Fabrizio Ceresa

Role of Oral Sildenafil in the Treatment of Right Ventricular Dysfunction After Heart Transplantation

OBJECTIVE Right ventricular dysfunction (RVD) after heart transplantation is a major complication, especially in patients with pulmonary hypertension (PH). Herein we have presented our initial experience with oral sildenafil for RVD following heart transplantation. MATERIALS AND METHODS From February 2006 to February 2008, 10 patients (7 males and 3 females) of overall mean age of 56.7 +/- 9.5 years suffered from acute RVD immediately after heart transplantation. Preoperative hemodynamic data before and after a vasodilatation test (sodium nitroprusside; NTP) showed: systolic pulmonary arterial pressure (SPAP) 59.5 +/- 12.9 and 44.2 +/- 12.4 mm Hg; cardiac output (CO) 3.3 +/- 0.9 and 3.7 +/- 0.8 L/min; transpulmonary gradient (TPG) 11.7 +/- 3.9 and 8.7 +/- 3.6 mm Hg; and pulmonary vascular resistance (PVR) 3.9 +/- 2.1 and 2.4 +/- 1.3 wood units (WU), respectively. All patients required inotropes and inhaled nitric oxide (iNO) to be weaned from cardiopulmonary bypass (CPB). RESULTS Intravenous (IV) or inhaled vasodilators could be weaned using oral sildenafil in all patients. The hemodynamic data obtained during IV or inhaled drugs (between postoperative days 5 and 10) compared with those obtained on sildenafil therapy alone (about 1 month after transplantation) showed a significant decrease in SPAP (39.0 +/- 8.2 vs 32.0 +/- 6.5 mm Hg; P = .049). CONCLUSION These data suggested that oral sildenafil may have a role in the treatment of RVD after heart transplantation.

Pocket infection as a complication of a subcutaneous implantable cardioverter-defibrillator

The use of implantable cardiac devices has increased in the last 30 years. The evolution of devices in serious cardiac rhythm pathology management has led progressively to the development of devices for the treatment of bradycardia, ventricular arrhythmia and heart failure and for the prevention of sudden cardiac arrest leading to delivery of pacemakers, implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) plus ICD (CRT-D) [1–22] and to the recent subcutaneous implantable cardioverter-defibrillator (S-ICD) [23–25]. Infectious complications leading also to endocarditis [1,8, 26–33] and noninfectious complications [9,21,23,34–37] often necessitating removal [1,2,8,37–43] affect patients well-being also leading to psychological difficulties increase [44–50]. In the emerging scenario of concomitant problems and diseases [51–67], the S-ICD can provide clinical advantages in patients undergoing possible complications and in those with limited intracavitary lead placements, chronic indwelling catheters, obstructed venous access and in young patients avoiding the need for electrodes within the heart [23–25]. Complications are always possible, such as pocket and system infections, lead dislodgement, suboptimal position, lead dislodgement, oversensing, inappropriate shock and premature battery depletion but the new alternative technique of s-ICD represents an important innovation in the field of device therapy

Complicated sternal dehiscence treated with the strasbourg thoracic osteosyntheses system (STRATOS) and the transposition of greater omentum: a case report

Sternal dehiscence is a serious complication after cardiac surgery. Sternal refixation, performed by simple rewiring or techniqual modification of rewiring as described by Robicsek, can fail, overall when the bone quality is poor or the sternum is completely destroyed. The sternal closure systems, consisting of plates, screws or rib clips and titanium bars, have been recently introduced to treat the complicated sternal dehiscence. We describe for the first time the use of the Strasbourg Thoracic Osteosyntheses System (STRATOS) and the greater omentum, to treat a complicated sternal dehiscence, causing chest pain and respiratory failure.

The use of Impella Recover in the treatment of post-infarction ventricular septal defect: A new case report

Ventricular septal defect (VSD) can occur as part of more congenital cardiac malformations or as an isolated finding. VSD can be also a serious complication of acute myocardial infarction. It seems that its prognosis improves if the operation can be deferred for 3-4 weeks. The treatment of VSD is changing and the surgical closure should be postponed in order to reduce the mortality risk. The use of Impella Recover left ventricular assistance device allowed to delay the surgery, stabilizing the patients hemodynamic condition. We describe a case of post-infarction VSD treated with the implantation of Impella Recover, which permitted to postpone a surgical closure for 2 weeks. Our results confirm the improvement of VSDs survival, depending on the use of Impella Recover, which allows to maintain the hemodynamic stability and to delay the operation.

Right atrial lipoma in patient with Cowden syndrome.

Primary cardiac tumors are rarest form of cancer and the lipoma represent about 8% of these tumors. Cowden disease is a rare autosomal dominant disorder, associated to a germline mutation of the PTEN gene, characterized by multiple hamartomas and an increased risk of breast, thyroid and endometrial carcinomas. For the first time, we describe a right atrial lipoma in a patient affected by Cowden syndrome. The patient suffered of some episodes of atrial flutter. The echocardiogram showed a cardiac mass, suggestive of lipoma with cardiac magnetic resonance images. Right atrial mass was completely resected and the histological examination confirmed the diagnosis of lipoma. The patient was discharged from hospital without any complications.

Left atrial paraganglioma: diagnosis and surgical management.

Cardiac paragangliomas are rare entities, that often remain asymptomatic. Complete surgical resection is the mainstay of treatment even if it can be difficult for the infiltration of the near mediastinal structures. We describe the case of a young man with hypertensive crisis, headache and diabetes, affected by cardiac paraganglioma, infiltrating the left atrial roof. The tumor was completely removed using cardiopulmonary bypass and the infiltrated portion of left atrial wall and the left superior pulmonary vein was excised and repaired with a pericardial patch. The patient was discharged without complications and currently enjoys good health.

Recurrent ventricular fibrillation due to coronary artery spasm immediately after ascending aorta replacement.

Coronary artery spasm (CAS) is a dangerous complication during cardiac surgery, causing arduous weaning of extracorporeal circulation (ECC) and myocardial tissue loss with consequent left and right ventricular dysfunctions. We describe the case of a 67-year-old man with hypertension and smoking habit, with ECG evidence of lateral myocardial ischemia without symptoms. On this basis, he was investigated with scintigraphy, which confirmed an anterior-lateral area of reversible ischemia and, subsequently, with angiography, which revealed just mild lesion (50%) of diagonal ramus associated with ascending aorta aneurysm: no sign of CAS was detected. Left ventricular function was normal, with mild hypokinesia of the apical segments and trivial aortic regurgitation. The patient underwent ascending aorta replacement with arduous ECC weaning due to CAS: exclusively, the use of intravenous administration of diltiazem led to the solution of this complication. Even if medical therapy is generally efficacious for this complication, the diagnosis is very complicated when it appears in the operating room immediately after cardiac surgery because of the lack of any useful device. The difficulty of diagnosis in the operating room might compromise patient outcome. In our opinion, when ECC weaning is complicated by several episodes of malignant tachyarrhythmia and there is the suspicion of underlying ischemic cause without other obvious causes, CAS must be considered and empirical therapy with calcium channel blockers should be used.

Minimally invasive non-endoscopic vein harvest using a laryngoscope. A preliminary experience

Minimally invasive vein harvesting (MIVH) has been developed in order to reduce the wound healing complications and the related cost. Therefore, the operative cost of endoscopic harvesting remains higher in comparison with the open harvesting. We describe a laryngoscope-assisted technique of saphenous vein harvesting, performing a few small skin incisions and with minimum additional cost. We have used our technique in 20 patients up to now without infection or other wound-related complications and with good cosmetic results.

Inadvertent implantation of a pacemaker lead in the left ventricle: A new challenge in cardiology

a Cardiologia Ospedale San Vincenzo— Taormina (Me) Azienda Sanitaria Provinciale di Messina, 98039, Taormina (Messina), Italy b Cardiochirurgia Ospedale Papardo Messina, Azienda Ospedaliera Ospedali Riuniti Papardo Piemonte, 98158 Messina, Italy c UOC Cardiologia Ospedale Umberto I° ASP Siracusa, Italy d Cardiologia Ospedale San Vincenzo— Taormina (Me) and Cardiologia Presidio Ospedaliero “G. Fogliani” — Milazzo (ME) Azienda Sanitaria Provinciale di Messina, Italy

Budd–Chiari syndrome complicating the surgical closure of patent foramen ovale in right minithoracotomy

We present the case of a 45-year old female operated on for minimally invasive closure of patent foramen ovale, who suffered in the postoperative course of the Budd-Chiari syndrome caused by the thrombotic occlusion of the inferior vena cava. Medical treatment with oral anticoagulants and heparin was promptly established, avoiding a further increase of the thrombus that completely disappeared 3 months later.