Matteo Attisani

Incidence and severity of primary graft dysfunction after lung transplantation using rejected grafts reconditioned with ex vivo lung perfusion

OBJECTIVES Ex vivo lung perfusion (EVLP) is a novel technique used to evaluate and recondition marginal or rejected grafts. Primary graft dysfunction (PGD) is a major early complication after lung transplantation (LTx). The use of marginal or initially rejected grafts may increase its incidence and severity. The aim of this study is to evaluate the incidence of PGD after LTx using rejected grafts reconditioned with EVLP. METHODS PGD has been evaluated immediately after LTx (t0) and after 72 h (t72) in patients receiving standard (Group A) or reconditioned (Group B) grafts. EVLP was performed using a controlled acellular perfusion according to the Toronto technique. RESULTS From July 2011 to February 2013, 36 LTxs have been performed: 28 patients (21 M/7 F, mean age 51.7 ± 14.7 years) in Group A and 8 (6 M/2 F, mean age 46.6 ± 9.8 years) in Group B (successful recondition rate of 73%, 8 of 11 cases). Incidence rate of PGD 3 at t0 and at t72 (Group A versus Group B) was 50 vs 37% (P = NS) and 25 vs 0% (P = NS), respectively. Post-transplant extracorporeal membrane oxygenation was required in 5 and 2 patients in Groups A and B, respectively (P = NS). CONCLUSIONS The use of initially rejected grafts treated with EVLP does not increase the incidence and severity of PGD after LTx. Although comparison of PGD 3 incidence in the two groups did not reach a statistical difference, all EVLP patients suffering from severe PGD early after transplant recovered normal lung function at 72 h, suggesting a protective role of EVLP against PGD occurrence and severity.

A simple device to secure ventricular assist device driveline and prevent exit-site infection

OBJECTIVES Driveline infections are one of the most common and important complications in patients with left ventricular assist device (LVAD). One of the causes favouring the development of this complication is the traumatism of the exit site, which occurs in response to movement of the driveline. In this work, we present a simple and feasible method to immobilize the driveline at the level of the exit site. METHODS From April 2013 until November 2013, 6 patients underwent implantation of HeartWare LVAD (HVAD) for an end-stage heart failure. When the patient has begun to mobilize after the implantation of the device, we have combined the use of two components with the aim of securing the driveline to the patients skin: a StatLock system and a silicone suture. RESULTS No case of local traumatism and no case of local infection at the driveline were observed during the follow-up. No patient reported pain or swelling at the driveline exit site. All patients were satisfied with their quality-of-life and they do not report any limitations in their daily activities. CONCLUSIONS One of the major long-term complications in patients with LVAD is the development of infections of the exit site of the driveline. The trauma of this skin region promotes the onset and maintenance of an inflammatory process and local infectious. Avoiding excessive mobilization of the driveline is likely to reduce the incidence of infections of the exit site and improve the quality-of-life.

Rapid Pacing for the Off-Pump Insertion of the Jarvik Left Ventricular Assist Device

We present our technique for the implantation of the Jarvik 2000 left ventricular assist device (Jarvik Heart, Inc, New York, NY) without cardiopulmonary bypass by the induction of rapid pacing that allows the insertion of the apical device into the left ventricle, minimizing blood loss and surgical complications. Although the off-pump implantation of left ventricular assist devices is not new, our experience of rapid pacing has not been previously reported to our knowledge.

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.

Low incidence of gastrointestinal bleeding and pump thrombosis in patients receiving the INCOR LVAD system in the long-term follow-up

Background Left ventricular assist device (LVAD) implantation improves survival and quality of life in patients with advanced heart failure (HF). Despite these advantages, LVADs are not free from risks. Among all adverse events (AE), pump thrombosis and bleeding, especially of the gastrointestinal (GI) tract, have been reported to occur with increasing frequency in some CF-LVADs. The INCOR LVAD system is a third-generation, continuous flow, axial pump with active magnetic levitation, avoiding the potential downsides of mechanical bearings. Methods The aim of this retrospective study was to review the Italian clinical experience with the INCOR LVAD and to determine the prevalence of GI bleeding and pump thrombosis. All patients implanted between January 2006 and May 2012 were considered eligible. Results The total population consisted of 42 patients. LVAD indication was BTT in 36 (86%) and DT in 6 (14%) patients; 31 patients (74%) were INTERMACS class 1 or 2. Mean support time was 525 ± 570 days. The 1-year and 2-year survival rates were 74% and 60%, respectively. The most frequent AE was driveline infection (0.33 events PPY) followed by stroke with consequence (0.17 events PPY), sepsis (0.07 events PPY), and right HF (0.05 events PPY). No episodes of pump thrombosis or GI bleeding were observed. Conclusions In this cohort of high-risk, advanced HF patients, the INCOR LVAD provided effective support with improved survival. Moreover, the absence of GI bleeding and pump thrombosis demonstrates a favorable characteristic of this device. Further prospective studies are needed to confirm these data.

Successful replacement of a detached pedestal during support with Jarvik 2000.

Infection in patients supported with left ventricular assist devices (LVAD) is common and it can limit widespread implantation of mechanical assistance as destination therapy (DT). The infection-resistance power delivery system could improve longevity and quality of life. The Jarvik 2000 (Jarvik Heart, New York, NY, USA) driveline design showed a prolonged infection-free survival and a better quality of life compared to those patients supported with traditional LVAD with an abdominal cable. We report a singular driveline complication in a 71-year-old patient supported with a Jarvik 2000. A new retroauricular pedestal was successfully repositioned after the detachement of the first one.

Mycotic pseudoaneurysm as aortic complication after heart transplantation.

Infective pseudoaneurysm is a rare cause of aortic complications in immunosuppressed heart transplant patients. It is associated with a significant and early morbidity and mortality [1]. An unusual site of complication is the anastomotic suture line of the ascending thoracic aorta [2]. A 58-year-old man with previous pacemaker implantation, for complete atrioventricular block, underwent orthotopic heart transplantation for severe idiopathic cardiomiopathy: pacemaker was easily removed but one of the wires was not displaced because it was integrated into the vessel wall. No abnormalities in terms of antibodies between donor and recipient were detected in pretransplant evaluation. Re-exploration of the pericardial cavity for bleeding was performed on third postoperative day (POD). From 27th POD, bradycardia and fever set in and antibiotic therapy with teicoplanin and meropenem was introduced. Blood culture was positive for methicillin-resistant Staphylococcus aureus (MRSA) and only intravenous teicoplanin was continued. Refractory bradycardia was treated with intravenous atrially inhibited and rate-modulated pacemaker implantation on 36th POD. Further episodes of fever were encountered; however, the subsequent course was uneventful and the patient was discharged without complications. Two episodes of acute rejection >3A were detected and treated with i.v. steroids; after three other episodes of acute rejection <3A, cyclosporine was switched with tacrolimus along with mycophenolate mofetil and oral steroids. Five months later, he was readmitted for fever and CT scanning revealed pneumonia with blood cultures proving positive for MRSA but no aortic pathologies were detected. Antibiotic therapy with levofloxacin and linezolid was started with complete recovery in patient condition and abating of fever. Recurrent episodes of fever and positive blood cultures occurred and the hypothesis of an intravenous site of infection was considered because of fever recurrence in case of antibiotic suspension. Two structures were strongly suspected as possible sites of infection: the wire implanted after transplantation and the wire incarcerated into the vessel wall. On this basis, the patient underwent procedure for removal both of the pacemaker both of the wires. However, it was impossible to remove the wires already incarcerated into the vessel. There were many other episodes of fever further that were treated with long-term antibiotic therapy. On January 2008, approximately 2 years after transplantation, echocardiography revealed pericardial effusion with evidence of infected vegetations on the pacemaker wires. Chest radiography showed an image indicative of pneumonia in the basal segment of the right lung without mediastinal mass. CT scanning, performed to confirm the suspicion of pneumonia, showed a 4.3 · 2.8 cm mycotic pseudoaneurysm at the posterior anastomotic site of the aortic anastomosis (Fig. 1). No signs of pneumonia were detected but just pulmonary congestion. Moreover, bacteriological exams did not reveal pulmonary infection. The patient underwent surgical treatment. Mycotic pseudoaneurysm was identified as a round structure of approximately 4 cm in diameter starting from the posterior section of the aortic suture and extending towards pulmonary artery, which was compressed and weakened by the mass (Fig. 2). The ascending aorta was replaced with Dacron graft and the infected wires were completely removed. The antibiotic treatment with intravenous teicoplanin was continued postoperatively and the patient was discharged in 14th POD without complication. No other episode of fever occurred despite discontinuation of antibiotics and the CT scanning performed 6 months later, did not show any signs of infection. The term mycotic aneurysm is used to describe any infection of the arterial wall other than syphilis [1]. Osler [2] first documented a mycotic aneurysm in 1885, developed from septic embolization caused by bacterial endocarditis. Infective pseudoaneurysms are usually caused by haematogenous bacterial seeding to the intima or the vasa vasorum, lymphatic spread, extension of a contiguous extravascular infection, or traumatic inoculation [3]. In patients with mediastinitis, with inflammatory oedema of the tissues, pressure and stress may facilitate

Enlargement of Mitral Valve Ring in a Young Woman with Severe Prosthesis-Patient Mismatch

Mechanical prosthesis is the first choice for valve replacement at the mitral position in children. Replacement of the original prosthesis because of prosthesis-patient mismatch (PPM) is almost inevitable when prostheses are implanted in small children. The impact of PPM on long-term mortality becomes significant when the effective orifice area (EOA) is severely reduced. In these cases prosthesis replacement can be technically difficult, and it often requires extended enlargement of the mitral valve annulus ring. We report a case of a woman who underwent a mitral valve replacement with a 19-mm St. Jude mechanical prosthetic valve at the age of 3 years. At the age of 33 years, the patient underwent a successful minimally invasive mitral annulus ring enlargement and implantation of a 23-mm St. Jude mechanical prosthetic valve via a right minithoracotomy.

VAD infections: the lead, the graft and the pump

Ventricular assist device (VAD) implantation has become an established treatment in the case of endstage heart failure. One of the most important limitations is represented by the need of an extra-corporeal power supply and controller connected to the pump through a percutaneous cable. This may lead to local or even systemic infections that can jeopardize post-operative results. In the case of cable infections, medical treatment is usually less effective because of the presence of biofilms reduces

Intraoperative Right Ventricular Failure Management

Left ventricular assist devices are currently implanted using three different techniques [1]: Median sternotomy with cardiopulmonary bypass (CPB). Left posterolateral thoracotomy with the outflow graft connected to the descending aorta with or without CPB. This approach is more frequently used in case of reoperations to avoid re-sternotomy. Minimally invasive left mini-thoracotomy (with or without CPB).