Piero Farina

From extracorporeal membrane oxygenation to ventricular assist device oxygenation without sternotomy

expect a positive association between these two methods of clinical measurement. Our results support other studies in which the sensitivity and specificity of echocardiography were poor for diagnosis of PAH. Despite the poor predictability of echocardiography, current guidelines recommend an extensive work-up for underlying causes be performed before patients are subjected to RHC. This may create a significant amount of unnecessary spending. For illustration, Table 2 shows the 2010 Medicare reimbursement for each test recommended prior to performing RHC. The combined cost of these tests is

Late reoperations after acute aortic dissection repair: Single-center experience

1,638 per patient. Using our study’s rate of true PAH diagnosis, for every 100 patients with elevated PaSP on echocardiography,

The use of internal thoracic artery grafts in patients with aortic coarctation

106,470 will be spent unnecessarily on testing for patients who do not actually have WHO Group 1 PAH. In addition, if a full work-up is performed prior to RHC, there may be a delay in treatment, which may allow irreversible progression of PAH. This is compounded by the significant delay from onset of symptoms to the suspicion of PAH. Similarly, patients with left ventricular failure with preserved ejection fraction need prompt treatment as well. In one third of our study population, pulmonary venous hypertension was not suspected because the ejection fraction was preserved on echocardiogram. Further studies are warranted to identify the percentage of WHO Group 2 patients diagnosed in this manner. This study has limitations. First, it is a retrospective review that only included patients with elevated PaSP according to echocardiography. Second, the results are from a single center, and there may be significant variability in the technique and interpretation of echocardiography and RHC across different institutions. We suggest that RHC be performed as the next step in evaluating elevated PaSP on echocardiography. This may save on unnecessary health-care spending and lead to an earlier diagnosis of the disease.

Long-Term Survival and Quality of Life of Patients Undergoing Emergency Coronary Artery Bypass Grafting for Postinfarction Cardiogenic Shock

Background After repair of acute type A aortic dissection, aortic complications can develop, and reoperations might be necessary. In our retrospective study, we wanted to assess early and late outcomes in this cohort of patients. Methods From September 2005 to July 2012, 21 consecutive patients previously operated on for acute type A aortic dissection underwent 27 redo aortic surgical procedures. Indications for redo procedures were: enlargement of the false lumen in the residual aorta (18 events), severe aortic regurgitation with or without aortic root dilatation (8 events), suture dehiscence and pseudoaneurysm at the proximal or distal aortic graft anastomosis (5 events) or at the coronary button anastomosis in patients who previously underwent a Bentall procedure (1 patient). In all cases, total or partial cardiopulmonary bypass was used. Hypothermic cardiocirculatory arrest was needed in 22 (81%) procedures. Results Hospital mortality was 3.7% (1/27), reexploration for bleeding and paraplegia rates were 7.4% and 7.4%, respectively. Marfan patients received 3.2 procedures per patient vs. 1.5 in non-Marfan patients (p < 0.01). At a mean follow-up of 6.5 years, 2 aortic events occurred: 1 aortic death, and 1 additional aortic redo surgery. Conclusions When procedures are carried out on elective basis, redo aortic surgery can be performed in all segments of the aorta with good early and late outcomes. Close lifelong clinical and radiological follow-up is mandatory. After repair of acute type A aortic dissection, Marfan patients are more prone to develop late complications, with a more rapid evolution.

Mini-aortic surgery with percutaneous cannulation and rapid-deployment valve.

The choice of conduits for surgical revascularization in patients with aortic coarctation can be puzzling, as the internal thoracic arteries can be dilated, atherosclerotic and unsuitable for grafting. Reports in the literature are controversial: in some cases, the internal thoracic artery was not suitable for revascularization, while in others, it could be used with discordant outcomes. Here, we review the literature on the subject.

Systematic bilateral internal mammary artery grafting: lessons learned from the CATHolic University EXtensive BIMA Grafting Study

BACKGROUND This study evaluated the long-term outcome of patients undergoing emergency coronary artery bypass grafting (eCABG) for cardiogenic shock after acute myocardial infarction. METHODS Sixty-seven consecutive patients underwent eCABG for cardiogenic shock at 2 European institutions during an 11-year period. Preoperative, intraoperative, postoperative, and long-term follow-up data of all patients were prospectively collected. RESULTS Hospital survival was 86% (58 of 67), with all deaths due to cardiac causes. At a mean follow-up of 78 ± 48 months (range, 1 to 153 months), 43 of the 58 patients (74%) discharged from the hospital were alive. Causes of death in 9 of the 15 follow-up deaths (60%) were noncardiac. Overall survival rate at the end of follow-up was 64% (43 of 67). Of the 43 survivors, 41 (95%) were in New York Heart Association Functional Classification I to II, ischemia free, had a Karnofsky performance status exceeding 80, and an excellent quality of life as assessed by the Seattle Angina Questionnaire. The use of cardiopulmonary bypass and the internal thoracic artery were associated with significantly better long-term survival. CONCLUSIONS The long-term survival and quality of life of patients who undergo eCABG for cardiogenic shock after acute myocardial infarction are good, and eCABG should be considered a valuable therapeutic option in this setting. The use of cardiopulmonary bypass and the internal thoracic artery at the time of the operation are strongly advocated.

Postoperative coronary artery spasm after mitral valve replacement

Background We aimed to evaluate the results of the combined use of rapid-deployment valves, percutaneous cardioplegia delivery and left heart venting during minimally invasive aortic valve replacement surgery. Methods We identified 2 propensity-matched cohorts of patients who underwent primary elective isolated minimally invasive aortic valve surgery at our center over a 3-years period: 30 patients in group A had a conventional valve prosthesis and 30 patients in group B received a rapid-deployment valve using percutaneous cardioplegia delivery and percutaneous left heart venting. Skin incision length, intraoperative times, postoperative hospital outcomes, and 30-day echocardiographic results were compared between the 2 groups. Results Patients in group B had significantly shorter operative times and shorter skin incisions compared to group A (total operative time 196.0 ± 40.6 vs. 225.1 ± 30.8 min, respectively, p < 0.003; cardiopulmonary bypass time 79.9 ± 10.6 vs. 92.9 ± 17.2 min respectively, p < 0.001; crossclamp time 52.3 ± 9.6 vs. 74.9 ± 10.2 min, respectively, p < 0.001; incision length 3.6 ± 0.5 vs. 6.0 ± 0.6 cm, respectively, p < 0.001). Postoperative hospital outcomes and echocardiographic evaluation showed no significant differences. Conclusions The combined use of rapid-deployment valves, percutaneous cardioplegia, and left heart venting is safe and effective and allows a significant reduction of the skin incision together with a significant reduction of intraoperative times without affecting hospital outcomes or hemodynamic performance of the prosthetic valves.

Myocardial revascularization with both internal thoracic arteries 25 years after delayed repair for aortic coarctation

OBJECTIVES Despite claims of feasibility, to date no study has examined the effect of systematic bilateral internal mammary artery (BIMA) use in a large cohort of real-world unselected patients. The CATHolic University EXtensive BIMA Grafting Study (CATHEXIS) registry was designed to assess the feasibility and safety of systematic BIMA grafting. METHODS The CATHEXIS was a single-centre, prospective, observational, propensity-matched study. The study was supposed to include 2 arms of 500 patients each: a prospective arm and a retrospective arm. The prospective arm included almost all patients referred for coronary artery bypass grafting (CABG) at our institution after the start of the CATHEXIS with very few exceptions. BIMA would have been used in all these patients. The retrospective arm included patients submitted to CABG before the start of the CATHEXIS and propensity matched to the prospective group (average BIMA use 50%; the radial artery was extensively used). Safety analyses were scheduled after enrolment of 200, 300 and 400 BIMA patients. RESULTS After the first 226 patients, the BIMA use percentage was 88.5% (200 of 226). In 178 (89%) patients, mammary arteries were used as Y graft. Postoperative mortality was 2%, and incidence of perioperative myocardial infarction, graft failure and sternal complications were 3.5%, 3% and 5.5%, respectively. No perioperative stroke occurred. The incidence of major adverse cardiac events (particularly graft failure and sternal complications) in the BIMA arm were significantly higher than those in the propensity-matched cohort; the study was stopped for safety. CONCLUSIONS In a real world setting the systematic use of BIMA was associated with a higher incidence of perioperative adverse events (particularly sternal complications). Individualization of the revascularization strategy and use of alternative arterial conduits are probably preferable to systematic use of BIMA.

Off-pump coronary artery bypass surgery: The long and winding road

Highlights • Coronary artery spasm occurred after mitral valve replacement in a patient with normal coronary arteries.• The patient had ST changes and inferior wall hypokinesia.• The diagnosis was established by urgent postoperative coronary angiography.• The spasm responded to the intracoronary injection of nitrates.• The remaining postoperative course was uneventful and the left ventricular function returned to normal.

ECMO in Drug Intoxication

Aortic coarctation has been reported to cause alterations in the internal thoracic arteries that make these vessels unsuitable to be used as grafts for myocardial revascularization, especially if coarctation repair was performed in adulthood. This is the first reported bilateral internal thoracic grafting for myocardial revascularization in a patient who had undergone aortic coarctation repair 25 years earlier.