Dario Salvo

Use of a novel anticoagulation strategy during ECMO in a pediatric population: single-center experience.

We describe a novel anticoagulation strategy with continuous intravenous antithrombin infusion and intermittent heparin infusion in pediatric population during extracorporeal membrane oxygenation (ECMO). From November 2004 through February 2006, 11 patients required ECMO for postcardiotomy cardiorespiratory failure. The mean duration of support time was 112 hours (range 68–192 hours). Since April 2005, we modified our anticoagulation protocol in the last six patients. Continuous antithrombin infusion was started immediately after surgery based on the lab result. The antithrombin level was maintained >100% using the following formula: 100 (target value) – (Antithrombin value on lab test) × weight in 4 hours. Antithrombin value was checked at 4-hour intervals. Heparin infusion was started when the antithrombin value was > 100% and remained stable for more than 12 hours and the amount of bleeding was < 2 ml/kg for more than 3 consecutive hours; then heparin infusion was started at 2 UI/kg/h via the oxygenator (target ACT was not < 150 seconds). Three patients in the first group died. Eight patients were weaned and discharged; the third, fourth, and fifth required surgical revision for bleeding. One experienced minor neurologic sequelae. Neither surgical revision nor thromboembolic complications occurred in the new anticoagulation group. A novel anticoagulation strategy utilizing continuous intravenous antithrombin and intermittent heparin infusion reduced significantly surgical revision for bleeding in the first 48 hours. This has translated into excellent overall outcomes.

DIDECMO : A new polymethylpentene oxygenator for pediatric extracorporeal membrane oxygenation

We reviewed the performance of a new polymethylpentene oxygenator (DIDECMO, Dideco, Mirandola, Italy) in terms of clinical safety and efficiency in priming, oxygenation, and oxygenator resistance in neonatal and pediatric extracorporeal membrane oxygenation (ECMO) patients. Between March 2005 and January 2006, 14 patients required ECMO in the San Vincenzo Hospital. Of these, 8 (median age, 9 days; range, 3 days to 15 months) received normothermic ECMO for postcardiotomy heart failure after surgery for congenital heart disease. The DIDECMO oxygenator was used in all patients (median weight, 2.4 kg; range, 2 to 7 kg). According to our previous experience, all patients received the same anticoagulation management. DIDECMO is a new phosphorylcholine-coated, polymethylpentene hollow-fiber oxygenator recommended for a maximum blood flow of 2300 ml/min with a membrane surface area of 0.67 m2 and validated to be used up to 5 days. Static priming was 100 ml and mean support time 05 hours (range, 36 to 198 hours). No oxygenators were changed during support. Median pressure drop during overall assistance was 24 mm Hg. Carbon dioxide elimination was obtained with a 1:1 blood flow/air flow ratio. Neither oxygenator-related major nor minor adverse events occurred during support. In our initial experience, the new polymethylpentene DIDECMO oxygenator provided adequate gas exchange and offered technical advantages in terms of low priming volume and acceptable hemodynamic resistance despite pulsatile flow regimen. Also, we used this device for more than 8 days without any technical problems.

Pulsatile ECMO and VAD: a dual use of a new device in pediatric cardiac patients.

The purpose of this investigation was to present the first European clinical experience with the new MEDOS DELTASTREAM® DP1 used in pulsatile extracorporeal membrane oxygenation (ECMO) or ventricular assist device (VAD) options in the pediatric population. Between January 2002 and April 2006, 11 patients required ECMO and 5 patients received a left VAD (LVAD) in the San Vincenzo Hospital. Indications were postcardiotomy heart failure in 15 patients and fulminant myocarditis in one patient. ECMO was established in all patients by cannulation of the right atrium and ascending aorta. LVAD was instituted by cannulation of the left atrium and ascending aorta. The DP1, an extracorporeal rotary blood pump, was used as an ECMO and an LVAD device. The pump features a diagonal-flow impeller and can be used for both continuous and pulsatile modes of perfusion. Priming volume of the pump was approximately 30 ml, with a flow rate of up to 8 l/min. Ten patients were discharged from ECMO and four from VAD. In the ECMO group, one patient died of peritonitis while on ECMO and two patients died on days 3 and 4 after weaning because of persistent pulmonary hypertension and major neurologic complications. In the VAD group, one patient died of low output syndrome 9 days after weaning. A 12-year-old patient was successfully given transplantation on day 8 of ECMO support and discharged on day 30 after heart transplant. All other patients were discharged. Three pumps were changed for pump failure and one pump was electively replaced because of improper anticoagulation management. No other thromboembolic adverse events occurred. Our results suggest that the MEDOS DELTASTREAM DP1 pulsatile pump system can be used as an ECMO or a VAD support. The opportunity to utilize pulsatile flow in postcardiotomy cardiogenic shock significantly improved the outcomes by producing more physiologic hemodynamics and superior end organ function. Easy implantation and simple management of this device represents the major advantage.

Acute respiratory insufficiency and giant coronary artery aneurysm with fistula

Several causes of acute respiratory insufficiency have been reported in the literature. We describe a case in which it was caused by a rare combination of a giant right coronary artery aneurysm with fistula that occurred in a 56-year-old woman with concomitant congenital hypothyroidism. Diagnostic tools, differential diagnosis, surgical techniques, and follow-up at 1 year are discussed.

Fenestrated arterial switch operation: surgical approach to an unusual transposition of the great arteries complex.

Transposition of the great arteries with intact ventricular septum and aortopulmonary window is an extremely rare anatomic combination, having been reported just twice previously. Other authors performed a physiologic repair, because the combination was considered unsuitable for an anatomic repair. We describe the case of a 26-day-old baby with such anatomy who was successfully treated with an arterial switch operation. A 4 mm fenestration at atrial level was made for a smoother postoperative course.

Clinical and electrophysiological characteristics, and relatively benign outcome, of typical atrioventricular nodal reentrant tachycardia in children and adolescents.

BACKGROUND Atrioventricular nodal re-entrant tachycardia is an uncommon arrhythmia in children. The natural history of this disturbance is poorly known in young patients. METHODS We analyzed the clinical and electrophysiological features, and the final outcome, in 19 children affected by typical atrioventricular nodal re-entrant tachycardia diagnosed by a transoesophageal electrophysiological study. RESULTS Of the cohort, 12 patients were female and 7 male, with a mean age of 11 years. Dual atrioventricular nodal physiology was demonstrated in 14 children (73%). The mean length of the tachycardia cycle was 297 milliseconds, with periods of 2 to 1 atrioventricular block during tachycardia noted in 5 children (26%). The mean cycle length was significantly shorter in the children who presented episodes of 2 to 1 atrioventricular block than in those who did not. After diagnosis, 12 children were not treated, 6 were treated with medical therapy, and 1 was submitted to radiofrequency transcatheter ablation. During a mean follow-up period of 41 months, 2 children with rare, but sustained, episodes of tachycardia that initially had not been treated were submitted to radiofrequency transcatheter ablation. Among children treated pharmacologically, 1 teenager was submitted to radiofrequency transcatheter ablation on the basis of parental choice, 3 children have discontinued medical therapy recording only sporadic episodes of tachycardia, and 2 children are still treated with antiarrhythmic drugs. At the last follow-up visit, 13 children (68%) were without any treatment, 4 had been successfully ablated, and 2 were still on medical treatment. CONCLUSIONS Our data indicates a relatively benign outcome in this group of children and adolescents with atrioventricular nodal re-entrant tachycardia.