Francesco Formica

Oral L-arginine supplementation improves endothelial function and ameliorates insulin sensitivity and inflammation in cardiopathic nondiabetic patients after an aortocoronary bypass

It is known that L-arginine treatment can ameliorate endothelial dysfunction and insulin sensitivity in type 2 diabetes mellitus patients, but little is known on L-arginine effects on these variables in nondiabetic patients with stable cardiovascular disease (coronary artery disease). We evaluated the effects of long-term oral L-arginine treatment on endothelial dysfunction, inflammation, adipokine levels, glucose tolerance, and insulin sensitivity in these patients. Sixty-four patients with cardiovascular disease previously submitted to an aortocoronary bypass and not known for type 2 diabetes mellitus had an oral glucose load to define their glucose tolerance. Thirty-two patients with nondiabetic response were eligible to receive, in a double-blind randomized parallel order, L-arginine (6.4 g/d) or placebo for 6 months. An evaluation of insulin sensitivity index during the oral glucose load, markers of systemic nitric oxide bioavailability and inflammation, and blood flow was performed before and at the end of the treatment in both groups. Compared with placebo, L-arginine decreased asymmetric dimethylarginine levels (P < .01), indices of endothelial dysfunction, and increased cyclic guanosine monophosphate (P < .01), L-arginine to asymmetric dimethylarginine ratio (P < .0001), and reactive hyperemia (P < .05). Finally, L-arginine increased insulin sensitivity index (P < .05) and adiponectin (P < .01) and decreased interleukin-6 and monocyte chemoattractant protein-1 levels. In conclusion, insulin resistance, endothelial dysfunction, and inflammation are important cardiovascular risk factors in coronary artery disease patients; and L-arginine seems to have anti-inflammatory and metabolic advantages in these patients.

Extracorporeal membrane oxygenation to support adult patients with cardiac failure: predictive factors of 30-day mortality

Adult patients supported on extracorporeal membrane oxygenation (ECMO) are very sick and many complications are often present in each single patient; therefore, it is not always easy to find some risk factors that can predict the early outcome. This retrospective study reports our experience in ECMO support treatment in adult cardiac patients suffering from cardiac failure (CF) in which one or more predictive factors of 30-day mortality were analyzed. Between January 2002 and August 2009, 42 consecutive adult cardiac patients with cardiogenic shock (mean age 64.3+/-11.3 years) were supported on ECMO for >2 days. They were divided into patients who had a survival <30 days (n=20) and patients who survived >30 days (n=22). Twenty-nine patients (69%) survived on ECMO. Sixteen patients were discharged with a survival rate of 38.1%. The overall mean ECMO duration was 7.9+/-5.3 days. The following variables were significantly different between the two groups: number of platelets and packed red blood cells (PRBCs) transfused per day during ECMO (P=0.002 and P=0.003), blood lactate levels 48 h and 72 h after the initiation of ECMO (P=0.01 and P=0.04), indexed blood flow after 48 h and 72 h (P=0.01 and P<0.0001), liver failure (P=0.001) and multiorgan failure (P=0.002). Stepwise logistic regression identified that blood lactate levels at 48 h and number of PRBCs transfused were associated with 30-day mortality [P=0.019, odds ratio (OR) =2.16; 95% confidence interval (CI)=1.13-4.14 and P=0.008, OR=1.08; 95% CI=1.02-1.14, respectively]. The predicted probability of mortality would be 52% when blood lactate levels are >3 mmol/l after 48 h. The blood lactate level at 48 h and PRBCs transfused per day can be considered as important parameters to predict the mortality in adult cardiac patients supported by ECMO for CF.

Myocardial revascularization with miniaturized extracorporeal circulation versus off pump: Evaluation of systemic and myocardial inflammatory response in a prospective randomized study.

OBJECTIVEnThis prospective randomized study sought to verify the systemic inflammatory response, inflammatory myocardial damage, and early clinical outcome in coronary surgery with the miniaturized extracorporeal circulation system or on the beating heart.nnnMETHODSnSixty consecutive patients were randomized to miniaturized extracorporeal circulation (n = 30) or off-pump coronary revascularization (off-pump coronary artery bypass grafting, n = 30). Intraoperative and postoperative data were recorded. Plasma levels of interleukin-6 and tumor necrosis factor-alpha were measured from systemic blood intraoperatively, at the end of operation, and 24 and 48 hours thereafter. Levels of the same markers and blood lactate were measured from coronary sinus blood intraoperatively to evaluate myocardial inflammation. Markers of myocardial damage were also analyzed.nnnRESULTSnOne patient died in the off-pump coronary artery bypass grafting group. There was no statistical difference in early clinical outcome in both groups. Release of interleukin-6 was higher in the off-pump coronary artery bypass grafting group 24 hours after the operation (P = .03), whereas levels of tumor necrosis factor-alpha were not different in both groups. Cardiac release of interleukin-6, tumor necrosis factor-alpha, and blood lactate were not different in both groups. Release of troponin T was not significantly different in both groups. Levels of creatine kinase mass were statistically higher in the miniaturized extracorporeal circulation group than in the off-pump coronary artery bypass grafting group, but only at the end of the operation (P < .0001). Hemoglobin levels were significantly higher in the miniaturized extracorporeal circulation group than in the off-pump coronary artery bypass grafting group after 24 hours (P = .01).nnnCONCLUSIONnMiniaturized extracorporeal circulation can be considered similar to off-pump surgery in terms of systemic inflammatory response, myocardial inflammation and damage, and early outcome.

ECMO for Ischemic Cardiogenic Shock

Cardiogenic shock (CS) is defined as a state of tissue hypoperfusion induced by cardiac failure after correction of preload [1].

Late driveline left ventricular assist device infection treated with frozen-and-thawed allogeneic platelet gel

In this case report, we report the application of frozen-and-thawed allogeneic platelet gel (PLT-gel) to treat a late driveline exit site infection in a 56-year old patient supported by a Heartware-HVAD left ventricular assist device. The treatment duration was 4 weeks and at the follow-up the skin around the exit site was free from further infection. PLT-gel can be used to treat local infection of the driveline exit site and to prevent further high-risk infections.

An unusual case of a cardiocutaneous fistula presenting 30 years after a breast carcinoma

A 77-year old woman presented with bleeding and purulent drainage from a cutaneous fistula appearing 30 years after left mastectomy and cobaltotherapy due to breast cancer, in the left anterior thoracic wall. A computed tomography scan showed a left ventricle connection (Figs 1 and 2). Surgical treatment was recommended, but she refused. After 4 months, she died in spite of an emergency operation following an haemorrhage.

Incidence of perioperative stroke in clampless aortic anastomosis during off-pump coronary artery bypass grafting

This study aimed to assess if clampless off-pump coronary artery bypass grafting (OPCAB) decreases the incidence of perioperative stroke (POS) rate and in-hospital mortality. The secondary aim was to evaluate 12-year rates of overall mortality. Between January 2003 to December 2015, data of 645 consecutive patients undergoing isolated CABG were retrospectively collected. 363 underwent aortic no-touch OPCAB (No-touch group) and 282 underwent OPCAB with the Heartstring device (HS group). In-hospital mortality and perioperative stroke rate as primary endpoint, as well as long-term follow-up outcome were analysed. In-hospital mortality was lower into No-touch group compared with HS group but without significant statistical difference (1.7 vs. 3.2%, pxa0=xa00.19, respectively); the rate of postoperative stroke was higher in No-touch group compared with HS group, although this difference did not reach statistically significance. Delirium was reported with higher presentation rate in HS group (3.9 vs. 0.8%, pxa0=xa00.01). Blood transfusions rate was higher in HS subjects (23.4 vs. 16.1%, pxa0=xa00.01). Intubation time, ICU, and hospital length of stay were increased in the HS group (pxa0=xa00.008, pxa0=xa00.001 and pxa0=xa00.003, respectively). Over a 12-year follow-up period, survival probabilities at 1, 5, and 10xa0years were 93.6xa0±xa01.3 vs. 93.2xa0±xa01.5, 80.4xa0±xa02.6 vs. 80.3xa0±xa02.2, and 57.9xa0±xa05 vs. 58.4xa0±xa03.8% in the No-touch and HS group, respectively (pxa0=xa00.97). In this retrospective study, clampless off-pump CABG lowers perioperative stroke rate whose incidence is, however, not inferior compared with No-touch technique, and no statistically significance was detected. Delirium has a higher presentation rate in clampless off-pump CABG.

Postinfarction left ventricular free wall rupture: a 17-year single-centre experience

OBJECTIVESnLeft ventricular free wall rupture (LVFWR) is a catastrophic complication following acute myocardial infarction with an estimated incidence of 0.2-7.6% and mortality can be as high as 60%. This study aimed to identify the risk factors for morbidity and mortality in patients affected by LVFWR.nnnMETHODSnThis is a retrospective study of 35 patients who underwent surgery for LVFWR between January 2000 and December 2016 at our institution.nnnRESULTSnThe mean age of patients was 68.3u2009years. The in-hospital survival was 65.7% (nu2009=u200923), and 13% of survived patients presented with cardiac arrest. The following characteristics were associated with in-hospital mortality at univariable analysis: pre-existing hypertension (Pu2009=u20090.02), need for inotropes (Pu2009=u20090.02) and cardiac arrest (Pu2009<u20090.0001) at presentation, cardiopulmonary resuscitation (Pu2009=u20090.004), preoperative extracorporeal membrane oxygenation (Pu2009=u20090.004), technique of LVFWR repair (Pu2009=u20090.013), operation on extracorporeal membrane oxygenation (Pu2009=u20090.005) and postoperative extracorporeal membrane oxygenation (Pu2009=u20090.001). In the multivariable analysis, cardiac arrest at presentation was an independent predictor of in-hospital mortality (odds ratio 11.7, 95% confidence interval 2.352-59.063; Pu2009=u20090.003). The overall mean postoperative follow-up was 8.3u2009±u20091.3u2009years. Overall survival rates at 5 and 10u2009years were 53.2u2009±u20098.6% and 49.1u2009±u20098.9%, respectively. Among the survivors, only 6 (26.1%) patients died during follow-up with a 5-year and 10-year overall survival rate of 80.9u2009±u20098.7% and 74.7u2009±u200910%, respectively.nnnCONCLUSIONSnThese data suggest a trend towards long-term benefit in patients surviving high-risk surgery for LVFWR repair. Considering the high lethality of LVFWR, the urgency and complexity of the primary surgical intervention early diagnosis and prompt surgery play a key role in the management of this complication.

Minimal Extracorporeal Circulation and Minimally Invasive Valve Operations: Should They Be the Right Combination in the Future?

1. Sartipy U. Loss to follow-up? (letter). Ann Thorac Surg 2017;103:1037. 2. Pag es P-B, Delpy J-P, Orsini B, et al. Propensity score analysis comparing videothoracoscopic lobectomy with thoracotomy: a French nationwide study. Ann Thorac Surg 2016;101:1370–8. 3. Paul S, Isaacs AJ, Treasure T, Altorki NK, Sedrakyan A. Longterm survival with thoracoscopic versus open lobectomy: propensity matched comparative analysis using SEERMedicare database. BMJ 2014;349:g5575.

Implantation of the Jarvik 2000® left ventricular assist device using the miniaturized extracorporeal circulation system - A case report

Myocardial failure is generally considered to be a progressive, irreversible medical condition with characteristic ventricular enlargement, spatial alteration of the heart chambers, diminished cardiac inotropy and resultant dysfunctional, mechanically inefficient heart. The Jarvik 2000®, similar to the mechanical pump, is an electrically powered, axial-flow left ventricular assist device (LVAD) designed to enhance the function of the chronically failing heart and, consequently, normalize the cardiac output for a long period of time. We report the case of 70-year-old man with congestive dilated cardiomyopathy and bioprosthetic mitral valve who underwent surgical implantation of the Jarvik 2000® LVAD, using the miniaturized extracorporeal circulation (MECC) system. The LVAD was implanted through a left thoracotomy and the MECC system was used to avoid intraoperative spontaneous hemodynamic instability and/or malignant ventricular arrhythmia. The circulatory support with the MECC system was optimal and no complication in terms of hemodynamic instability and perioperative bleeding was recorded. The MECC system obliterated the adverse effects associated with conventional extracorporeal circulation, which are often fatal in critically-ill patients.