Antonio Campanella

Endoscopic Saphenous harvesting with an Open CO2 System (ESOS) trial for coronary artery bypass grafting surgery: study protocol for a randomized controlled trial

BackgroundIn coronary artery bypass grafting surgery, arterial conduits are preferred because of more favourable long-term patency and outcome. Anyway the greater saphenous vein continues to be the most commonly used bypass conduit. Minimally invasive endoscopic saphenous vein harvesting is increasingly being investigated in order to reduce the morbidity associated with conventional open vein harvesting, includes postoperative leg wound complications, pain and patient satisfaction. However, to date the short and the long-term benefits of the endoscopic technique remain controversial. This study provides an interesting opportunity to address this gap in the literature.Methods/DesignEndoscopic Saphenous harvesting with an Open CO2System trial includes two parallel vein harvesting arms in coronary artery bypass grafting surgery. It is an interventional, single centre, prospective, randomized, safety/efficacy, cost/effectiveness study, in adult patients with elective planned and first isolated coronary artery disease. A simple size of 100 patients for each arm will be required to achieve 80% statistical power, with a significant level of 0.05, for detecting most of the formulated hypotheses. A six-weeks leg wound complications rate was assumed to be 20% in the conventional arm and less of 4% in the endoscopic arm. Previously quoted studies suggest a first-year vein-graft failure rate of about 20% with an annual occlusion rate of 1% to 2% in the first six years, with practically no difference between the endoscopic and conventional approaches. Similarly, the results on event-free survival rates for the two arms have barely a 2-3% gap. Assuming a 10% drop-out rate and a 5% cross-over rate, the goal is to enrol 230 patients from a single Italian cardiac surgery centre.DiscussionThe goal of this prospective randomized trial is to compare and to test improvement in wound healing, quality of life, safety/efficacy, cost-effectiveness, short and long-term outcomes and vein-graft patency after endoscopic open CO2 harvesting system versus conventional vein harvesting.The expected results are of high clinical relevance and will show the safety/efficacy or non-inferiority of one treatment approach in terms of vein harvesting for coronary artery bypass grafting surgery.Trial registrationwww.clinicalTrials.gov NCT01121341.

Hybrid repair of aortic arch aneurysm in high-risk patients.

Objectives Morbidity and mortality after conventional surgery of aortic arch aneurysms remain high. Alternative techniques are the subject of this report. Methods and results Open surgery requires cardiopulmonary bypass and hypothermic circulatory arrest. Thoracic endovascular aneurysm repair has a less invasive therapeutic alternative. The number of high-risk patients has considerably increased over the past decade. The proximity of the aneurysm to the supraaortic vessels makes it difficult to achieve a satisfactory proximal landing zone for endovascular stenting. Two methods have been proposed to address this issue: branched stent grafts and extraanatomic bypass, defined as a hybrid approach, which combines aortic debranching and endovascular procedures. Experience with hybrid repair is limited. Today there are no formal guidelines for the management of aortic arch aneurysm in high-risk patients. Conclusion Hybrid repair of aortic arch aneurysm in high-risk patients is a feasible and safer option.

ECMO as a bridge to transplantation in biventricular dysfunction due to primary spontaneous coronary artery dissection

(...) The overall number of patients requiring extra-corporeal membrane oxygenation (ECMO) support is considerable; however, its use as a bridge to HTx in patient with (...) spontaneous coronary artery dissection (SCAD) due to eosinophil arteritis has never been reported and only few cases of successful HTx after left ventricular assist device (L-VAD) have been described [1]. SCAD has been defined as an intramural haematoma of the coronary artery wall which occludes the true lumen, determining blood flow obstruction and acute myocardial ischemia without any obvious causes [2]. Use of oral contraceptives and arterial wall changes during pregnancy have been advocated as facility factors, nevertheless the occasional report of SCAD in men suggest that other factors are involved (..) [3]. Systemic hypertension, (...) cystic medial necrosis and intense coronary vasospasm, caused by strong emotional stresses (...) have rarely been reported as the cause of coronary artery dissection (...) [4]. Some authors affirm that it may be caused by inflammatory mechanism with release of dangerous substances against the wall of the coronary arteries [5]. Finally, the possibility that an intramural haematoma and unknown alterations of the collagen tissue turns out in a SCAD, may be considered [6]. (...) Some of these factors have been observed in the case following described. A 37-year-old woman (blood type O+) presented to the emergency care unit of a peripheral hospital with abdominal and ongoing chest pain associated to dyspnea. In anamnesis she had history of smoke, use of oral contraceptives, colon diverticula and previous use of high estrogens dose to induce pregnancy. EKG showed atrial fibrillation and inferior ST-segment elevation. The increase in creatine kinase-MB and troponine confirmed the diagnosis of acute myocardial infarction. Transthoracic echocardiography showed a preserved left ventricular function and mild hypokinesia of the inferior and basal segments. Subsequent echo showed left ventricular function worsening (EF 15%) and diffuse hypokinesia. Angiography showed an unexpected finding: SCAD involved left main trunk, anterior descending artery (LAD) (Fig. 1) and right coronary artery (RCA) (Fig. 2) but EKG showed only inferior STsegment elevation. (...) Intra-aortic balloon pump was inserted and the patient underwent coronary artery bypass graft (CABG): left mammary artery was grafted on LAD and two segments of saphenous vein were grafted on obtuse marginal and RCA. CABG failure was probably related to the long interval between myocardial infarction and surgery. Despite good flow measurements, weaning from ECC was impossible and the surgeons of the peripheral hospital (which had in their availability only ECMO) used this support to ensure patient’s survival, positioning the inflow cannula in the right atrium and the outflow in the ascending aorta and maintaining the flow around 75% of the ideal: left ventricular vent was not used because pulmonary circulation was well decompressed by the right atrial cannula as checked by us with echo. To prevent pulmonary atelectasis, lungs were ventilated and hemogasanalysis was stable. ECMO advantages in this case were the easiness of implantation, its widespread availability

Mycotic pseudoaneurysm as aortic complication after heart transplantation.

Infective pseudoaneurysm is a rare cause of aortic complications in immunosuppressed heart transplant patients. It is associated with a significant and early morbidity and mortality [1]. An unusual site of complication is the anastomotic suture line of the ascending thoracic aorta [2]. A 58-year-old man with previous pacemaker implantation, for complete atrioventricular block, underwent orthotopic heart transplantation for severe idiopathic cardiomiopathy: pacemaker was easily removed but one of the wires was not displaced because it was integrated into the vessel wall. No abnormalities in terms of antibodies between donor and recipient were detected in pretransplant evaluation. Re-exploration of the pericardial cavity for bleeding was performed on third postoperative day (POD). From 27th POD, bradycardia and fever set in and antibiotic therapy with teicoplanin and meropenem was introduced. Blood culture was positive for methicillin-resistant Staphylococcus aureus (MRSA) and only intravenous teicoplanin was continued. Refractory bradycardia was treated with intravenous atrially inhibited and rate-modulated pacemaker implantation on 36th POD. Further episodes of fever were encountered; however, the subsequent course was uneventful and the patient was discharged without complications. Two episodes of acute rejection >3A were detected and treated with i.v. steroids; after three other episodes of acute rejection <3A, cyclosporine was switched with tacrolimus along with mycophenolate mofetil and oral steroids. Five months later, he was readmitted for fever and CT scanning revealed pneumonia with blood cultures proving positive for MRSA but no aortic pathologies were detected. Antibiotic therapy with levofloxacin and linezolid was started with complete recovery in patient condition and abating of fever. Recurrent episodes of fever and positive blood cultures occurred and the hypothesis of an intravenous site of infection was considered because of fever recurrence in case of antibiotic suspension. Two structures were strongly suspected as possible sites of infection: the wire implanted after transplantation and the wire incarcerated into the vessel wall. On this basis, the patient underwent procedure for removal both of the pacemaker both of the wires. However, it was impossible to remove the wires already incarcerated into the vessel. There were many other episodes of fever further that were treated with long-term antibiotic therapy. On January 2008, approximately 2 years after transplantation, echocardiography revealed pericardial effusion with evidence of infected vegetations on the pacemaker wires. Chest radiography showed an image indicative of pneumonia in the basal segment of the right lung without mediastinal mass. CT scanning, performed to confirm the suspicion of pneumonia, showed a 4.3 · 2.8 cm mycotic pseudoaneurysm at the posterior anastomotic site of the aortic anastomosis (Fig. 1). No signs of pneumonia were detected but just pulmonary congestion. Moreover, bacteriological exams did not reveal pulmonary infection. The patient underwent surgical treatment. Mycotic pseudoaneurysm was identified as a round structure of approximately 4 cm in diameter starting from the posterior section of the aortic suture and extending towards pulmonary artery, which was compressed and weakened by the mass (Fig. 2). The ascending aorta was replaced with Dacron graft and the infected wires were completely removed. The antibiotic treatment with intravenous teicoplanin was continued postoperatively and the patient was discharged in 14th POD without complication. No other episode of fever occurred despite discontinuation of antibiotics and the CT scanning performed 6 months later, did not show any signs of infection. The term mycotic aneurysm is used to describe any infection of the arterial wall other than syphilis [1]. Osler [2] first documented a mycotic aneurysm in 1885, developed from septic embolization caused by bacterial endocarditis. Infective pseudoaneurysms are usually caused by haematogenous bacterial seeding to the intima or the vasa vasorum, lymphatic spread, extension of a contiguous extravascular infection, or traumatic inoculation [3]. In patients with mediastinitis, with inflammatory oedema of the tissues, pressure and stress may facilitate

Acute bioprosthetic thrombosis immediately after aortic valve replacement.

We present the case of a 72-year-old woman referred for dyspnea and vertigo when admitted to the hospital with a diagnosis of aortic stenosis. She had hypertension with previous deep venous thrombosis with no known hypercoagulable diathesis. She underwent aortic valve replacement with a Carpentier-Magna bioprosthesis without intraoperative complications; selective cardioplegia before aortic wall suture confirmed that coronary ostia were free. After extracorporeal circulation weaning, an episode of ventricular fibrillation occurred; sinus rhythm was restored using 20 J shock. Considering new episodes of ventricular fibrillation, the increasing number of polymorph ectopic ventricular systoles and the worsening of patient condition despite the use of high doses of inotropes, an intra-aortic balloon pump 1: 1 was inserted via the right femoral artery. Echocardiography (ECG) did not show alteration of the bioprosthesis in the presence of severe left ventricular impairment (ejection fraction <30%) with ipokinesia of the anterior-lateral wall and moderate-severe mitral regurgitation. Considering the rapid decline of the patients condition despite the use of high doses of inotropes and an intra-aortic balloon pump, the aortic wall was reopened to control bioprosthesis. The intraoperative finding was unexpected; a thrombus of length 3-4 cm was found, attached to the prosthetic annulus and protruding into the left main trunk. The thrombus was immediately sucked up to avoid coronary embolization and, after that, the prosthesis was replaced with a Mitroflow 19 (Sorin Group Inc, Mitroflow Division, Vancouver, Canada) bioprosthesis. Probably, an association between factors could induce thrombosis-like aortic sinuses: annulus dimensions, endothelium damage caused during decalcification, tears in the bioprosthetic sewing ring, unknown coagulation diathesis and the structure of the Carpentier-Magna support may have induced this very unusual complication. However, we do not have enough information to establish with certainty the causes of this complication, but discussion of this topic may be useful.

Unexpected long durability of a low-profile porcine Liotta bioprosthesis in mitral position.

We report a case in which replacement of a low-profile porcine Liotta bioprosthesis was required 21 years after initial implantation. The patient underwent mitral valve replacement with a 28-mm Liotta bioprosthesis in 1985 for mitral stenosis. Twenty-one years later, severe mitral regurgitation was detected at echocardiography and mitral valve reoperation combined with tricuspid annuloplasty was successfully performed. Focal perforation of two cusps with consequent intravalvular leak on bioprosthesis was found. This is the longest durability report for a Liotta bioprosthesis in mitral position.