Gianluca Torregrossa

Posttraumatic stress disorder and depression in heart transplantation recipients: the relationship with outcome and adherence to medical treatment

OBJECTIVE There is growing evidence of the importance of psychiatric risk factors for predicting the outcome of heart transplantation (HT) recipients. The aim of our study was to investigate the role of major depression and posttraumatic stress disorder (PTSD) in the prediction of the outcome of HT in a consecutive sample of 107 recipients. METHOD All subjects of the study underwent a structured diagnostic interview for assessing the presence of pretransplant and posttransplant major depression and transplantation-related PTSD 1 to 5 years after HT. The adherence to medical treatment was assessed some months after the structured interview. The medical outcome (acute rejections, cancer, mortality) was followed up for 8 years on average after the interview, using a prospective design. RESULTS Estimated frequency of psychiatric diagnoses after HT was 12% for transplantation-related PTSD and 41% for major depression. The presence of an episode of major depression prior to HT is a significant independent risk factor for posttransplant malignancies. Age, posttransplant malignancies and poor adherence are significant predictors of mortality in the survival analyses. CONCLUSIONS The present study highlights the importance of the assessment of psychosocial variables and psychiatric diagnoses before and after transplantation in HT recipients. Our findings have important clinical implications and require replication with larger samples.

Can C4d immunostaining on endomyocardial biopsies be considered a prognostic biomarker in heart transplant recipients

Background. The aim of this study was to assess the significance of positive C4d capillary immunostaining of endomyocardial biopsies and its correlation to clinical outcome in adult heart transplant recipients. Methods. Nine hundred eighty-five endomyocardial biopsies from 107 heart transplant recipients were evaluated. Immunostaining for detection of intragraft C4d capillary deposition was performed on paraffin-embedded tissue using anti-human C4d polyclonal antibody. Results. Positive staining of C4d was present in 36 patients (34%) and antibody-mediated rejection in eight patients (7%). The patients were subdivided into four groups on the basis of their C4d, circulating antidonor antibodies (donor-specific antibodies [DSAs]), and graft function: group 1=C4d positive, DSA negative, and no graft dysfunction; group 2=C4d positive, DSA positive, and no graft dysfunction; group 3=C4d positive, DSA positive, and signs of graft dysfunction, and group 0 (control)=all negative. An higher mortality risk was found in C4d-positive patients, when compared with negative ones (unadjusted hazard ratios: group 1: 18, group 2: 61, and group 3: 32-fold risk; P<0.0001). Conclusions. Antibody-mediated rejection is a complex and ongoing phenomenon with different phenotypic features. C4d positive predicts worse prognosis. C4d negative and DSA can be used as early mortality predictors in patients without signs of graft dysfunction.

Clones of Interstitial Cells From Bovine Aortic Valve Exhibit Different Calcifying Potential When Exposed to Endotoxin and Phosphate

Objective—Our purpose was to study in vitro whether phenotypically-distinct interstitial cell clones from bovine aortic valve (BVIC) possess different calcifying potential in response to endotoxin (lipopolysaccharide [LPS]) and phosphate (Pi). Methods and Results—Among various clones of BVIC obtained by limited dilution technique we selected 4 clones displaying different growth patterns and immunophenotypes. Uncloned and cloned cells were treated with combinations of LPS (100 ng/mL) and Pi (2.4 mmol/L). Uncloned BVIC showed increased alkaline phosphatase activity (ALP) after treatment with LPS, which resulted in calcification after addition of Pi. Among BVIC clones, only Clone 1 (fibroblast-like phenotype) showed a relevant increase in ALP after LPS treatment in parallel with prevention of smooth muscle (SM) α-actin accumulation. No effect was observed in clonal cells harboring a more stable SM cell-like profile (Clone 4). None of the isolated clones calcified but mineralization was induced in the presence of LPS plus Pi when Clone 1 was cocultured with Clone 4 or after seeding on type I collagen sponges. Conclusion—Endotoxin and phosphate can act as valve calcification promoters by targeting specific fibroblast-like interstitial valve cells that possess a unique procalcific potential.

Present and future perspectives on total artificial hearts

Due to shortages in donor organ availability, advanced heart-failure patients are at high risk of further decompensation and often death while awaiting transplantation. This shortage has led to the development of effective mechanical circulatory support (MCS). Currently, various implantable ventricular-assist devices (VADs) are able to provide temporary or long-term circulatory support for many end-stage heart-failure patients. Implantation of a total artificial heart (TAH) currently represents the surgical treatment option for patients requiring biventricular MCS as a bridge to transplant (BTT) or destination therapy (DT). However, the clinical applicability of available versions of positive displacement pumps is limited by their size and associated complications. Application of advanced technology is aimed at solving some of these issues, attempting to develop a new generation of smaller and more effective TAHs to suit a wider patient population. Particular targets for improvement include modifications to the biocompatibility of device designs and materials in order to decrease hemorrhagic and thromboembolic complications. Meanwhile, new systems to power implanted driving units which are fully operational without interruption of skin barriers represent a potential means of decreasing the risk of infections. In this review, we will discuss the history of the TAH, its development and clinical application, the implications of the existing technological solutions, published outcomes and the future outlook for TAHs.

Transapical off-pump mitral valve repair with Neochord Implantation (TOP-MINI): step-by-step guide

A wide variety of surgical approaches for mitral valve repair (MVR) are available. Recent studies have demonstrated that the techniques which “respect rather than resect” the diseased portion of the mitral valve (MV) have comparable clinical outcomes and potentially superior results in terms of physiology (1). Artificial chordal implantation has received increased attention as an MVR strategy during the last few decades, especially when performed through a minimally invasive approach. The Transapical Off-Pump Mitral Valve Repair with Neochord Implantation (TOP-MINI) is a new MVR option that has been approved for patients presenting with severe mitral regurgitation (MR) due to leaflet(s) prolapse or flail (2-4). The procedure is performed using the NeoChord DS1000 system (NeoChord, Inc., Eden Praire, MN) under guidance of direct 2D and 3D transesophageal echocardiography (TEE) (5,6) for both implantation and tension adjustment of the neochordae. The aim of this article is to describe the TOP-MINI procedure in a step-by-step fashion.

Pediatric Coronary Artery Revascularization: A European Multicenter Study

BACKGROUND We sought to evaluate the hospital and midterm results of different surgical revascularization techniques in pediatric patients within the European Congenital Heart Surgeons Association. METHODS From 1973 to 2011, 80 patients from 13 European Congenital Heart Surgeons Association centers underwent 65 pediatric coronary artery bypass grafting (PCABG) and 27 other coronary artery procedures (OCAP; 12 patients had combined PCABG and other coronary artery procedures). Excluded were patients with Kawasaki disease. Median age at the time of coronary procedure was 2.3 years (range, 2 days to 16.9 years); 33 patients (41.2%) were younger then 12 months. An emergency procedure was necessary in 34 patients (42.5%). RESULTS Twelve patients (15%) died in the hospital; age at surgery (p=0.02) and the need for an emergent procedure (p=0.0004) were related to hospital mortality. Median follow-up time was 7.6 years (range, 0.9 to 23 years). There were 3 late cardiac deaths, all after a median time of 4 years (range, 9 months to 8.8 years) after PCABG. Fourteen patients (20.5%) presented with symptoms, including congestive heart failure (n=10) and angina (n=4), that were significantly associated with a low ejection fraction (p<0.001) and the presence of moderate or severe mitral valve regurgitation (p=0.0003). Six patients underwent a reintervention for impaired myocardial perfusion; all of them had a stenotic or atretic PCABG (p=0.001), and the majority were symptomatic (5 of 6 patients; 83.3%; p=0.001). CONCLUSIONS Both PCABG and other coronary artery procedures are suitable surgical options in pediatric patients with impaired myocardial perfusion, which increases operative and midterm survival. Such population of patients needs to be followed for life to prevent and treat any possible cause of further myocardial ischemia.

SynCardia: the total artificial heart.

The SynCardia total artificial heart (TAH) currently provides the most definitive option for patients with biventricular failure who are not candidates for isolated left ventricular (LV) assist device placement. The techniques for implantation are adaptable to almost all patients with advanced heart failure, including those with severe biventricular cardiomyopathy, complex congenital heart disease, failed LV assist devices, failed transplantations, and acquired structural heart defects that have failed or are not amenable to conventional surgical treatment. Over the years, the implantation technique has evolved in order to minimize the surgical invasiveness of the procedure, in anticipation of additional future surgery. Meticulous hemostasis with double layer sutures, use of Gore-Tex sheets around the TAH and the pericardial cavity, and use of tissue expanders to avoid contraction of pericardial cavity around the device are discussed in detail in the following report. Additionally, we will provide our experience with implantation of TAH in various challenging scenarios, such as patients with a small chest cavity, congenital heart defects, and simultaneous use of extracorporeal membrane oxygenation (ECMO).

Peripheral Adaptation Mechanisms in Physical Training and Cardiac Rehabilitation: The Case of a Patient Supported by a Cardiowest Total Artificial Heart

BACKGROUND The benefits of exercise training in patients with chronic heart failure (CHF) are due to a combination of cardiac and peripheral adaptations. Separating these 2 components is normally impossible, except for patients implanted with total artificial heart (TAH), where cardiac adaptation cannot occur. METHODS AND RESULTS We report the case of a patient implanted with a CardioWest-TAH who underwent a comprehensive strength and endurance training program and was evaluated by repeated peak cardiopulmonary exercise tests. The patient experienced a 24% increase of peak oxygen consumption and an improvement in recovery kinetics during the training period of 29 months. CONCLUSION This unique situation of a patient with a TAH, and therefore a fixed peak cardiac output, allows us to isolate training-induced changes in the periphery, that suggest greater oxygen extraction and more efficient metabolic gas kinetics during the exercise and recovery phases.

ABO-incompatible heart transplantation: crossing the immunological barrier

Due to the shortage of organ donors, heart transplantation cannot be offered to many infants with end-stage heart failure; this issue leads to mortality rates of 30-50% in patients in the paediatric age group awaiting operation. ABO-incompatible heart transplantation has been performed safely with no particular or invasive preparatory procedures other than plasma exchange during cardiopulmonary bypass for removing preformed antibodies, with no reports of hyperacute rejection. We report our first clinical experience of heart transplantation on a 2-month-old-infant (blood group O), diagnosed with intracardiac tumour, in which the donor was a 19-day-old newborn of blood group A. Sharing the know-how about ABO-incompatible heart transplantation in newborns and infants awaiting transplantation will help in decreasing mortality among this group of patients.

Asymptomatic right ventricular perforation by an implantable cardioverter defibrillator lead detected by home monitoring system.

Right ventricular lead perforation is a rare but serious and potentially life-threatening complication of pacemaker or defibrillator lead implantation. This report describes a patient with Brugada syndrome in whom the diagnosis of asymptomatic right ventricular perforation by an implantable cardioverter defibrillator lead was detected 12 days after implantation, thanks to a report from home monitoring system. The patient was admitted to our institution, where the lead was explanted and replaced. This case illustrates the potential lifesaving benefit of the home monitoring system in patients with implantable cardioverter defibrillator.