Gianluca Santise

Extracorporeal membrane oxygenation for graft failure after heart transplantation: A multidisciplinary approach to maximize weaning rate

Objectives Primary graft failure (PGF) after heart transplantation is a detrimental complication, and carries high morbidity and mortality. The aim of this study was to analyze the results of our multidisciplinary approach in supporting patients affected with PGF after heart transplantation. Methods Out of 114 consecutive patients receiving orthotopic heart transplantation between January 2006 and July 2013, 18 (15.7%) developed PGF requiring veno-arterial extracorporeal membrane oxygenator (VA-ECMO) support. Fourteen patients were male and the mean age was 49 ± 11 years. General principles in treating the patients were based on a low dose of adrenaline (0.05 mic/kg per min) infusion; femoral intra-aortic balloon pump (13 of the 18 patients); low dose of vasoconstrictors; careful fluid balance; daily echocardiographic transesophageal monitoring. Results Mean graft recipient pulmonary vascular resistance was 3.6 ± 3.2 WU. Five patients had absolute contraindication to IABP placement. The mean left ventricle ejection fraction pre-VA-ECMO was 18.4% ± 10.2%. The mean VA-ECMO and IABP support times were 6.7 ± 3.2 and 9.2 ± 7.6 days, respectively. Mean VA-ECMO flow was 4164 ± 679 l/min. The mean left ventricle ejection fraction increased to 43.4% ± 17.7% at the end of support. Weaning and discharge rates in patients treated with VA-ECMO+IABP were 84% and 53%, respectively. Causes of death were primarily end-stage organ failure. Conclusions A multidisciplinary evaluation of ECMO patients done by intensivists, cardiologists, and surgeons may influence weaning and survival rate. Our approach seems to be a safe and reproducible strategy for avoiding left ventricle distension and fluid overload, and for detecting complications that negatively affect outcomes.

Can learning to interpret pump messages help lead to an early diagnosis of HeartWare ventricular assist device thrombosis

Left ventricular assist device thrombosis is a detrimental complication that, if not properly diagnosed and treated, can lead to low output syndrome and death. When ongoing thrombus formation is caused by inappropriate anticoagulation, timely identification is possible, and could perhaps be the key to successful treatment.

Innate immunity in cardiac myxomas and its pathological and clinical correlations

Cardiac myxomas are the most common benign cardiac tumor. We investigated the immunohistochemical properties of 11 surgically excised cardiac myxomas, in order to analyze the correlation between macrophages and mast cell populations and clinical parameters. CD68+/CD163−/iNOS− (M0) cells represent the most abundant macrophage phenotype; however, CD68+/CD163+ cells (M2) were also frequent. CD68+/iNOS+ (M1) elements were rare. Mast cells, defined as a population of c-kit (CD117)+ and/or tryptase+ cells were also detected. Statistical analysis showed significant correlations between c-kit (CD117)+ and tryptase, CD68 and erythrocyte sedimentation rate (ESR), ESR and red blood cell count (RBC), and prothrombin time and platelet count. The inverse correlation between RBCs in peripheral blood and ESR suggested that anemia associated with chronic inflammatory disease is a noncasual event in patients suffering from cardiac myxoma. Mechanical hemolysis may be only a minor component of anemia, according to the lack of correlation between echographic surface and RBCs. Moreover, tumor size did not correlate with ESR, showing that inflammatory state may depend from both tumor cells population and inflammatory infiltrate. In the future, modulation of macrophage polarization in cardiac myxomas might represent important therapeutic target.

Prosthesis embolization into the left ventricle during transcatheter aortic valve implantation

: Images and movie clips documenting the rare occurrence of a percutaneous prosthesis embolization into the left ventricle are presented. The case outcome and the circumstances leading to the event are discussed.

TAVI without surgical standby: Is history repeating itself? A word of caution

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An Unexpected Finding Complicating Pericardial Effusion and Tamponade

69-YEAR-OLD WOMAN with a history of diabetes, diffuse joint pain, and previous left anterior descending coronary artery angioplasty was admitted to a community hospital with low-grade fever (37.51C) and vague chest pain associated with respiratory movements. The erythrocyte sedimentation rate and C-reactive protein were both elevated. The cardiac enzymes were normal. The electrocardiogram showed 1.5-mm ST-segment elevation in leads I, aVL, and V3 to V6. An initial transthoracic echocardiogram (TTE) showed a small pericardial effusion (0.8 cm). Suspecting an inflammatory pericarditis, the patient was treated with indomethacin, 50 mg twice a day. Three days later, the patient suffered an episode of orthostatic hypotension with nausea. A followup TTE showed worsening of the pericardial effusion (1.8 cm on the anterior wall, 1.7 cm on the lateral one), traces of fibrin, and collapse of the right atrium. The patient was urgently sent to the authors’ institution with a diagnosis of cardiac tamponade due to inflammatory pericarditis. Upon admission to the authors’ institution, the white blood cell count was 16,000 cells/µL. Another TTE confirmed the cardiac tamponade (Fig 1), and the patient was transported to the operating room for subxiphoid pericardial window during which 350 mL of serous fluid and fibrin adhesions were removed. Postoperatively, the patient remained hemodynamically stable and denied further pain. The white blood cell count rapidly returned to the normal range, and a TTE examination conducted before the patient was discharged from the hospital excluded pericardial effusion. Pathology confirmed the diagnosis of nonspecific pericarditis. The patient returned to the referring hospital to complete the rheumatologic diagnostic workup and physical rehabilitation on the sixth postoperative day. A week later, the authors were consulted again because of purulent drainage from the surgical wound with fever, an elevated white blood cell count, and blood culture positive for methicillin-resistant Staphylococcus aureus (MRSA). In order to define mediastinal involvement, a computed tomography (CT) scan was obtained (Fig 2). What is the diagnosis?