B. Chiominto

Polarizing microplegia improves cardiac cycle efficiency after CABG for unstable angina.

BACKGROUND Myocardial protection during coronary artery bypass grafting (CABG) for unstable angina (UA) still represents a major challenge, ought to the risk for further ischemia/reperfusion injury. Few studies investigate the biochemical, hemodynamic and echocardiographic results of microplegia (Mic) in UA. METHODS Eighty UA-patients undergoing CABG were randomized to Mic (Mic-Group) or standard 4:1 blood Buckberg-cardioplegia (Buck-Group). Troponin-I and lactate were sampled from coronary sinus at reperfusion (T1), and from peripheral blood preoperatively (T0), at 6 (T2), 12 (T3) and 48 (T4) hours. Cardiac index (CI), indexed systemic vascular resistances (ISVR), Δp/Δt, cardiac cycle efficiency (CCE), and central venous pressure (CVP) were collected preoperatively (T0), and since Intensive Care Unit (ICU)-arrival (T1) to 24h (T5). Echocardiographic E-wave (E), A-wave (A), E/A, peak early-diastolic TDI-mitral annular-velocity (Ea), and E/Ea investigated the diastolic function and Wall Motion Score Index (WMSI) the systolic function, preoperatively (T0) and at 96h (T1). RESULTS Mic-Group showed lower troponin-I and lactate from coronary sinus (p=.0001 for both) and during the postoperative course (between-groups p=.001 and .0001, respectively). WMSI improved only after Mic (time-p=.001). Higher CI Δp/Δt and CCE (between-groups p=.0001), with comparable CVP and ISVR (p=N.S.) were detected after Mic. Diastolic function improved in both groups, but better after Mic (between-groups p=.003, .001, and .013 for E, E/A, and Ea, respectively). Mic resulted in lower transfusions (p=.006) and hospitalization (p=.002), and a trend towards lower need/duration of inotropes (p=.04 and p=.041, respectively), and ICU-stay (p=.015). CONCLUSION Microplegia attenuates myocardial damage in UA, reduces transfusions, improves postoperative systo-diastolic function, and shortens hospitalization.

Results With Expanded Donor Acceptance Criteria in Heart Transplantation

OBJECTIVE Over the past years both donor and recipient profiles have changed in heart transplantation. Satisfactory clinical outcomes of marginal donors in candidates >60 years of age have led us to allocate suboptimal donors to younger recipients as well. Therefore, we retrospectively reviewed our experience. METHODS Among 199 patients undergoing heart transplantation from January 2000 to February 2010, there were 83 (41%) aged 61-72 years. The other 116 (59%) ranged in age between 18 and 60 years. According to their clinical conditions as heart transplantation candidates, They were classified into 4 groups: younger recipients (n=116) of either optimal donors (n=72; group 1 [G1]) or marginal donors (n=44; group 2 [G2]) and older recipients (n=83) of either marginal grafts (n=70, group 3 [G3]) or optimal grafts (n=13; group 4 [G4]). The gender distribution, cause of end-stage heart failure, preoperative pulmonary hypertension incidence, pretransplantation clinical status, and mean follow-up were not significantly different among the 4 groups. RESULTS Overall 30-day survival was 90 ± 1% and 10-year rate was 78 ± 9%. Among the groups, 30-day and 10-year actuarial survival rates were, respectively: 94 ± 4% and 87 ± 1% for G1; 86 ± 5% and 84 ± 7% for G2; 88 ± 4% and 71 ± 7% for G3 and were 100% and 82 ± 7% for G4 (P=.7). In comparison among the 4 groups, there was no significant difference regarding freedom from graft failure (P=.3), right ventricular failure (P=.3), acute rejection episodes (P = .2), chronic rejection (P=.2), neoplasia (P=.5), or chronic renal failure (P=.1). Older recipients of marginal donors [G3] had a 4% (n=3) prevalence of permanent pacemaker implant, versus G2: 3% (n=2) among (P=.1). CONCLUSION Our results suggest that extended donor and recipient criteria do not compromise clinical outcomes after transplantation.

Blood versus crystalloid cardioplegia for myocardial protection of donor hearts during transplantation: a prospective, randomized clinical trial

OBJECTIVE To assess the safety and efficacy of myocardial protection of the donor heart during transplantation with the use of blood cardioplegia, a prospective randomized clinical trial was undertaken between January 1997 and March 1998. METHODS Forty-seven consecutive patients were assigned either to crystalloid (27 patients; group 1) or blood cardioplegia (20 patients; group 2). Comparison of recipient age (54 +/- 11 years vs 55 +/- 7 years; P =. 9), sex (89% vs 90% male patients; P =.9), diagnosis (63% vs 65% dilated cardiomyopathy; P =.8), elevated pulmonary vascular resistance (30% vs 30%; P =.9), prior cardiac operations (22% vs 30%; P =.5), need for urgent heart transplantation (7% vs 20%; P =. 2), donor age (32 +/- 11 years vs 31 +/- 13 years; P =.7), cause of death (33% vs 40% vascular; P =.5), and global myocardial ischemia (176 +/- 51 minutes vs 180 +/- 58 minutes; P =.5) showed no difference. Hemodynamically unstable donors (15% vs 45%; P =.02) were more prevalent in group 2. RESULTS Operative mortality rates (4% vs 5%; P =.8), high-dose inotropic support (41% vs 30%; P = 0.6), and postoperative mechanical assistance (11% vs 10%; P = 0.9) were comparable in the 2 groups. Prevalence of acute right heart failure (27% vs 0; P =.02) and of temporary complete atrioventricular block (52% vs 20%; P =.02) were greater in group 1. Spontaneous sinus rhythm recovery was more prevalent in group 2 (11% vs 40%; P =.02). Higher peak creatine kinase (1429 +/- 725 u/L vs 868 +/- 466 u/L; P =.01) and creatine kinase MB (144 +/- 90 u/L vs 102 +/- 59 u/L; P =. 06) levels suggested more severe ischemic injury in group I. CONCLUSION Use of blood cardioplegia was associated with a lower prevalence of right heart failure, cardiac rhythm dysfunction, and laboratory evidence of ischemia.

Impact of donor quality on outcome of heart transplantation

OBJECTIVE Over the last few years, there have been changes in both donor and recipient profiles in heart transplantation. Encouraging clinical outcome of marginal donors in candidates older than 60 years of age led us to allocate suboptimal donors for younger recipients as well. We reviewed our experience retrospectively so as to assess the impact of donor quality on heart transplantation. METHODS Among 181 patients who underwent heart transplantation between January 2000 and February 2009, there were 75 patients (41%) aged 61-70 years and 106 patients (59%) ranging in age between 18 and 60 years. According to the recipients age, they were classified into four groups. The younger recipients (106 patients) had either optimal donors (70 patients, group 1) or marginal donors (36 patients, group 2). The older recipients (75 patients) had either marginal grafts (64 patients, group 3) or optimal grafts (11 patients, group 4). Sex distribution, cause of end-stage heart failure, preoperative pulmonary hypertension, pre-heart-transplantation clinical status or mean follow-up duration did not show any statistically significant difference among the four groups. RESULTS Overall, the 9-year actuarial survival rate was 78%±1%. The 30 days and 9-year actuarial survival rates were 94%±2% and 80%±1% in group 1; 86%±5% and 55%±12% in group 2; 90%±4% and 73%±7% in group 3; 99%±1% and 82%±7% in group 4 (P=0.07). Comparison among the four groups did not show any statistical difference in terms of freedom from graft failure (P=0.3), right ventricular failure (P=0.3), acute rejection (P=0.2), chronic rejection (P=0.2), neoplasia (P=0.5) and chronic renal failure (P=0.2). Older recipients of marginal donors (group 3) had slightly higher prevalence of permanent pacemaker implants: eight permanent pacemakers versus two in group 2, and none in group 1 and group 4 (P=0.4). CONCLUSIONS Our results suggest that extended donor acceptance criteria may not compromise clinical outcome after heart transplantation. Further follow-up is warranted.

Surgical treatment of an aortopulmonary artery fistula complicating a syphilitic aortic aneurysm

Spontaneous rupture of an aortic aneurysm into the pulmonary artery is unusual and is rarely reported in the literature. The case of a patient with a syphilitic aneurysm of the ascending aorta perforated into the pulmonary artery is presented. In an attempt to define the best surgical treatment for this complication the literature has been comprehensively reviewed.

Myocardial protection in heart transplantation using blood cardioplegia: 12-year outcome of a prospective randomized trial.

BACKGROUND Blood cardioplegia yields a lower prevalence of right heart failure, arrhythmias, and myocardial ischemia early after heart transplantation (HTx). Because depolarizing (high [K(+)]) cardioplegic solutions may alledgedly cause endothelial damage, the 12-year outcome of a prospective randomized trial was reviewed. METHODS Between January 1997 and March 1998, 47 consecutive patients received crystalloid (Group 1, n = 27) or blood cardioplegia (Group 2, n = 20). The groups were similarly matched: recipient age (54 ± 11 vs 55 ± 7 years, p = 0.9), sex (89% vs 90% males, p = 0.9), diagnosis (63% vs 65% dilated cardiomyopathy, p = 0.8), elevated (>4 WU) pulmonary vascular resistance (30% vs 30%, p = 0.9), prior operations (22% vs 30%, p = 0.5), urgent HTx (7% vs 20%, p = 0.2), donor age (32 ± 11 vs 31 ± 13 years, p = 0.7), donor sex (78% vs 70% males, p = 0.5), donor cause of death (33% vs 40% vascular, p = 0.5), and global myocardial ischemia (176 ± 51 vs 180 ± 58 minutes p = 0.5). Hemodynamically unstable donors were more prevalent in Group 2 (15% vs 45%, p = 0.02). The 45 hospital survivors underwent yearly echocardiography, coronary angiography, and coronary intravascular ultrasound (IVUS) imaging during follow-up. RESULTS During follow-up (10.4 ± 5.2, range, 0.9-12.7 years), Groups 1 and 2 had comparable mortality (46% vs 42%, p = 0.7) and cause of death (chronic rejection: 50% vs 50%; neoplasia: 33% vs 25%, p = 0.8). Survival at 12 years was 50% ± 12% vs 52% ± 11% (p = 0.9). Follow-up echocardiogram showed similar mean left ventricular ejection fraction (LVEF; 47% ± 12% vs 49% ± 11%, p = 0.7) and prevalence of LVEF < 35% (21% vs 18%, p = 0.8). Prevalence of chronic rejection was comparable (42% vs 32%, p = 0.1), yet severe allograft vasculopathy (International Society for Heart and Lung Transplantation cardiac allograft vasculopathy 3) was more prevalent in Group 1 (64% vs 17%, p = 0.04). Freedom from chronic rejection was higher in Group 2 (44% ± 15% vs 63% ± 13%), albeit not significantly (p = 0.5). A trend toward greater prevalence of intimal disease at IVUS (thickness > 0.5 mm) in the proximal and distal left anterior descending artery (67% vs 40%; 58% vs 45%) and higher number of percutaneous coronary interventions (2.7 ± 0.5 vs 1.8 ± 0.3, p = 0.3) was noted in Group 1. CONCLUSIONS Use of blood cardioplegia is safe and results in comparable survival and prevalence of adverse events late after HTx. The trend towards greater freedom from chronic rejection and more limited extent of coronary artery disease in grafts protected with blood cardioplegia awaits confirmation.

Clinical Evaluation of New Generation Oxygenators With Integrated Arterial Line Filters for Cardiopulmonary Bypass

New generation oxygenators with integrated arterial line filters have been marketed to improve the efficacy of cardiopulmonary bypass (CPB). Differences in designs, materials, coating surfaces, pore size of arterial filter, and static prime exist between the oxygenators. Despite abundant preclinical data, literature lacks clinical studies. From September 2010 to March 2011, 80 consecutive patients were randomized to CPB using Terumo Capiox FX25 (40 patients, Group-T) or Sorin Synthesis (40 patients, Group-S) oxygenators. Pressure drop and gas exchange efficacy were registered during CPB. High-sensitivity C-reactive protein (hs-CRP), white blood cells (WBCs), fluid balance, activated clotting time, international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen, platelets (PLTs), serum albumin, and total proteins were measured perioperatively at different timepoints. Clinical outcome was recorded. Repeated measure analysis of variance and nonparametric statistics assessed between-groups and during time differences. The two groups showed similar baseline and intraoperative variables. No differences were recorded in pressure drop and gas exchange (group-P and group*time-P = N.S. for all) during CPB. Despite similar fluid balance (P = N.S. for static/dynamic priming and ΔVolume administered intraoperatively), Group-T showed higher hs-CRP (group-P = 0.034), aPTT (group-P = 0.0001), and INR (group-P= 0.05), with lower serum albumin (group-P = 0.014), total proteins (group-P = 0.0001), fibrinogen (group-P = 0.041), and PLTs (group-P = 0.021). Group-T also showed higher postoperative bleeding (group-P = 0.009) and need for transfusions (P = 0.008 for packed red cells and P = 0.0001 for fresh frozen plasma and total transfused volumes). However, clinical outcome was comparable (P = N.S. for all clinical endpoints). Both oxygenators proved effective and resulted in comparable clinical outcomes. However, Sorin Synthesis seems to reduce inflammation and better preserve the coagulative cascade and serum proteins, resulting in lower transfusions and post-CPB inflammatory response.

Veno-Venous Extracorporeal Membrane Oxygenation as a Bridge to and Support for Pulmonary Thromboendarterectomy in Misdiagnosed Chronic Thromboembolic Pulmonary Hypertension

Diagnostic delay in patients suffering massive pulmonary embolism (PE) on chronic thromboembolic pulmonary hypertension (CTEPH) has inevitably fatal consequences. Indications to pulmonary thromboendarterectomy (PTE) and extracorporeal membrane oxygenation (ECMO) are limited by severe comorbid conditions, some of which, as neurologic disease, absolutely contraindicate these procedures. We reported the clinical course of a severely diseased patient with a history of meningitis, psychosis and epilepsy, experiencing acute massive pulmonary embolism complicated by acute respiratory failure, successfully treated by ECMO and PTE. A 51-year-old woman with massive PE complicating a misdiagnosed CTEPH needed mechanical ventilation because of acute respiratory insufficiency. Thoracic computed tomography (CT) scan demonstrated PE, and brain CT showed multiple cerebral and cerebellar ischemic lesions. Veno-venous ECMO assistance was instituted despite CT imaging. She recovered from acute respiratory insufficiency by means of veno-venous ECMO. Weaning from ECMO was however impossible until surgical exploration demonstrated an underlying chronic CTEPH, which was successfully addressed by PTE, switching the ECMO system to a standard cardiopulmonary bypass. Postoperative course was uneventful and the patient was discharged home in healthy condition. Despite the fact that the cost-effective ratio should always be considered in advanced life support, expanding the commonly accepted selection criteria for expensive procedures might be advisable in selected acute life-threatening cases, in view of the possibility to unexpectedly save lives.

Safety and efficacy of automatic implantable defibrillator used as a bridge to heart transplant

DESPITE CONTINUOUS improvements in the clinical management of patients (pts) affected by chronic heart failure (CHF), heart transplant (Htx) still remains the treatment of choice in end-stage cardiac diseases. However, the discrepancy between numbers of pts and donor shortage and increasing waiting time is leading to a sensible worsening in terms of candidate survival rate. McManus et al. have reported threefold increase (from 0.07 in 1983 to 0.21 in 1989) in the ratio between the number of pts dying while awaiting transplantation and those successfully transplanted. Among the several different causes of death, malignant cardiac arrhythmias are responsible for sudden death of Htx candidates, ranging from 25% to 40%. Although different authors have suggested the implant of automatic cardioverter defibrillator (AICD) as a bridging device to Htx by reducing sudden death occurrence, debate is still running over the impact of the AICDs on prognosis of pts affected by severe left ventricular (LV) dysfunction. To assess safety and efficacy of AICD as bridge to Htx, our 6 years experience was reviewed.

Emergency Use of Wearable Left Ventricular Assist Devices in Patients Not Eligible for Heart Transplantation

BACKGROUND We reviewed our experience concerning the clinical outcomes of emergency implantation of left ventricular assist devices (LVAD) in patients not eligible for heart transplantation (HTX). PATIENTS AND METHODS Between January 1998 and September 2006, 62 patients were referred for emergency HTX including 35 (55%) who received cardiac allografts; 9 (14%) died on the waiting list. The other 18 subjects (31%) did not meet listing criteria due to pulmonary hypertension with massive transpulmonary gradients (TPG), severe diabetes, or another factor; 7 patients had wearable LVAD implants and the remaining 11 who had contraindications both to HTX and to LVAD implantation remained on medical therapy. RESULTS Twelve month actuarial survivals were 47% in LVAD G1 vs 1% in medical therapy G2 (P< .005). Four G1 patients died either due to cerebrovascular vascular episodes or to thromboembolic events. The beneficial use of LVAD in 3 patients led to consistent improvement in hemodynamic performance allowing listing for HTX. Two of them have been successfully transplanted; 1 is still waiting. Due to refractory heart failure, 90% of G2 died within the first months after evaluation. CONCLUSION Our limited experience indicated that emergency use of LVAD ensued a satisfactory outcome allowing better actuarial survival.