Antonio Loforte

Extracorporeal Membrane Oxygenation for Primary Allograft Failure

OBJECTIVE Herein we have reported our experience concerning the usefulness of extracorporeal membrane oxygenation (ECMO) in heart transplant patients. PATIENTS AND METHODS Between July 2002 and March 2007, 11 heart transplant patients, namely, 8 men and 3 women of overall mean age of 49.4 +/- 13.9 years (range, 19-62 years) with primary graft failure underwent ECMO implantation. Two patients had pulmonary hypertension; 3 had been transplanted with hearts from marginal donors. At the time of implantation, all were in severe cardiogenic shock despite maximal inotropic support. In 6 patients, the ECMO was implanted centrally in the operating room when there was failure of weaning of cardiopulmonary bypass. Among the 5 remaining patients, ECMO was implanted peripherally in the intensive care unit, during the first 60 hours, including 3 cases of hemodynamic instability and 1 of irreversible cardiac graft arrest. The last patient was implanted on day 30 after transplantation because of acute rejection. RESULTS Mean pump outflow was 2.7 +/- 0.4 L/min/m(2). One patient died on circulatory support due to a cerebral hemorrhage. Ten patients were weaned from ECMO after a mean duration of 9.1 +/- 6.9 days (range, 1-18 days). All of them were successfully discharged. No retransplantation occurred. CONCLUSION Rapid operating room or bedside placement of ECMO allowed stabilization of hemodynamics with potential myocardial recovery in patients with cardiac graft failure.

Surgical therapy in patients with active infective endocarditis: seven-year single centre experience in a subgroup of 255 patients treated with the Shelhigh® stentless bioprosthesis

OBJECTIVE We investigated outcomes after surgical therapy in patients with active infective endocarditis (AIE) with regard to survival in relation to surgical urgency, valve position, number of valves implanted and abscess formation. We aimed to identify independent risk factors for early mortality. METHODS AND RESULTS Two hundred and fifty-five patients received Shelhigh bioprostheses between February 2000 and March 2007. A total of 74.1% had native and 25.9% prosthetic AIE. Surgery was regarded as urgent in 57.3% and as an emergency procedure in 38.4%. There was a highly significant difference in survival rate between patients who were operated on urgently versus in an emergency (p<0.0001), between single and double valve replacement (p=0.0206) and between patients with and without abscess formation (p=0.0245). There were two cases of early reinfection (0.78%) and six of late reinfection (2.35%) leading to re-operation. CONCLUSIONS The survival of patients differs significantly in dependence on their surgical urgency. Better outcome could have been achieved if patients had been referred earlier for surgery and operated upon before heart failure or septic shock developed. Long-term survival was better in patients without abscess formation. The low reinfection rate of Shelhigh bioprostheses in AIE is promising and the early and mid-term results achieved need to be verified in the long-term course.

Peripheral Extracorporeal Membrane Oxygenation System as Salvage Treatment of Patients With Refractory Cardiogenic Shock: Preliminary Outcome Evaluation

The novel Permanent Life Support (PLS; Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany) as peripheral veno-arterial extracorporeal membrane oxygenation (ECMO) support system has been investigated as treatment for patients with refractory cardiogenic shock (CS). Between January 2007 and July 2011, 73 consecutive adult patients were supported on peripheral PLS ECMO system at our institution (55 men; age 60.3 ± 11.6 years, range: 23-84 years). Indications for support were failure to wean from cardiopulmonary bypass in the setting of postcardiotomy (n = 50) and primary donor graft failure (n = 8), post-acute myocardial infarction CS (n = 12), and CS on chronic heart failure (n = 3). Mean support time was 10.9 ± 7.6 days (range: 2-34 days). Overall, 26 (35.6%) patients died on ECMO. Among survivors on ECMO, 44 (60.2%) patients were successfully weaned from support, and three (4.1%) were switched to a mid-long-term ventricular assist device. Thirty-three (45.2%) were successfully discharged. The following variables were significantly different if survivors and nonsurvivors on ECMO were compared: age (P = 0.04), female gender (P < 0.01), cardiopulmonary resuscitation before ECMO (P < 0.01), lactate level before ECMO (P = 0.01), number of platelets, fresh frozen plasma units, and packed red blood cells (PRBCs) transfused during ECMO support (P = 0.03, P = 0.02, and P < 0.01), blood lactate level (P = 0.01), and creatine kinase isoenzyme MB (CK-MB) relative index 72 h after ECMO initiation (P < 0.001), and multiple organ failure on ECMO (P < 0.01). Stepwise logistic regression identified blood lactate level and CK-MB relative index at 72 h after ECMO initiation, and number of PRBCs transfused on ECMO as significant predictors of mortality on ECMO (P = 0.011, odds ratio [OR] = 2.48; 95% confidence interval [CI] = 1.11-3.12; P = 0.012, OR = 2.81, 95% CI = 1.026-2.531; and P = 0.012, OR = 1.94, 95% CI = 1.02-5.21; respectively). Patients with an initial poor hemodynamic status could benefit by rapid peripheral installation of PLS ECMO. The blood lactate level, CK-MB relative index, and PRBCs transfused should be strictly monitored during ECMO support.

Body mass index and outcome after ventricular assist device placement.

BACKGROUND The implantation of ventricular assist devices (VAD) is an established treatment for end-stage congestive heart failure. Extremes of body mass index (BMI) are associated with decreased survival after cardiac surgery. Many patients with congestive heart failure develop cardiac cachexia. In this study the association between BMI and outcomes after VAD implantation was investigated. METHODS Consecutive patients (n = 590) who underwent VAD placement between 1996 and 2006 were divided into five groups based on BMI (kg/m2) quintiles (<20; 20-24; 25-29; 30-35; and >35). In a multivariate analysis adjusted for age, sex, diagnosis, emergency level, and type of device (left ventricular or biventricular assist device), procedural success (recovery, transplantation, or 30-day survival) and complications were analyzed. The best group was set as reference category for calculation of odds ratios. RESULTS The groups with both extremes of BMI had the worst outcomes. The best procedural success was in the group with BMI 25 to 29 kg/m2. Underweight patients had similar survival rates to patients with normal weight. Overweight and obese patients did not have decreased survival. Extreme obesity at the time of VAD implantation showed elevated risk for postoperative death. There was no significant difference for BMI groups in the type of complications and cause of death. Cumulative survival curves for BMI category and overall VAD patient survival showed no significant differences. CONCLUSIONS Cardiac cachexia need not be an exclusion criterion for VAD placement. Underweight patients appear to have benefit from mechanical support. Severely obese patients should be carefully selected before VAD placement.

Temporary right ventricular mechanical support in high-risk left ventricular assist device recipients versus permanent biventricular or total artificial heart support.

Early planned institution of temporary right ventricular assist device (RVAD) support with the CentriMag (Levitronix LLC, Waltham, MA, USA) in left ventricular assist device (LVAD) recipients was compared with permanent biventricular assist device (BVAD) or total artificial heart (TAH) support. Between 2007 and 2011, 77 patients (age range: 25-70 years) with preoperative evidence of biventricular dysfunction (University of Pennsylvania score >50; University of Michigan score >5) were included. Forty-six patients (38 men; median age 54.5 years, range: 25-70 years) underwent LVAD placement combined with temporary RVAD support (group A); in 31 patients (25 men; median age 56.7 years, range: 28-68 years), a permanent BVAD or TAH implantation (group B) was performed. Within 30 days, 12 patients from group A (26.08%) and 14 patients from group B (45.1%) died on mechanical support (P = 0.02). Thirty patients (65.2%) in group A were weaned from temporary RVAD support and three (6.5%) underwent permanent RVAD (HeartWare, Inc., Framingham, MA, USA) placement. A total of 26 patients (56.5%) were discharged home in group A versus 17 (54.8%) in group B (P = 0.56). Three patients (8.5%) received heart transplantation in group A and six (19.3%) in group B (P = 0.04). In group A, 90-day and 6-month survival was 54.3% (n = 25) versus 51.6% (n = 16) in group B (P = 0.66). In group A, 1-year survival was 45.6% (n = 21) versus 45.1% (n = 14) in group B (P = 0.81). The strategy of planned temporary RVAD support in LVAD recipients showed encouraging results if compared with those of a similar permanent BVAD/TAH population. Weaning from and removal of the temporary RVAD support may allow patients to be on LVAD support only despite preoperative biventricular dysfunction.

Extracorporeal membrane oxygenation support in refractory cardiogenic shock: treatment strategies and analysis of risk factors.

Two centrifugal pumps, the RotaFlow (Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany) and Levitronix CentriMag (Levitronix LCC, Waltham, MA, USA), used in central or peripheral veno-arterial extracorporeal membrane oxygenation (ECMO) support systems have been investigated, in terms of double-center experience, as treatment for patients with refractory cardiogenic shock (CS). Between January 2006 and December 2012, 228 consecutive adult patients were supported on RotaFlow (n=213) or CentriMag (n=15) ECMO, at our institutions (155 men; age 58.3±10.5 years, range: 19-84 years). Indications for support were: failure to wean from cardiopulmonary bypass in the setting of postcardiotomy (n=118) and primary donor graft failure (n=37); postacute myocardial infarction CS (n=27); acute myocarditis (n=6); and CS on chronic heart failure (n=40). A peripheral ECMO setting was established in 126 (55.2%) patients while it was established centrally in 102 (44.7%). Overall mean support time was 10.9±9.7 days (range: 1-43 days). Eighty-four (36.8%) patients died on ECMO. Overall success rate, in terms of survival on ECMO (n=144), weaning from mechanical support (n=107; 46.9%), bridge to mid-long-term ventricular assist device (n=6; 2.6%), and bridge to heart transplantation (n=31; 13.5%), was 63.1%. One hundred twenty-two (53.5%) patients were successfully discharged. Stepwise logistic regression identified blood lactate level and MB isoenzyme of creatine kinase (CK-MB) relative index at 72 h after ECMO initiation, and number of packed red blood cells (PRBCs) transfused on ECMO as significant predictors of mortality on ECMO (P=0.010, odds ratio [OR]=2.94; 95% confidence interval [CI]=1.10-3.14; P=0.010, OR=2.82, 95% CI=1.014-3.721; and P=0.011, OR=2.69; 95% CI=1.06-4.16, respectively). Central ECMO population had significantly higher rate of continuous veno-venous hemofiltration need and bleeding requiring surgery events compared with the peripheral ECMO setting population. No significant differences were seen by comparing the RotaFlow and CentriMag populations in terms of device performance. At follow-up, persistent heart failure with left ventricle ejection fraction (LVEF)≤40% was a risk factor after hospital discharge. Patients with a poor hemodynamic status may benefit from rapid central or peripheral insertion of ECMO. The blood lactate level, CK-MB relative index, and PRBCs transfused should be strictly monitored during ECMO support. In addition, early ventricular assist device placement or urgent listing for heart transplant should be considered in patients with persistent impaired LVEF after ECMO.

HeartWare third-generation implantable continuous flow pump as biventricular support: mid-term follow-up

A long-term mechanical biventricular support by HeartWare HVAS third-generation continuous flow pump (HeartWare, Inc, Miramar, FL, USA) was implanted in a Korean patient with a small chest size for treatment of a refractory end-stage heart failure due to an idiopathic dilative cardiomyopathy. We report our experience with a single patient and the early mid-term follow-up results with such a mechanical ventricular support.

Levitronix CentriMag to Berlin Heart Excor: A "Bridge to Bridge" Solution in Refractory Cardiogenic Shock

Levitronix CentriMag is a third generation bearingless temporary rotary pump designed for short-term mechanical support. The device, combined with Berlin Heart cannulas, was implanted in 30 patients suffering from acute cardiogenic shock with biventricular failure. Fifteen patients were successfully bridged to long-term Excor support due to lack of myocardial recovery. The approach produces good results, avoiding the risks of repeated sternotomy and cardiopulmonary bypass and reducing the costs involved.

Left ventricular assist device or heart transplantation: impact of transpulmonary gradient and pulmonary vascular resistance on decision making

OBJECTIVES Fixed pulmonary hypertension is a contraindication for heart transplantation. Left ventricular assist device support may lower it and bridge patients to heart transplantation. The aim of the study was to investigate the optimal parameters for treatment decisions and the time course of their potential reversal to normal values during preoperative inotropic support. METHODS Mean pulmonary arterial pressure, pulmonary vascular resistance and transpulmonary gradient were retrospectively analysed in 120 heart failure patients with severe pulmonary hypertension (mean age 51.7 ± 1.1 years, 93.3% males) treated between 2000 and 2009 with inotropes before left ventricular assist device implantation. The population was divided into three groups: patients with mean pulmonary arterial pressure > 25 mm Hg (group A, n = 113), patients with pulmonary vascular resistance > 2.5 Wood units (WU) (group B, n = 75) and patients with transpulmonary gradient > 12 mm Hg (group C, n = 55). Patients could be assigned to more than one group. RESULTS After 24h of inotropic support, pulmonary vascular resistance decreased (4.1 ± 0.2 to 3 ± 0.1, -25%, p<0.001), as did the transpulmonary gradient (17 ± 0.5 to 14 ± 0.7, -18%, p < 0.001). There was no significant decrease of mean pulmonary arterial pressure. Fifty percent of patients presented transpulmonary gradient < 12 mmHg on the 3rd day and pulmonary vascular resistance < 2.5 WU on the 4th day. No further changes were observed in the following days. Left ventricular assist device support allowed 63 patients to be listed for heart transplantation and 40 received transplantation. A 30-day mortality after heart transplantation was higher in patients with fixed pulmonary hypertension, despite inotropes, than in those with reversible hypertension in groups B and C (12.5% and 11.1% vs 0%, respectively). CONCLUSIONS Transpulmonary gradient and pulmonary vascular resistance, but not mean pulmonary arterial pressure, are predictive parameters for successful heart transplantation in cases of severe postcapillary pulmonary hypertension. When no significant decrease in pulmonary vascular resistance and transpulmonary gradient after 3-4 days of pharmacological therapy is observed, mechanical circulatory support is the only option to bridge end-stage heart failure patients to heart transplantation. Survival after heart transplantation is strictly related to the reversibility of pulmonary vascular resistance and transpulmonary gradient before assist implantation, but not related to mean pulmonary artery pressure.

Biventricular support with the HeartWare implantable continuous flow pump: An additional contribution

rgans, it would be of interest to determine whether emote organ injury is blocked by therapeutic gas therpy. The suggestions made by Dr Schibilsky et al regarding elective treatment of either donors or recipients are insightul. We also believe that testing the combined gas for ifferent durations and with different timing (preor posteperfusion) is important and will allow us to determine the inimal therapeutic dose and duration of inhaled gas and lso to differentiate the protective effects of combined gas herapy at various stages. Reactive oxygen species (ROS) re generated to a greater extent at the onset of reperfusion; herefore, the best timing for combined gas therapy is likely mmediately after reperfusion when ROS are generated. We ave some reservations regarding donor pre-treatment, beause this would be difficult to undertake in clinical pracice. However, both CO and hydrogen prevent organ injuies and reduce systemic inflammation, suggesting that the ombined gas therapy may mitigate graft injury prior to ransplantation and may increase the number of potential onors. We believe organ-targeted exposure of the therapeutic as by dissolving the gas in perfusion and storage soluion before implantation is likely a more clinically appliable and promising approach. We agree that cardiac reperusion using leukocyte-depleted blood cardioplegia solution ollowed by leukocyte-depleted non-cardioplegic blood is a romising, although technically demanding approach. It is of nterest to compare both strategies. Finally, we believe that lood cardioplegia can be administered concurrently with therpeutic medical gases during heart transplantation, and may ead to “additive” benefits.