Nicola Pederzolli

Different results of cardiac transplantation in patients with ischemic and dilated cardiomyopathy.

We retrospectively analyzed 275 consecutive transplanted patients, dividing them into group A (128 patients) affected by ischemic cardiomyopathy and group B (147 patients) affected by dilated cardiomyopathy. The difference in demographic, clinical and hemodynamic preoperative and postoperative data between the groups was studied; group A patients presented at transplantation with a less compromised hemodynamic picture, requiring inotrope infusion and mechanical assistance less frequently. The influence of etiology on early postoperative complications was also analyzed: group A patients needed postoperative mechanical assistance, inotrope, infusion and prolonged mechanical ventilation more often, therefore requiring a longer stay in the intensive care unit (ICU). Hospital mortality was twice as high in group A. The older age of group A patients per se did not influence these results significantly. The long-term follow-up was then studied with particular attention to parenchymal functions, hemodynamics, coronary artery disease, metabolic and surgical complications, and survival. The complication rate was higher in group A, with more severe hypertension and higher cholesterol levels at 1 year, a higher prevalence of accelerated coronary artery disease (CAD) and a more frequent onset of insulin-dependent diabetes. Surgical and vascular complications were also more frequent. The final result was a better 5-year actuarial survival rate for group B patients. Donor and recipient ages at the time of transplant did not influence this result. We conclude that ischemic patients, even if they are transplanted in better condition and operated more electively, have a more critical early and long-term postoperative course and a worse survival rate. These findings are not explained by advanced age, but could be due to the impact of atherosclerosis and metabolic impairments associated with ischemic disease.

Successful treatment of aortic dissection after heterotopic heart transplantation

Heterotopic heart transplantation is a valid option when there is a large donor-recipient size mismatch. However, the presence of the diseased native heart can jeopardize the medium-term and long-term outcome. The problems stemming from this most commonly described in the literature are thromboembolism, angina, and arrhythmias. In this report, we describe the case of a type A aortic dissection in the native aorta that occurred 30 months after heterotopic heart transplantation and the surgical technique successfully applied for its repair. We also discuss some of the alternative techniques.

Emergency and elective cardiac retransplantation

Among 265 patients transplanted at our Institution, 7 underwent cardiac retransplantation. There were five emergency retransplantations, the indication being graft failure in one case and acute rejection in four cases. Two patients, retransplanted because of acute rejection, had a positive panel reactivity antibody and a negative donor crossmatch. In the rejection cases immunosuppression was enhanced by perioperative plasmapheresis and a postoperative 1-month course of cyclophosphamide. In two cases emergency retransplantations were successfully performed despite a highly positive prospective crossmatch. Two patients underwent elective retransplantations for chronic rejection 12 and 41 months, respectively, after the primary transplants. The overall early and late survival rates are 71% and 57%, respectively, with a mean follow-up of 48.5 months. The early and late mortality for elective retransplantation is zero. Our experience confirms both the high operative risk for emergency retransplantation and the excellent results for elective retransplantation. The use of plasmapheresis and cyclophosphamide allowed us to undertake retransplantation successfully in 2 cases with positive donor crossmatch. Both hyperimmunized patients in our series were retransplanted because of irreversible acute rejection despite a negative crossmatch with the primary donor. The meaning of negative crossmatch in patients with preformed cytotoxic antibodies is therefore questionable.

Left ventricle remodelling by double-patch sandwich technique

BackgroundThe sandwich double-patch technique was adopted as an alternative method for reconstruction of the left ventricle after excision of postinfarction dysfunctional myocardium to solve technical problems due to the thick edges of the ventricular wall.MethodsOver a 5-year period, 12 of 21 patients with postinfarction antero-apical left ventricular aneurysm had thick wall edges after wall excision. It was due to akinetic muscular thick tissue in 6 cases, while in the other 6 with classic fibrous aneurysm, thick edges remained after the cut of the border zone. The ventricular opening was sandwiched between two patches and this is a technique which is currently used for the treatment of the interventricular septum rupture. In our patients the patches are much smaller than the removed aneurysm and they were sutured simply by a single row of single stitches. However, in contrast to interventricular septum rupture where the patches loosen the tension of the tissues, in our patients the patches pull strongly and restrain the walls by fastening their edges and supporting tight stitches. In this way they could narrow the cavity and close the ventricle.ResultsThe resected area varied from 5 × 4 to 8 × 8 cm. Excision was extended into the interventricular septum in 5 patients, thus opening the right ventricle. CABG was performed on all patients but two. Left ventricular volumes and the ejection fraction changed significantly: end-systolic volume 93.5 ± 12.4 to 57.8 ± 8.9 ml, p < 0.001; end-diastolic volume 157.2 ± 16.7 to 115.3 ± 14.9 ml, p < 0.001; ejection fraction 40.3 ± 4.2 to 49.5 ± 5.7%, p < 0.001. All patients did well. One patient suffered from bleeding, which was not from the wall suture, and another had a left arm paresis. The post-operative hospital stay was 5 to 30 days with a mean 10.5 ± 7.5 days/patient. At follow-up, 9 to 60 months mean 34, all patients were symptom-free. NYHA class 2.5 ± 0.8 changed to 1.2 ± 0.4, p < 0.001.ConclusionThe double-patch sandwich technique (bi-patch closure) offers some advantages and does not result in increased morbidity and mortality. In the case of excising a left ventricular aneurysm, this technique in no way requires eversion of the edges, felt strips, buttressed and multiple sutures, all of which are needed for longitudinal linear closure. Moreover, it does not require purse string sutures, endocardial scar remnant to secure the patch or folding the excluded non-functional tissue, all of which are needed for endoventricular patch repair.

Left atrial ball thrombus after edge-to-edge mitral valve repair

A thrombus can develop in the left atrium during atrial fibrillation because the loss of contractile function leads to blood flow stasis. Anticoagulation therapy is indicated for prevention of systemic embolism, usually maintaining an international normalized ratio between 2 and 3. Rarely a massive thrombosis develops in the atrium resulting in a peduncolated ball valve thrombus or in a free-floating thrombus. These two conditions are characterized by variables in the physical findings. Such masses are hazardous and upon discovery surgical treatment, often in emergency, is mandatory. We present here the case of a patient who developed an unnoticed huge left atrial ball thrombus despite warfarin therapy after previous mitral valve surgery. <Learning objective: Risk of atrial thrombosis threatens patients suffering from atrial fibrillation. The presence of a ring and a modified valve anatomy following a surgical repair could represent an additional drive in the thrombus formation pathway. A free-floating ball thrombus in the left atrium is an unusual occurrence that may cause fatal systemic emboli or left ventricular inflow obstruction, often resulting in sudden death. In such cases, even in the absence of symptoms, prompt surgical excision is recommended.>.