Paolo Centofanti

Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: A 5-year multi-institutional experience

BACKGROUND Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period. METHOD From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access. RESULTS Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation. CONCLUSIONS Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.

Sternal closure using semirigid fixation with thermoreactive clips

Sternomy represents the standard approach to the heart and great vessels in most cardiothoracic procedures. Closure of this incision is simple; however, healing complications such as dehiscence, osteomyelitis, mediastinitis, and superficial wound infection or fistula may occur. We describe an alternative technique for sternal closure using semirigid fixation with thermoreactive clips.

Outcome of pregnancy after organ transplantation: a retrospective survey in Italy

The number of women who decide to have a child after organ transplantation has increased. We determined the outcomes of 67 pregnancies of women who had undergone kidney, liver or heart transplantation. All recipients had been maintained on immunosuppressive therapy before and during pregnancy. Pregnancy complications at term were observed in 17 out of 67 women (25%), hypertension being the most frequent complication (16.17%). Two transplant rejections were reported. Sixty-eight infants were delivered (including one pair of twins); five women had two pregnancies at term. Twenty-eight miscarriages (29.2%) were recorded. Of these 68 babies (including the pair of twins), 40 (58.8%) were born at term and 28 (41.2%) before term. The babies were followed-up for 2 months to 13 years. According to our previous experience, our study shows that patients who have undergone organ transplantation can give birth to healthy infants as long as they are monitored accurately during pregnancy.

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.

Potential role of the Impella Recover left ventricular assist device in the management of postinfarct ventricular septal defect.

Subsequently, the diseased section of the lateral wall along the incision was excluded, and the incision was closed in a double-layered fashion with felt strips to achieve PLV (Video E1). The aortic crossclamp time was 135 minutes, and the cardiopulmonary bypass time was 241 minutes. The postoperative course was uneventful, and the postoperative echocardiogram showed improved LV shape/ dimension and function (LVDd 1⁄4 57 mm, LVEF 1⁄4 30%) with no mitral, tricuspid, or aortic regurgitation. She was discharged, able to walk, on postoperative day 49. Three years after the operation, she is doing well; her cardiac status is NYHA class I, LVDd is 56 mm, and LVEF is 33%.

Too large resection of pectus excavatum in young patients: A reason to worry?

We read with great interest the report by Dr Haller regarding the repair of chest deformity as pectus excavatum (PE) at an early age [1], and we desire to contribute to this subject our experience. In a recent review of our patients, operated on for PE with one surgical technique (Fig 1 ) during a long period (1958 to 1991), we found results worthy of consideration regarding the indications and the correct timing for operation [2]. The patient population features and clinical operative and postoperative conditions are reported in Table 1 .

Results With Cyclosporine Monotherapy in Long-Term Cardiac Transplant Recipients

BACKGROUND Triple therapy is the gold standard after heart transplantation while few reports have described experiences with cyclosporine monotherapy (CM). We have analyzed our experience with CM in long-term heart transplant recipients, surviving >5 years. METHODS Of the 219 patients transplanted between January 1990 and December 1998, 143 survived >5 years (mean age, 49.6 +/- 10.4). There were 124 (86.7%) male subjects. Matching patients respect to follow-up length, we obtained 2 groups: group A of 41 patients on double therapy (DT; cyclosporine plus Azathioprine) and group B of 41 patients on CM. RESULTS After a mean follow-up of 119.8 +/- 32.2 months, we did not observe a significant difference in terms of survival and major events: heart failure, malignancy, dialysis, infections, and CAV. CONCLUSION We strongly support the use of triple therapy in cardiac transplant recipients because of its known safety and efficacy. However, our experience with CM suggests the utility of this approach.

Left ventricular pseudoaneurysm after pericardiocentesis

We present the case of a patient with recurrent episodes of pericardial effusion and fever. During approximately one month, the patient was treated with double pericardiocentesis for cardiac tamponade and the last of them was interrupted for the suspect of left ventricular puncture due to aspiration of arterial blood from the needle used for pericardiocentesis. Considering the suspect of infective pleuro-pericarditis and patients symptoms, a surgical drainage of the pericardial effusion was performed via right thoracotomy. The echocardiography and CT-scan performed after right thoracotomy showed only a mild pericardial effusion. Fifteen days later, the patient suffered from congestive heart failure and fever. The echocardiography and CT-scanning which were performed urgently, showed a large pseudoaneurysm (approx. 26 mm x 36 mm) of the apex of the left ventricle. Ventriculography confirmed the presence of the pseudoaneurysm in connection with the left ventricular apex. Exclusion of the LV pseudoaneurysm was performed using a Prolene 0 running suture on two strips of bovine pericardium, avoiding ECC use. The patient was discharged on the 7th postoperative day. Iatrogenic pseudoaneurysm caused by pericardiocentesis represents a very rare complication and it should be prevented by identifying the high-risk patients.

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.