Emanuele Pilato

Acute kidney injury following transcatheter aortic valve implantation: incidence, predictors and clinical outcome

BACKGROUND Limited data exist on renal complications of transcatheter aortic valve implantation (TAVI) within a comprehensive program using different valves with transfemoral, transapical, and trans-subclavian approach. METHODS Prospective single-center registry of 102 consecutive patients undergoing TAVI using both approved bioprostheses and different access routes. The main objective was to assess the incidence, predictors and the clinical impact of acute kidney injury (AKI). AKI was defined according to the valve academic research consortium (VARC) indications. RESULTS Mean age was 83.7 ± 5.3 years, logistic EuroSCORE 22.6 ± 12.4%, and STS score 8.2 ± 4.1%. Chronic kidney disease at baseline was present in 87.3%. Periprocedural AKI developed in 42 patients (41.7%): 32.4% stage 1, 4.9% stage 2 and 3.9% stage 3. The incidence of AKI was 66.7% in transapical, 30.3% in transfemoral, and 50% in trans-subclavian procedures. The only independent predictor of AKI was transapical access, with a hazard ratio (HR) between 4.57 and 5.18 based on the model used. Cumulative 1-year survival was 88.2%. At Cox regression analysis, the only independent predictor of 30-day mortality was diabetes mellitus (HR 7.05, 95% CI 1.07-46.32; p=0.042), whilst the independent predictors of 1-year death were baseline glomerular filtration rate<30 mL/min (HR 5.74, 95% CI 1.42-23.26; p=0.014) and post-procedural AKI 3 (HR 8.59, 95% CI 1.61-45.86, p=0.012). CONCLUSIONS TAVI is associated with a high incidence of AKI. Although in the majority of the cases AKI is of mild entity and reversible, AKI 3 holds a strong negative impact on 1-year survival. The incidence of AKI is higher with transapical access.

Complex thoracic aortic disease: Single-stage procedure with the frozen elephant trunk technique

OBJECTIVE Extensive thoracic aortic aneurysms represent a challenging pathology in cardiac surgery. The frozen elephant trunk procedure, combining conventional surgery with endovascular techniques, allows single-stage treatment for such pathology. Here we present our surgical technique and results with the single-stage frozen elephant trunk procedure. METHODS Between January 2007 and December 2009, 67 patients were treated with the frozen elephant trunk procedure in our institution. Mean age was 61 ± 11 years. Indications for surgery included chronic aneurysm (n = 22, 32.8%), acute type A dissection (n = 4, 6.0%), acute type B dissection (n = 2, 3.0%), chronic type A dissection (n = 30, 44.8%), and chronic type B dissection (n = 9, 13.4%). Thirty-six patients (53.7%) had undergone 38 previous cardiac or aortic operations. Thirty-two associated aortic and cardiac operations were performed. Brain protection was achieved by means of antegrade selective cerebral perfusion and moderate hypothermia (26°C) in all cases. RESULTS In-hospital mortality was 13.4%. Postoperatively, permanent neurologic dysfunction (coma) occurred in 5 cases (7.5%), paraplegia in 2 (3.2%), and paraparesis in 3 (4.9%). Follow-up was 100% complete, with mean duration of 11.1 ± 8.4 months. The 1- and 2-year survivals were 76.7 ± 5.6% and 70.3 ± 8.0%, respectively. Ten patients (14.9%) required endovascular completion 2.3 ± 3.1 months after the first procedure, with 100% technical and procedural success. CONCLUSIONS In contrast to the conventional elephant trunk technique, the frozen elephant trunk technique offers a potentially curative single-stage procedure for patients with extensive thoracic aortic disease, with encouraging short-term and midterm results.

Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: A 5-year multi-institutional experience

BACKGROUND Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period. METHOD From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access. RESULTS Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation. CONCLUSIONS Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.

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.

Short- and midterm results after hybrid treatment of chronic aortic dissection with the frozen elephant trunk technique

OBJECTIVE The purpose of this study was to examine our experience with the frozen elephant trunk in patients with chronic aortic dissection. METHODS In our Institution, between January 2007 and August 2010, 49 patients (mean age: 59.6 ± 9.0 years) underwent total arch replacement with the frozen elephant trunk technique for chronic aortic dissection (type A, n=2; residual type A, n=37; type B, n=10). Forty patients (81.6%) patients had undergone previous cardiovascular procedures. Associated cardiac procedures were indicated in 21 (42.8%) patients. Brain protection was achieved with antegrade selective cerebral perfusion in all cases. RESULTS Hospital mortality (n=5) was 10.2%. Postoperative serious complications included coma (n=3; 6.1%), paraplegia (n=2; 4.1%), respiratory failure (n=6; 12.2%), and definitive dialysis (n=2; 4.1%). Follow-up was 100% completed (mean period: 12.9 ± 11.7 months). The estimated 1- and 3-year survival rates were 91.2 ± 4.2% and 81.6 ± 6.5%, respectively. Endovascular extension was required in 11 (22.4%) patients, with technical success of 100%. Complete thrombosis of the peri-stent false lumen was achieved in 82.9% of cases, with significant reduction of the false lumen diameter (preoperative: 36 ± 11 mm; postoperative: 24 ± 17 mm; p=0.001) and increase of the true lumen diameter (preoperative: 15 ± 5 mm; postoperative: 26 ± 6 mm; p=0.001). CONCLUSIONS The frozen elephant trunk technique, allowing treatment of extensive disease of the thoracic aorta, was associated with encouraging short- and midterm results. Longer-term follow-up is warranted.

Cerebral protection during surgery of the aortic arch

Brain injury represents a primary concern during aortic arch surgery. Valid surgical techniques and reliable methods of brain protection are required to obtain a favorable outcome after such a complex surgery. Our aim was to review available methods of brain protection including deep hypothermia and circulatory arrest, retrograde cerebral perfusion and antegrade cerebral perfusion.

Combined heart-liver transplantation: a single-center experience.

Combined orthotopic heart and liver transplantation (CHLT) is a lifesaving procedure for patients with end‐stage heart–liver disease. We reviewed the long‐term outcome of patients who have undergone CHLT at the University of Bologna, Italy. Fifteen patients with heart and liver failure were placed on the transplant list between November 1999 and March 2012. The pretransplant cardiac diagnoses were familial amyloidosis in 14 patients and chronic heart failure due to chemotherapy with liver failure due to chronic hepatitis in one patient. CHLT was performed as a single combined procedure in 14 hemodynamically stable patients; there was no peri‐operative mortality. The survival rates for the CHLT recipients were 93%, 93%, and 82% at 1 month and 1 and 5 years, respectively. Freedom from graft rejection was 100%, 90%, and 36% at 1, 5, and 10 years, respectively, for the heart graft and 100%, 91%, and 86% for the liver graft. The livers of eight recipients were transplanted as a “domino” with mean overall 1‐year survival of 93%. Simultaneous heart and liver transplantation is feasible and was achieved in this extremely sick cohort of patients. By adopting the domino technique, we were able to enlarge the donor cohort and include high‐risk patients.

Management of traumatic implantable cardioverter defibrillator lead perforation of the right ventricle after car accident: a case report

The authors reported a case of traumatic implantable cardioverter defibrillator (ICD) lead perforation of the right ventricular (RV) apex caused by a motor vehicle accident. Clinical and echocardiographic features combined with changes in electrical parameters of the offending lead were decisive for the final diagnosis. Optimal management of ICD lead RV wall perforation is currently unclear. In our report, RV perforation was responsible for cardiac tamponade. This complication was uneventfully managed by open surgical procedure.

Cardiac transplantation from a carbon monoxide intoxicated donor.

Heart transplantation is a demonstrated successful and life-saving treatment for an increasing number of patients. The growth of heart transplantation surgery is limited by the relative lack of suitable donors, and the increasing demand has lead to the expansion of acceptance criteria. Patients succumbing to carbon monoxide (CO) poisoning are usually considered not suitable organ donors and they are routinely rejected in many centers. Although organs from CO poisoning donors have been occasionally used, cardiac transplantation in this scenario remains very uncommon. We report the successful heart transplantation from a CO intoxicated donor, who was previously refused by two other transplantation teams. Standard donor evaluation criteria, transplantation techniques and management were used. Limited cases are described in literature. The present case may increase awareness among emergency department physicians, as well as transplantations teams, that patients dying of CO exposure may be acceptable cardiac donors.

Bio-ValsalvaTM prosthesis: ‘new’ conduit for ‘old’ patients

A new bio-prosthetic valved conduit (Bio-Valsalva) has recently been introduced into surgical practice in order to offer a valid option for elderly patients undergoing composite aortic root replacement. The conduit is made up of a stentless porcine valve (elan valve) pre-sewn inside a triple layer Valsalva prosthesis and it is entirely preserved in a glutaraldehyde solution. In our Department, 21 patients (16 males, mean age 67.8+/-5.5 years) underwent aortic root replacement using the Bio-Valsalva prosthesis. Composite root replacement was extended to the hemiarch in three cases while a complete arch replacement was performed in two patients. Type A aortic dissection was present in two cases while a bicuspid aortic valve was detected in eight patients. In-hospital mortality was 4.7% (1 patient). Re-thoracotomy for bleeding was performed in one case. The median in-hospital stay was 12 days. The median follow-up was six months and is 100% complete. There were no re-operations or structural deterioration during this early phase of observation. The Bio-Valsalva graft, readily available in different sizes, demonstrates ease of implantability and shows good haemostatic characteristics. More patients and a longer follow-up are necessary to confirm the advantages of this graft.