Antonino M. Grande

Orthotopic heart transplantation: Standard versus bicaval technique

We compared orthotopic heart transplantation (HT) by bicaval technique with the standard technique. Between January 1995 and December 1997, 117 patients underwent 118 HTs; 71 patients (15 women and 56 men) had 72 HTs by standard technique and 46 patients (9 women, 37 men) underwent HT using bicaval procedures. Preoperative parameters were similar in both groups; 5 patients who underwent the standard technique and no patients who underwent bicaval procedures required permanent pacemakers (p = NS). Isoproterenol infusion was significantly longer in the standard technique. Major perioperative arrhythmias (ventricular tachycardia and fibrillation, asystole) appeared in 8.2% and 7.0% of standard and bicaval HTs, respectively; atrial fibrillation appeared in 13.1% and 4.6%, respectively (p = NS). At 1 month, mitral and tricuspid regurgitation rates were higher in the standard group (p = NS); at 1 year only tricuspid regurgitation was still higher (p = NS). Right atrial pressure, Wood units, cardiac output, and cardiac index were examined (p = NS). At multivariate analysis, interaction between preoperative Wood units and transplant type was elicited for Wood units at 1 month and for right atrial pressure at 1, 3, and 6 months. In the high resistance subgroup, the patients who underwent bicaval procedures had higher resistances at 1 month. In the low resistance subgroup, right atrial pressure was higher in patients who underwent standard techniques at 1, 3, and 6 months follow-up. Thus, bicaval HT was found to be safe, without surgically related complications, it provoked significantly less blood loss, and required less isoproterenol use. No significant advantages were observed in conduction disturbances and major arrhythmias or regarding the need for temporary or permanent pacemakers.

The spectrum of aortic complications after heart transplantation.

BACKGROUND The connection between the donor and the recipient aorta is a potential source of early and late complications as a result of infection, compliance mismatch, and technical and hemodynamic factors. Moreover, the abrupt change in systolic pressure after heart transplantation involves the entire thoracic aorta in the risk of aneurysm formation. The aim of this study was to analyze the types of aortic complications encountered in our heart transplantation series and to discuss etiology, diagnostic approach, and modes of treatment. METHODS Of the 442 patients having orthotopic heart transplantation and the 11 patients having heterotopic heart transplantation at our center, 9 (2%) sustained complications involving the thoracic aorta. These 9 patients were divided into four groups according to the aortic disease: acute aortic rupture (2 patients); infective pseudoaneurysm (3 patients); true aneurysm and dissection of native aorta (2 patients); and aortic dissection after heterotopic heart transplantation (2 patients). Surgical intervention was undertaken in 8. RESULTS Five (83%) of 6 patients who underwent surgical treatment for noninfective complications survived the operation, and 4 are long-term survivors. One patient who underwent a Bentall procedure 71/2 years after heterotopic heart transplantation died in the perioperative period of low-output syndrome secondary to underestimated chronic rejection of the graft. One patient with pseudoaneurysm survives without surgical treatment but died several years later of cardiac arrest due to chronic rejection. Both patients operated on for evolving infective pseudoaneurysm died in the perioperative period. CONCLUSIONS Infective pseudoaneurysms of the aortic anastomosis are associated with a significant mortality. In noninfective complications, an aggressive surgical approach offers good long-term results. The possibility of retransplantation in spite of complex surgical repair should be considered in the late follow-up after heart transplantation, due to the increasing incidence of chronic rejection.

Risk factors for early death in patients awaiting heart-lung or lung transplantation: experience at a single European center.

BACKGROUND Our purpose was to establish whether patients on the waiting list for heart-lung or lung transplantation had different survival rates according to diagnosis and to determine the specific variables responsible for early death. METHODS Between 1988 and 1996, 278 patients were placed on the waiting list for organ transplant. Diagnoses were pulmonary vascular disease in 128, parenchymal disease in 141, and retransplantation in 9 patients. Eighty patients received transplants, 100 patients died awaiting transplantation, and 98 patients are still awaiting transplantation. Univariate and multivariate analyses of risk factors for early death on the waiting list were performed. Patients still listed < or =6 months (n=24), transplanted < or =6 months (n=37), or in the retransplantation group (n=9) were excluded. Of the remaining 208 patients, 52 died < or =6 months and 156 survived >6 months. RESULTS Patients with primary pulmonary hypertension, pulmonary fibrosis, or cystic fibrosis had statistically significantly lower survival rates at 6, 12, and 24 months (31%, 36% and 26%, respectively, at 24 months) than patients with Eisenmengers syndrome and chronic obstructive pulmonary disease (76% and 71%). Patients with Eisenmengers syndrome who died < or =6 months had significantly higher systolic pulmonary artery pressure (134+/-39 vs. 108+/-25 mmHg) and pulmonary vascular resistance (1928+/-1686 vs. 1191+/-730 dyn/sec/cm(-5)) than those who survived longer. Patients with pulmonary fibrosis who died < or =6 months had significantly lower forced vital capacity (36+/-15 vs. 47+/-13% predicted), forced expiratory volume (37+/-14 vs. 48+/-14% predicted), room air PO2 (42+/-11 vs. 50+/-11 mmHg), and room air O2-saturation (78+/-10 vs. 84+/-8%) than those who survived longer. In the multivariate analysis, only the type of pathology was a significant risk factor for death after being on the waiting list < or =6 months. CONCLUSIONS Certain pathologies and variables are risk factors for early death in patients on the waiting list. This information may be used to allocate specific donor organs to patients in greater need.

Heart transplantation in chemotherapeutic dilated cardiomyopathy

Anthracycline cardiotoxicity can induce dilated cardiomyopathy (DCM). Nine patients (four men) experienced postchemotherapy DCM: age at time of tumour diagnosis ranged from 1-45 years (mean 13.5 +/- 19 years); interval time between tumour and HT was 3-23 years (mean 10.8 +/- 6.6) and age at HT ranged from 10-65 years (30.8 +/- 20.1). Interval between end of chemotherapy and beginning of cardiac symptoms was 5.71 +/- 4.6 years. Mean age at DCM diagnosis was 19.2 +/- 19.7 (range 1-50 years). Interval between start of chemotherapy and DCM ranged from 1 month to 10 years (mean 3.15 +/- 3.6 years). Tumours were Ewing sarcoma (7-year-old boy), paratesticular rabdomyosarcoma (1-year-old boy), Wilms tumor with pulmonary metastasis (3-year-old girl), bilateral breast carcinoma (45-year-old woman), uterine leiomyosarcoma (44-year-old woman), acute myelocytic leukemia (1.5-year-old boy and 17-year-old girl), and chronic myelocytic leukemia (5-year-old boy). All patients had high pulmonary resistance values. One patient with chronic myelocytic leukemia (14 year-old at HT) died due to graft failure on the first postoperative day. At follow-up (mean, 80.4 +/- 69.3 months) two patients died: a 32-year-old woman (acute myelocytic leukemia) 1 year after HT for sepsis and a 68-year-old woman who had breast adenocarcinoma recurrence 81 months after HT. The remaining patients are alive, in good condition with no difference in survival from other transplanted patients (P =.757). Patients with end-stage postchemotherapy DCM without evidence of tumour recurrence can safely undergo HT.

The axillary artery as an alternative site of cannulation for redo port access-assisted minimally invasive mitral valve surgery: early report of 2 cases

The minimally invasive Heartport (HP)-assisted technique has become first choice option for mitral valve surgery in many centres.The pool of patients potentially treated using HP techniques, however, is still limited by the presence of peripheral vessel disease, expecially in the elderly population. Alternative approaches to using the HP technique safely in such a subset of patients, therefore, should be evaluated. Here, we present our preliminary experience using the axillary artery as an alternative site of cannulation for HP-assisted redo mitral valve surgery in patients with concomitant peripheral vessel disease.

Nonpenetrating right atrial and pericardial trauma

Nonpenetrating chest trauma can cause cardiac rupture. Ventricles are affected more frequently than atria. Survival is rare and depends upon prompt diagnosis and immediate surgical intervention. We report the case of a 42-year-old man involved in a car accident with consequent right atrial rupture and pericardial tearing.

Heart transplantation without informed consent: discussion of a case

AbstractObjective: To discuss informed consent to heart transplantation in the case of an intensive care unit (ICU) patient: relatives’ informed consent was refused by the patient himself whose cognitive ability appeared to be reasonable for the purpose. Setting: ICU of a university teaching hospital. Patient: a 62-year-old man who underwent myocardial revascularization had in the immediate post-operative hemodynamic instability, continuous serious arrhythmias, ventilatory support, fentanyl infusion. Heart transplantation could be the only chance for his survival. Intervention: heart transplantation. Results: despite patient’s refusal, we decided to hold the relative’s consent as valid, and transplantation was accordingly performed, to the subsequent satisfaction of the patient. Conclusions: Our decision was based on two beliefs: (1) the severity of the patient’s clinical condition may have impaired his cognitive abilities; (2) the very same conditions may mask impairment and certainly make reliable assessment of cognition and judgment impossible. This being so, the preservation of life assumes priority.

Superior Transseptal Approach for Surgical Removal of Left Atrial Myxoma

Abstract Eight patients (4 men, 4 women), mean age 51 years, referred to our Institution for left atrial myxoma underwent removal of the tumor through a superior transseptal approach. All patients in sinus rhythm with normal conduction time. The myxomas were localized in the fossa ovalis (3 cases), interatrial septum (2 cases), left appendage (2 cases), and mitral annulus (1 case). One patient died in hospital after emergency operation for low‐output syndrome complicated by septic shock. All other patients had an uneventful postoperative course. Atrial arrhythmias did not represent a major postoperative complication. Transient PR interval elongation was occasionally seen. Electrophysiological studies showed normal sinus node function. At 6 months following operation, patients were evaluated with transeso‐phageal echocardiography. There was no tumor recurrence. There were no episodes of arrhythmia in 24‐hour electrocardiographic monitoring, and all patients were in NYHA Class I. We believe that the superior transseptal approach gives optimal exposure of the left atrial cavity, overcoming all difficulties related to a small left atrium which is an usual pattern in left atrial myxomas.

Comparison of standard and bicaval approach in orthotopic heart transplantation: 10-year follow-up.

Background The present study compared 86 patients who underwent orthotopic heart transplantation by bicaval and standard techniques. Methods Patients already followed in the first year after heart transplantation were studied at 10 years of follow-up, this time evaluating the prevalence of arrhythmias, conduction disturbances and mitral or tricuspid regurgitation. Results The following arrhythmias were observed: atrial fibrillation (one patient from the standard group), ventricular premature beats and ventricular fibrillation (each in one patient from the bicaval group). Conduction disturbances were found in 25 patients in the standard group (48.1%) and in 19 patients in the bicaval group (55.9%, P = 0.515). Twenty patients had a mono- or bifascicular block in the standard group (38.5%) versus 19 patients in the bicaval group (55.9%); furthermore, five patients in the standard group (9.6%) and none in the bicaval group had a permanent pacemaker (Fishers exact test: P = 0.074). Mitral regurgitation was present in 13 (26.5%) and five (16.1%) patients, respectively, in the standard and bicaval groups (Fishers exact test: P = 0.411): it was grade 1 in 12 and five patients and grade 2 in one and zero patients, respectively. Tricuspidal regurgitation was observed in 26 (53.1%) and 13 (41.9%) patients, respectively, in the standard and bicaval groups (Fishers exact test: P = 0.366): it was grade 1 in 23 and 13 patients and grade 2 in three and zero patients, respectively. Cumulative survival was 75% at 10 years from transplant in this relatively old population of patients (mean age = 58 years). Conclusion In conclusion, our data do not support any definite mandate for either of the surgical techniques.

Reconstruction of Anterior Descending Artery after Removal of Stents

A 65-year-old man who had previously undergone multiple stenting on the coronary tree, was referred for urgent surgery. The left anterior descending coronary artery was found to be completely stented from the proximal to the distal portion. Open endarterectomy was required for removal of multiple thrombosed stents and reconstruction of the left anterior descending artery using left internal mammary artery. This highlights the need to spare the distal parts of coronary vessels for future surgery.