Salvatore Agati

Use of a novel anticoagulation strategy during ECMO in a pediatric population: single-center experience.

We describe a novel anticoagulation strategy with continuous intravenous antithrombin infusion and intermittent heparin infusion in pediatric population during extracorporeal membrane oxygenation (ECMO). From November 2004 through February 2006, 11 patients required ECMO for postcardiotomy cardiorespiratory failure. The mean duration of support time was 112 hours (range 68–192 hours). Since April 2005, we modified our anticoagulation protocol in the last six patients. Continuous antithrombin infusion was started immediately after surgery based on the lab result. The antithrombin level was maintained >100% using the following formula: 100 (target value) – (Antithrombin value on lab test) × weight in 4 hours. Antithrombin value was checked at 4-hour intervals. Heparin infusion was started when the antithrombin value was > 100% and remained stable for more than 12 hours and the amount of bleeding was < 2 ml/kg for more than 3 consecutive hours; then heparin infusion was started at 2 UI/kg/h via the oxygenator (target ACT was not < 150 seconds). Three patients in the first group died. Eight patients were weaned and discharged; the third, fourth, and fifth required surgical revision for bleeding. One experienced minor neurologic sequelae. Neither surgical revision nor thromboembolic complications occurred in the new anticoagulation group. A novel anticoagulation strategy utilizing continuous intravenous antithrombin and intermittent heparin infusion reduced significantly surgical revision for bleeding in the first 48 hours. This has translated into excellent overall outcomes.

Bidirectional Glenn and antegrade pulmonary blood flow: temporary or definitive palliation?

BACKGROUND We sought to investigate the role of the bidirectional Glenn with antegrade pulmonary blood flow in the surgical history of children with univentricular hearts. METHODS A series of 246 patients, from three joint institutions, having univentricular heart with restricted but not critical pulmonary blood flow received a bidirectional cavopulmonary shunt with additional forward pulmonary blood flow. All patients have been studied according to their progression, or not, to Fontan operation. Two hundred and eight (84.5%) patients underwent bidirectional cavopulmonary anastomosis as primary palliation. Twenty patients (8.1%) with previous pulmonary artery banding were also enrolled in the study. Patients who had received additional pulmonary blood flow through a previous systemic to pulmonary artery shunt for the critical pulmonary blood flow were excluded. RESULTS No in-hospital death occurred. Follow-up was complete at 100%. Mean follow-up was 4.2 +/- 2.8 years (range, 6 months to 7 years). During the observational period 73 (29.7%) patients, considered optimal candidates, underwent Fontan completion for increasing cyanosis and (or) hematocrit and (or) fatigue with exertion. Three patients expired after total cavopulmonary connection (3 of 73; 4.1% mortality rate). The remaining 173 (70.3%) patients are alive with initial palliation. All patients were still well palliated with an arterial oxygen saturation at rest about 90%. CONCLUSIONS According to our experience and results, bidirectional Glenn with antegrade pulmonary blood flow may be an excellent temporary palliation prior to a Fontan operation, which can be performed at the onset of symptoms. Bidirectional Glenn may also be the best possible palliation for a suboptimal candidate for Fontan.

Papillary muscle rupture and pericardial injuries after blunt chest trauma.

Non-penetrating cardiac trauma resulting in mitral valve rupture is uncommon, requiring a high degree of suspicion for diagnosis. Sudden and severe mitral regurgitation, unless surgically corrected rapidly lead to congestive heart failure and death. We report a patient with traumatic rupture of the antero-lateral papillary muscle of the mitral valve and pericardial injury, after a lateral blunt chest trauma, who successfully underwent emergency mitral valve replacement.

DIDECMO : A new polymethylpentene oxygenator for pediatric extracorporeal membrane oxygenation

We reviewed the performance of a new polymethylpentene oxygenator (DIDECMO, Dideco, Mirandola, Italy) in terms of clinical safety and efficiency in priming, oxygenation, and oxygenator resistance in neonatal and pediatric extracorporeal membrane oxygenation (ECMO) patients. Between March 2005 and January 2006, 14 patients required ECMO in the San Vincenzo Hospital. Of these, 8 (median age, 9 days; range, 3 days to 15 months) received normothermic ECMO for postcardiotomy heart failure after surgery for congenital heart disease. The DIDECMO oxygenator was used in all patients (median weight, 2.4 kg; range, 2 to 7 kg). According to our previous experience, all patients received the same anticoagulation management. DIDECMO is a new phosphorylcholine-coated, polymethylpentene hollow-fiber oxygenator recommended for a maximum blood flow of 2300 ml/min with a membrane surface area of 0.67 m2 and validated to be used up to 5 days. Static priming was 100 ml and mean support time 05 hours (range, 36 to 198 hours). No oxygenators were changed during support. Median pressure drop during overall assistance was 24 mm Hg. Carbon dioxide elimination was obtained with a 1:1 blood flow/air flow ratio. Neither oxygenator-related major nor minor adverse events occurred during support. In our initial experience, the new polymethylpentene DIDECMO oxygenator provided adequate gas exchange and offered technical advantages in terms of low priming volume and acceptable hemodynamic resistance despite pulsatile flow regimen. Also, we used this device for more than 8 days without any technical problems.

Pulsatile ECMO and VAD: a dual use of a new device in pediatric cardiac patients.

The purpose of this investigation was to present the first European clinical experience with the new MEDOS DELTASTREAM® DP1 used in pulsatile extracorporeal membrane oxygenation (ECMO) or ventricular assist device (VAD) options in the pediatric population. Between January 2002 and April 2006, 11 patients required ECMO and 5 patients received a left VAD (LVAD) in the San Vincenzo Hospital. Indications were postcardiotomy heart failure in 15 patients and fulminant myocarditis in one patient. ECMO was established in all patients by cannulation of the right atrium and ascending aorta. LVAD was instituted by cannulation of the left atrium and ascending aorta. The DP1, an extracorporeal rotary blood pump, was used as an ECMO and an LVAD device. The pump features a diagonal-flow impeller and can be used for both continuous and pulsatile modes of perfusion. Priming volume of the pump was approximately 30 ml, with a flow rate of up to 8 l/min. Ten patients were discharged from ECMO and four from VAD. In the ECMO group, one patient died of peritonitis while on ECMO and two patients died on days 3 and 4 after weaning because of persistent pulmonary hypertension and major neurologic complications. In the VAD group, one patient died of low output syndrome 9 days after weaning. A 12-year-old patient was successfully given transplantation on day 8 of ECMO support and discharged on day 30 after heart transplant. All other patients were discharged. Three pumps were changed for pump failure and one pump was electively replaced because of improper anticoagulation management. No other thromboembolic adverse events occurred. Our results suggest that the MEDOS DELTASTREAM DP1 pulsatile pump system can be used as an ECMO or a VAD support. The opportunity to utilize pulsatile flow in postcardiotomy cardiogenic shock significantly improved the outcomes by producing more physiologic hemodynamics and superior end organ function. Easy implantation and simple management of this device represents the major advantage.

Successful intraventricular thrombolysis during ventricular assist device support

Different types of mechanical ventricular assist devices are available for treating end stage congestive heart failure. Despite technical improvements, however, various complications are still reported for patients during mechanical support. We report our experience with intraventricular thrombolysis as a treatment for possible thrombosis of a continuous flow device that had been implanted as a bridge to heart transplantation. This approach has been demonstrated to be both effective and safe.

Pulsatile ecmo in neonates and infants : First European clinical experience with a new device

This study presents the first European clinical experience with the Medos DeltaStream DP1, a new pulsatile flow pump, in neonates and infants. Between January 2002 and December 2004, 420 patients at our institution underwent congenital heart surgery on cardiopulmonary bypass. During this period, 10 patients required extracorporeal membrane oxygenation (ECMO) support for acute postcardiotomy heart failure. Seven patients (median age 7 days, range 1–70 days), were supported by a nonpulsatile Biomedicus centrifugal pump, whereas three patients (aged 1 month, 1 year, and 12 years) were supported by a pulsatile Medos DP1. The DP1 is an extracorporeal rotary blood pump. The pump features a diagonal-flow impeller, and can be used for both continuous and pulsatile output. Special characteristics include a small priming volume of approximately 30 ml and a high pumping capacity. A temperature sensor and speed sensors are integrated in the pump. The pump has a delivery rate of up to 8 l/min and a speed range of 100–10,000 rpm. Overall mortality was 40% (4 of 10 patients), and all four deaths were in the nonpulsatile Biomedicus group. In the nonpulsatile group, the median support duration was 95 hours with a range of 48–140 hours. Two patients assisted with the pulsatile pump system were successfully weaned after 36 and 53 hours, respectively; the 12-year-old patient was successfully transplanted on the eighth postimplant day and discharged from the hospital on the 32nd posttransplant day. Although this preliminary experience doesn’t allow for statistical analysis, clinically it was possible to observe a better performance in pulsatile flow recipients with faster lactate recovery, reduced need for inotropic support, reduced assistance duration in bridge-to-recovery settings, and smoother intensive care management. ECMO for postcardiotomy heart failure in neonates and infants still carries high mortality and morbidity rates. Pulsatile flow with the Medos DeltaStream DP1 pump system improves results by producing more physiologic hemodynamics, reducing the duration of support in the case of bridge to recovery, and improving end-organ function.

First successful Italian clinical experience with DeBakey VAD

The growing number of patients waiting for heart transplantation more than tripled between 1989 and 1998. Various non-pulsatile mechanical circulatory support devices have been developed as bridge to heart transplantation in recent years. We report the first successful Italian clinical experience with an axial-flow pump, DeBakey VAD, in a patient supported as bridge to transplantation for 55 days.

Acute respiratory insufficiency and giant coronary artery aneurysm with fistula

Several causes of acute respiratory insufficiency have been reported in the literature. We describe a case in which it was caused by a rare combination of a giant right coronary artery aneurysm with fistula that occurred in a 56-year-old woman with concomitant congenital hypothyroidism. Diagnostic tools, differential diagnosis, surgical techniques, and follow-up at 1 year are discussed.

Efficacy of closed-loop stimulation with epicardial leads in an infant with congenital atrioventricular block

We present the case of an infant with a congenital atrioventricular block and sinus node dysfunction that was implanted with a pacemaker with physiological closed-loop stimulation (DDD-CLS) pacing mode with two epicardial leads. We have observed the response of DDD-CLS system with respect to conventional rate responsive accelerometer-based mode (DDDR): the atrial pacing percentage and the 24 h rate trend showed higher values during DDD-CLS compared with DDDR. In this patient, rate responsive feature seems preserved in DDD-CLS also using epicardial leads.