreover the CT-scan confirmed the presence of an under-dome liver lesion of 40 mm with hypervascular shell and cystic core (Fig. 1D). Diagnosis of HCC was made and transarterial chemoembolization was scheduled three months after surgery. A second liver chemoembolisation was necessary eight months after surgery and oral chemotherapy with Sorafenib-Tosilato was started. After 19 months follow-up, he leads a normal life without cardiac reoccurrence.

OBJECTIVE: For patients in advanced heart failure, emergency transplantation or ventricular assist devices (VADs) are possible strategies. The aim of this single-centre, retrospective study was to evaluate early and long-term results for these two strategies. METHODS: From 2005 to 2011, we analysed 49 INTERMACS level 1 and 2 patients, who were divided into the following two groups: group A comprised 26 patients on the waiting list for heart transplantation with urgent conditions; and group B comprised 23 patients who underwent VAD implantation as a bridge to candidacy. RESULTS: In group A, 25 patients underwent transplantation. In group B, 19 patients were supported with left VAD and four with biventricular VAD. Of these 23 patients, 13 underwent transplantation (mean time 279 ± 196 days). The 30 day mortality was 42.3 and 4.3% in group A and B, respectively. Survival at 6 and 12 months was significantly better in group B than in group A (87 vs 53%, P= 0.018 at 6 months; and 77 vs 48%, P= 0.045 at 12 months). CONCLUSION: Improved outcomes may justify the use of mechanical assistance devices as a bridge to candidacy or bridge to transplantation in INTERMACS 1 and 2 patients in order to avoid high-risk transplants. Evaluation of long-term multicentre outcomes is needed to assess future strategies.

Infection in patients supported with left ventricular assist devices (LVAD) is common and it can limit widespread implantation of mechanical assistance as destination therapy (DT). The infection-resistance power delivery system could improve longevity and quality of life. The Jarvik 2000 (Jarvik Heart, New York, NY, USA) driveline design showed a prolonged infection-free survival and a better quality of life compared to those patients supported with traditional LVAD with an abdominal cable. We report a singular driveline complication in a 71-year-old patient supported with a Jarvik 2000. A new retroauricular pedestal was successfully repositioned after the detachement of the first one.

Objective To analyze the risk reduction of cardiopulmonary bypass complications between on-pump and off-pump coronary artery bypass grafting in high-risk patients. Methods This multicenter, prospective, randomized, parallel trial enrolled patients for elective or urgent isolated coronary artery bypass grafting with an additive European System for Cardiac Operative Risk Evaluation of 6 or more. The patients in cardiogenic shock were excluded. The composite primary end point included operative mortality, myocardial infarction, stroke, renal failure, reoperation for bleeding and adult respiratory distress syndrome within 30 days after surgery. The total sample size was 693 patients, according to a scheduled interim analysis at 400 patients enrolled (α-spending = 0.029, Pocock method). Results A total of 411 patients were included in the interim analysis. Randomization assigned 203 patients to on-pump and 208 patients to off-pump treatment. Of the 411 patients, 24 crossed over; thus, 195 patients were actually treated on-pump and 216 off-pump. According to the intention to treat analysis, the rate of the composite primary end point was significantly lower (unadjusted P = .009, adjusted P = .010) in the off-pump group (5.8% vs 13.3%). The risk of experiencing the primary end point was significantly greater for the on-pump group (unadjusted odds ratio, 2.51; 95% confidence interval, 1.23–5.10; P = .011; adjusted odds ratio, 3.07; 95% confidence interval, 1.32–7.14; P = .009). Conclusions Off-pump coronary artery bypass grafting reduces early mortality and morbidity in high-risk patients.

Urgent repair (within 48 hr after diagnosis) of posterior ventricular septal defect in the presence of cardiogenic shock, consequent to acute myocardial infarction, is associated with a very high mortality rate. The use of left ventricular mechanical support devices has the potential to impart hemodynamic stability and to delay surgical treatment until such time as scar tissue forms around the defect, sufficient to hold a suture patch.From May 2004 through July 2007, 5 patients who were in cardiogenic shock as a consequence of acute posterior ventricular septal defect underwent early implantation of a transfemoral microaxial Impella® Recover® LP 5.0 Support System as mechanical support (bridge to surgery).The mean duration of support by the left ventricular assist device was 14.4 ± 6 days. No one died during assistance. The device reduced left-to-right shunting, systolic pulmonary artery pressure, central venous pressure, and pulmonary capillary wedge pressure. Liver, kidney, and lung function improved, and the 30-day mortality rate was 40%.Although this is a retrospective study of a very small patient population, without benefit of a control group, it is the first report of its kind. This initial experience using the Impella Recover 5.0 in cases of cardiogenic shock due to posterior ventricular septal defect suggests that this conservative approach is a feasible and safe way to improve hemodynamic conditions and delay surgery. Further clinical experience is needed to confirm these early results.

Patients awaiting cardiac transplantation often require ventricular assist devices (VADs) due to instable circulatory condition. Device-related infections remain the 'Achilles heel' of mechanical circulatory support and wound complications after VAD placement are a formidable challenge to surgeons. Up to 25% of deaths in VAD patients are due to systemic sepsis, which occurs in 11-26% of patients and bacteria that are common pathogens including Staphylococcus, Pseudomonas, Enterococcus, and Candida. Sepsis, infection of implanted pump components, and infections of percutaneous drivelines continue to limit survival. The Berlin Heart-EXCOR VAD is a para-corporeal pulsatile system that has been successful in patients with severe biventricular dysfunction. We report a case of a 35-year-old male suffering from a postischemic cardiomyopathy who received an EXCOR biventricular assist device as a bridge to transplant. During the assistance the patient developed concomitant methicillin-resistant Staphylococcus aureus infection of implanted pump components which was resistant to conventional therapy. The patient developed sepsis with splenic infarctions due to septic embolization which was successfully treated with a heart transplant. In some extreme cases of VAD infections, such as this, the only therapeutic option is transplantation or device replacement.

There is no standardised approach for cardioplegia administration during ascending aorta replacement (AAR) and the techniques used so far are quite variable and show important limitations. In order to overcome these limitations, we propose a simple and inexpensive technique using a Foley catheter for cardioplegia administration and bleeding control in case of AAR or aortic root surgery. The benefits of our technique are the technical simplicity and the low cost that makes this approach an ideal solution for cardioplegia administration in all cases of AAR.

Background Triple therapy is the gold standard after heart transplantation while few reports have described experiences with cyclosporine monotherapy (CM). We have analyzed our experience with CM in long-term heart transplant recipients, surviving >5 years. Methods Of the 219 patients transplanted between January 1990 and December 1998, 143 survived >5 years (mean age, 49.6 ± 10.4). There were 124 (86.7%) male subjects. Matching patients respect to follow-up length, we obtained 2 groups: group A of 41 patients on double therapy (DT; cyclosporine plus Azathioprine) and group B of 41 patients on CM. Results After a mean follow-up of 119.8 ± 32.2 months, we did not observe a significant difference in terms of survival and major events: heart failure, malignancy, dialysis, infections, and CAV. Conclusion We strongly support the use of triple therapy in cardiac transplant recipients because of its known safety and efficacy. However, our experience with CM suggests the utility of this approach.

Adverse events due to anticoagulation and antiplatelet therapy during left ventricular assistance device (LVAD) support are very common, and every effort must be made to reduce their impact. We report our experience using a low dose of double antiplatelet therapy for patients provided with the INCOR LVAD system as a bridge to transplantation. Twelve patients (10 males, 35-60 years old) with acute or end-stage heart failure were included in this study. The mean follow-up was 10 months (cumulative 4.9 years). For antiplatelet therapy, we use an association of variable doses of aspirin and clopidogrel. The use of a platelet aggregation test (PAT) allows reducing the dose of the drugs to the minimum needed. The primary end point was to check the safety of the therapy, analyzing the incidence of major and minor bleeding complications. The secondary end point was to check the effectiveness of the therapy, evaluating the incidence of major and minor thromboembolic events. We had three (25%) cases of early postoperative mediastinal bleeding. On the contrary, no episodes of major bleeding occurred during the follow-up period. The rate of minor bleeding complications was low: 0.2 events per patient/year. The rate of major and minor thromboembolic events was acceptable (respectively 0.09 and 0.2 per patient/year). During LVAD support, double antiplatelet therapy with a low dose of aspirin and clopidogrel was safe and effective. PAT allows reducing the dose of antiplatelet drugs, avoiding complications related to excessive or insufficient dose administration.

We present the case of a patient with recurrent episodes of pericardial effusion and fever. During approximately one month, the patient was treated with double pericardiocentesis for cardiac tamponade and the last of them was interrupted for the suspect of left ventricular puncture due to aspiration of arterial blood from the needle used for pericardiocentesis. Considering the suspect of infective pleuro-pericarditis and patient's symptoms, a surgical drainage of the pericardial effusion was performed via right thoracotomy. The echocardiography and CT-scan performed after right thoracotomy showed only a mild pericardial effusion. Fifteen days later, the patient suffered from congestive heart failure and fever. The echocardiography and CT-scanning which were performed urgently, showed a large pseudoaneurysm (approx. 26 mm x 36 mm) of the apex of the left ventricle. Ventriculography confirmed the presence of the pseudoaneurysm in connection with the left ventricular apex. Exclusion of the LV pseudoaneurysm was performed using a Prolene 0 running suture on two strips of bovine pericardium, avoiding ECC use. The patient was discharged on the 7th postoperative day. Iatrogenic pseudoaneurysm caused by pericardiocentesis represents a very rare complication and it should be prevented by identifying the high-risk patients.

The obstructive calcifying aortic disease refers to severe calcifications of the descending aorta that obstruct or slow blood flow. Here, we report the case of a 65-year-old woman with recent onset of a very tight intermittent claudication and concomitant severe and uncontrolled hypertension, treated with a bypass graft between the proximal descending thoracic aorta and the supravisceral abdominal aorta.