Abstract: Cardiac paragangliomas are rare entities, that often remain asymptomatic. Complete surgical resection is the mainstay of treatment even if it can be difficult for the infiltration of the near mediastinal structures. We describe the case of a young man with hypertensive crisis, headache and diabetes, affected by cardiac paraganglioma, infiltrating the left atrial roof. The tumor was completely removed using cardiopulmonary bypass and the infiltrated portion of left atrial wall and the left superior pulmonary vein was excised and repaired with a pericardial patch. The patient was discharged without complications and currently enjoys good health.
Abstract: The incidence of cardiac dysfunction after routine cardiac surgical procedures is quite high (3-5%), but the majority of patients improve using inotropic drugs or intraaortic balloon counterpulsation. However, approximately 1% of these patients do not benefit from using these supports, and they need more invasive strategies, such as ventricular assist devices. Extracorporeal membrane oxygenation (ECMO) is one of them, and it offers biventricular support, can be managed very easily and is one of the cheapest devices. We describe our experience with ECMO in a case of postocardiotomy failure after myotomy for myocardial bridge. Because of failure of medical therapy, we decided to perform surgical myotomy of the bridge and coronary artery bypass grafting of the LAD with the left internal mammary artery. Many episodes of ventricular fibrillation occurred with quick worsening of biventricular function requiring extracorporeal membrane oxygenation (ECMO) support. The pump flow was maintained at about 1.8-2 l/m(2) (about 80% of the ideal flow) in order to reduce cardiac work offering a more rapid recovery of cardiac function. ECMO support was slowly reduced because EKG progressively improved and the hemodynamic parameters were stable. ECMO was interrupted in the 4th postoperative day when mean pressure was >90 mmHg and organ perfusion was adequate. The particularity of our case was the complicated management of MB: it is very uncommon that myotomy of the LAD results in biventricular dysfunction. Our experience confirms that benign pathologies such as MB may hide life-threatening complications and that ECMO support is the simplest solution in case of biventricular dysfunction.
Abstract: Primary graft failure (PGF) is one of the major complications that occurs immediately following lung transplantation and greatly contributes to increased morbidity and mortality. The incidence of PGF is correlated with a marked decline in endogenous nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) levels. Therefore, the administration of NO during lung transplantation has been proposed as a possible therapeutic treatment to prevent or attenuate PGF pathogenesis. Despite the initial positive results of experimental and uncontrolled clinical trials, recent randomized clinical trials do not support the prophylactic administration of inhaled nitric oxide (iNO) for the prevention of PGF following lung transplantation under the conditions tested. Nonetheless, there is evidence that iNO administration during PGF can improve oxygenation and reduce pulmonary hypertension without altering systemic vascular resistance. This suggests that iNO may prevent the need for extracorporeal membrane oxygenation (ECMO) during the hypoxic phase of PGF. During the intraoperative phase of transplantation, one-lung ventilation (OLV) and pulmonary artery clamping usually increase PVR, causing decreased right ventricular function and hemodynamic instability. The administration of iNO during these lung transplant procedures could decrease right ventricular dysfunction by reducing PVR and help to avoid the use of cardiopulmonary bypass.
Abstract: This report describes the case of a 60-year-old woman with a history of hysterectomy for myomas, totally asymptomatic, with incidental evidence of a pelvic intracaval mass extending to the right atrium. She underwent a staged procedure (sternothomic and abdominal) through a thoracolaparotomic approach in circulatory arrest and deep hypothermia. Using a one-stage surgical approach, we were able to withdraw one portion of the mass from the right atrium and another from the abdominal inferior vena cava, thus minimizing the risk of unexpected venous or atrial wall injury during surgical manipulation.
Abstract: Candidemia is a well-recognized complication of hospital stay, especially in critically ill patients. There is not a general consensus that predictors for candidemia in cardiosurgical intensive care unit (cICU) are different from a general ICU and it has been reported that cardiopulmonary bypass time is a specific risk factor in the cICU. We performed a prospective study to evaluate the main predictors for candidemia in patients admitted to the cICU. Included patients were adults admitted between July 2005 and December 2007 with an ICU-length of stay (ICU-LOS) â¥48 hours after cardiac surgery. Exclusion criteria were solid organ or bone marrow transplants, previous diagnosis of candidemia or other invasive infections and ICU stay before surgery. A multiple regression analysis was performed to identify the risk factors. Among 1955 patients admitted to the cICU, 345 were enrolled. Only 26 patients (1.3%) had candidemia after an ICU-LOS of 20 days (inter-quartile range, IQR 8-49 days). Total parenteral nutrition [odds ratio (OR)=9.56; confidence interval (CI)=1.741-52.534], severe sepsis (OR=4.20; CI=1.292-13.667), simplified acute physiology score II (OR=1.16; CI=1.052-1.278) and ICU-LOS >20 days (OR=6.38; CI=1.971-20.660) were independent predictors of candidemia. Patients undergoing cardiac surgery developed candidemia late after cICU admission and the independent predictors were similar to the general ICU. Keywords: Invasive candidemia; Cardiac surgery; Cardiopulmonary bypass.
Abstract: Re-do mitral valve procedures performed through median sternotomy carry substantial mortality and morbidity. To avoid complications of sternal re-entry and to provide adequate mitral valve exposure, antero-lateral thoracotomy has been suggested by some authors.
Abstract: The number of lung transplants performed worldwide is low and early and late results are worse in comparison with other solid organ transplants. The present review will focus on these two aspects analyzing the causes and describing the possible strategies to overcome these limitations.
Abstract: Lung transplantation is the treatment of choice for patients with end-stage lung failure. Limitations are presented by the shortage of donors and the long waiting list periods. New techniques, such as extracorporeal membrane ventilator devices with or without pump support, have been developed as bridges to transplantation for patients with severe, unresponsive respiratory insufficiency.
Abstract: Early right ventricular dysfunction after heart transplantation (HTx) is a major complication especially in patients with pre-transplant pulmonary arterial hypertension (PH). The possibility to reverse secondary PH using sodium nitroprusside (NPS) or inhaled nitric oxide has been already established and there is a well-known stratification of the incidence of early death after HTx related to the reversibility of PH. Despite this, in a group of patients with irreversible disorders of the pulmonary vascular bed, conventional therapy may not be useful. However, the decision to disqualify non-responsive HTx candidates may be inappropriate, considering that PH unresponsiveness to NPS does not exclude the possibility to decrease pulmonary pressures with other medications. In case of non-responsive patients, the debate regarding the role of new selective pulmonary vasodilators is still open and oral sildenafil use in cardiac transplant candidates and recipients is growing. Despite this, there are many reports of the use of phosphodiesterase 5 inhibitors in patients with chronic heart failure and several studies describe the positive effects of sildenafil in reducing pulmonary vascular resistance and pulmonary arterial pressure and in increasing cardiac output. Oral sildenafil use in cardiac transplant candidates or recipients is still limited.
Abstract: The monitoring of herpesvirus infection plays a central role in lung transplantation (LT). Herein we evaluated the prevalence of human cytomegalovirus (HCMV), human herpesvirus-6 (HHV-6), human herpesvirus-7 (HHV-7), and Epstein-Barr Virus (EBV) DNA in bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) specimens from LT patients. We associated the findings with the occurrence of interstitial pneumonia, acute rejection, or organizing pneumonia. Viral DNA was detected using real-time polymerase chain reaction (PCR) on 76 paired samples (BAL and TBB) from 27 patients who were receiving a universal combined prophylaxis (cytomegalovirus [CMV] immunoglobulin [Ig] + gancyclovir or valgancyclovir). Histopathological analysis was performed in accordance with the International Society for Heart and Lung Transplantation (ISHLT) criteria. Overall, HCMV results were positive in 25/76 (32.9%) specimens (BAL and/or TBB); HHV-6 in 16 (21.1%); HHV-7 in 40 (52.6%); and EBV in 13 (17.1%). Interstitial pneumonia was diagnosed in 6/76 (7.9%) cases: 5 (83.3%) were positive to HCMV (combined specimens; P < .0001); 5 (83.3%) to HHV-7; and 2 (33.3%) to EBV. An acute rejection episode was diagnosed in 19/76 (25%) cases: 7 (36.8%) were positive to HCMV; 5 (26.3%) to HHV-6; 10 (52.6%) to HHV-7, and 3 (15.8%) to EBV. No significant association was observed between virus detection or load and acute rejection. Organizing pneumonia was diagnosed in 4/76 (5.3%) cases: 1 (25%) positive to HCMV; 4 (100%) to HHV-6 (P < .05); 2 (50%) to HHV-7; and none to EBV. In conclusion, the prevalence of HCMV tended to be lower than that reported in the literature, confirming the importance of universal combined prophylaxis. HCMV was a relevant agent for interstitial pneumonia; although the small numbers limit the statistical analysis, our data did not support an association between herpesviruses and acute rejection episodes, whereas the role of HHV-6 in the pathogenesis of organizing pneumonia deserves further study. Viral detection on TBB could represent an adjunctive tool to complement that on BAL.
Abstract: Adverse events due to anticoagulation and antiplatelet therapy during left ventricular assistance device (LVAD) support are very common, and every effort must be made to reduce their impact. We report our experience using a low dose of double antiplatelet therapy for patients provided with the INCOR LVAD system as a bridge to transplantation. Twelve patients (10 males, 35-60Â years old) with acute or end-stage heart failure were included in this study. The mean follow-up was 10Â months (cumulative 4.9Â years). For antiplatelet therapy, we use an association of variable doses of aspirin and clopidogrel. The use of a platelet aggregation test (PAT) allows reducing the dose of the drugs to the minimum needed. The primary end point was to check the safety of the therapy, analyzing the incidence of major and minor bleeding complications. The secondary end point was to check the effectiveness of the therapy, evaluating the incidence of major and minor thromboembolic events. We had three (25%) cases of early postoperative mediastinal bleeding. On the contrary, no episodes of major bleeding occurred during the follow-up period. The rate of minor bleeding complications was low: 0.2 events per patient/year. The rate of major and minor thromboembolic events was acceptable (respectively 0.09 and 0.2 per patient/year). During LVAD support, double antiplatelet therapy with a low dose of aspirin and clopidogrel was safe and effective. PAT allows reducing the dose of antiplatelet drugs, avoiding complications related to excessive or insufficient dose administration.
Abstract: Patients awaiting cardiac transplantation often require ventricular assist devices (VADs) due to instable circulatory condition. Device-related infections remain the 'Achilles heel' of mechanical circulatory support and wound complications after VAD placement are a formidable challenge to surgeons. Up to 25% of deaths in VAD patients are due to systemic sepsis, which occurs in 11-26% of patients and bacteria that are common pathogens including Staphylococcus, Pseudomonas, Enterococcus, and Candida. Sepsis, infection of implanted pump components, and infections of percutaneous drivelines continue to limit survival. The Berlin Heart-EXCOR VAD is a para-corporeal pulsatile system that has been successful in patients with severe biventricular dysfunction. We report a case of a 35-year-old male suffering from a postischemic cardiomyopathy who received an EXCOR biventricular assist device as a bridge to transplant. During the assistance the patient developed concomitant methicillin-resistant Staphylococcus aureus infection of implanted pump components which was resistant to conventional therapy. The patient developed sepsis with splenic infarctions due to septic embolization which was successfully treated with a heart transplant. In some extreme cases of VAD infections, such as this, the only therapeutic option is transplantation or device replacement. Keywords: Biventricular assist device infection; Splenic infarctions; Transplantation.
Abstract: BACKGROUND: The treatment of severe bloodstream infections (sepsis, endocarditis, and infections of vascular prostheses) caused by Gram-positive microorganisms is made even more difficult by the emergence of resistant strains. The introduction of new antibiotics with activity against these strains has created new opportunities, but many controversial issues remain. CONTROVERSIAL ISSUES: The aim of this GISIG (Gruppo Italiano di Studio sulle Infezioni Gravi) working group - a panel of multidisciplinary experts - was to define recommendations for some controversial issues using an evidence-based and analytical approach. The controversial issues concerned the duration of therapy and role of aminoglycosides and teicoplanin in the treatment of Gram-positive bacterial endocarditis, the optimal use of the new antibiotics in the treatment of bloodstream infections caused by resistant Gram-positive strains, and the use of microbiological techniques (i.e., bactericidal serum testing and synergy testing) and of pharmacokinetic data (e.g., monitoring of plasma levels of antibiotics) in the treatment of difficult-to-treat Gram-positive bloodstream infections. METHODS: A systematic literature search of randomized controlled trials and/or non-randomized studies was performed mainly using the MEDLINE database. A matrix was created to extract evidence from original studies using the CONSORT method to evaluate randomized clinical trials and the Newcastle-Ottawa Quality Assessment Scale for non-randomized studies. The GRADE method for grading the quality of evidence and strength of recommendation was applied.
Abstract: There is no standardised approach for cardioplegia administration during ascending aorta replacement (AAR) and the techniques used so far are quite variable and show important limitations. In order to overcome these limitations, we propose a simple and inexpensive technique using a Foley catheter for cardioplegia administration and bleeding control in case of AAR or aortic root surgery. The benefits of our technique are the technical simplicity and the low cost that makes this approach an ideal solution for cardioplegia administration in all cases of AAR.
Abstract: OBJECTIVES: Morbidity and mortality after conventional surgery of aortic arch aneurysms remain high. Alternative techniques are the subject of this report. METHODS AND RESULTS: Open surgery requires cardiopulmonary bypass and hypothermic circulatory arrest. Thoracic endovascular aneurysm repair has a less invasive therapeutic alternative. The number of high-risk patients has considerably increased over the past decade. The proximity of the aneurysm to the supraaortic vessels makes it difficult to achieve a satisfactory proximal landing zone for endovascular stenting. Two methods have been proposed to address this issue: branched stent grafts and extraanatomic bypass, defined as a hybrid approach, which combines aortic debranching and endovascular procedures. Experience with hybrid repair is limited. Today there are no formal guidelines for the management of aortic arch aneurysm in high-risk patients. CONCLUSION: Hybrid repair of aortic arch aneurysm in high-risk patients is a feasible and safer option.
Abstract: 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.
Abstract: Pericardial cysts are benign intrathoracic lesions that are considered to be congenital. They are usually found incidentally upon chest radiography and typically cause few symptoms. Their true incidence is unknown. Herein, we describe the case of a 41-year-old man who, over nearly a decade, had undergone frequent hospital admissions for fever and thoracic pain. Computed tomography had shown no evidence of any intrathoracic mass. He was admitted to the hospital with fever, chest pain, tachycardia, dyspnea, and cough. The symptoms persisted despite medical therapy. Computed tomography revealed a pericardial cyst on the right side of the anterior mediastinum, near the confluence of the brachiocephalic vein and the superior vena cava and very close to the ascending aorta. The mass compressed the right main bronchus. Due to the cyst's unusual location and the ineffectiveness of medical therapy, we excised the tumor via median sternotomy. We found a large (7 x 4-cm), well-circumscribed, unilocular cyst, which unexpectedly involved the outside pericardial surface and the phrenic nerve. Histopathologic examination confirmed that the lesion was a simple mesothelial cyst of the pericardium. After the surgery, the patient's fever and chest pain resolved. We know of no other report of a pericardial cyst that had gone undetected upon earlier computed tomography. We believe that surgical treatment of pericardial cysts should be reserved for patients who have severe symptoms due to complications, or when diagnosis is uncertain and malignancy is suspected.
Abstract: We describe the case of a 75-year-old man admitted to hospital for chest pain and syncope. Physical examination was normal with evidence of a very small wound on the left chest. Considering the presence of multiple coronary risk factors, an acute coronary syndrome was initially suspected, but the electrocardiogram (EKG) was normal and only a slight increase of cardiac enzymes was detected. The hypothesis of aortic dissection was also considered and in order to discriminate between the aortic and coronary syndrome, a thoracic and coronary computed tomography (CT) scan was performed. The CT scan showed a metallic structure, suggestive of a nail, about 6 cm in length, in the deep layers of the left ventricular wall and a small pneumothorax due to a lung lesion. The patient was therefore transferred to our department for urgent cardiac surgery that was performed without complications.
Abstract: Insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding proteins (IGFBPs) might play a pathogenic role in heart failure. We showed significantly increased myocardial IGFBP-3 expression (investigated by real-time polymerase chain reaction) and apoptosis (detected by flow cytometry) in 23 failing hearts from patients undergoing cardiac transplantation for end-stage dilated or ischemic cardiomyopathy, when compared with 10 controls. Higher IGF-1 mRNA levels were shown only in end-stage dilated cardiomyopathy.
Abstract: Pacemaker and implantable-cardioverter defibrillator lead infections widely increased with consequent need to accurately recognize responsible bacteria.
Abstract: We report a case in which replacement of a low-profile porcine Liotta bioprosthesis was required 21 years after initial implantation. The patient underwent mitral valve replacement with a 28-mm Liotta bioprosthesis in 1985 for mitral stenosis. Twenty-one years later, severe mitral regurgitation was detected at echocardiography and mitral valve reoperation combined with tricuspid annuloplasty was successfully performed. Focal perforation of two cusps with consequent intravalvular leak on bioprosthesis was found. This is the longest durability report for a Liotta bioprosthesis in mitral position.
Abstract: Increased oxidative stress has been implicated in the pathogenesis of a number of cardiovascular diseases. Recent findings suggest that myeloperoxidase (MPO) may play a key role in the initiation and maintenance of chronic heart failure (CHF) by contributing to the depletion of the intracellular reservoir of nitric oxide (NO). NO consumption through MPO activity may lead to protein chlorination or nitration, leading to tissue damage. Primary cultures of human endocardial endothelial cells (EEC) obtained at heart transplantation of patients with CHF and human umbilical vein endothelial cells (HUVEC) were subjected to oxidative stress by incubation with hydrogen peroxide at non lethal (60 microM) dose for different exposure times (3 and 6 h). Treated and control cells were tested by immunohistochemistry and RT-PCR for MPO and 3-chlorotyrosine expression. Both endothelial cell types expressed myeloperoxidase following oxidative stress, with higher levels in EEC. Moreover, 3-chlorotyrosine accumulation in treated cells alone indicated the presence of MPO-derived hypochlorous acid. Immunohistochemistry on sections from post-infarcted heart confirmed in vivo the endothelial positivity to MPO, 3-chlorotyrosine and, to a minor extent, nitrotyrosine. Immunohistochemical observations were confirmed by detection of MPO mRNA in both stimulated EEC and HUVEC cells. This study demonstrates for the first time that EEC can express MPO after oxidative stress, both in vitro and in vivo, followed by accumulation of 3-chlorotyrosine, an end product of oxidative stress. Deregulation of endothelial functions may contribute to the development of a number of cardiovascular diseases, including CHF. The results also highlight the notion that endothelium is not only a target but also a key player in oxidative-driven cardiovascular stress.
Abstract: We present the case of a 72-year-old woman referred for dyspnea and vertigo when admitted to the hospital with a diagnosis of aortic stenosis. She had hypertension with previous deep venous thrombosis with no known hypercoagulable diathesis. She underwent aortic valve replacement with a Carpentier-Magna bioprosthesis without intraoperative complications; selective cardioplegia before aortic wall suture confirmed that coronary ostia were free. After extracorporeal circulation weaning, an episode of ventricular fibrillation occurred; sinus rhythm was restored using 20 J shock. Considering new episodes of ventricular fibrillation, the increasing number of polymorph ectopic ventricular systoles and the worsening of patient condition despite the use of high doses of inotropes, an intra-aortic balloon pump 1: 1 was inserted via the right femoral artery. Echocardiography (ECG) did not show alteration of the bioprosthesis in the presence of severe left ventricular impairment (ejection fraction <30%) with ipokinesia of the anterior-lateral wall and moderate-severe mitral regurgitation. Considering the rapid decline of the patient's condition despite the use of high doses of inotropes and an intra-aortic balloon pump, the aortic wall was reopened to control bioprosthesis. The intraoperative finding was unexpected; a thrombus of length 3-4 cm was found, attached to the prosthetic annulus and protruding into the left main trunk. The thrombus was immediately sucked up to avoid coronary embolization and, after that, the prosthesis was replaced with a Mitroflow 19 (Sorin Group Inc, Mitroflow Division, Vancouver, Canada) bioprosthesis. Probably, an association between factors could induce thrombosis-like aortic sinuses: annulus dimensions, endothelium damage caused during decalcification, tears in the bioprosthetic sewing ring, unknown coagulation diathesis and the structure of the Carpentier-Magna support may have induced this very unusual complication. However, we do not have enough information to establish with certainty the causes of this complication, but discussion of this topic may be useful.
Abstract: Among solid-organ recipients, those with lung transplants are at highest risk of cytomegalovirus (CMV) infection or to die of CMV-associated disease. We evaluated the effect of combined CMV antiviral prophylaxis and CMV-immunoglobulin prophylaxis on CMV-associated pneumonia diagnosed in 303 follow-up transbronchial biopsy (TBB) specimens from lung transplant recipients. At our center, 24 recipients (control group; 1999-2002) received acyclovir for 24 months and 33 recipients (study group; 2003-2008) received combined CMV prophylaxis consisting of CMV immunoglobulin on days 1, 4, 8, 15, and 30 and monthly for 12 months plus gancyclovir or valgancyclovir from postoperative day 21 for 3 weeks followed by acyclovir for up to 24 months. The percentage of pneumonia-positive TBB specimens at 1-month follow-up was similar in the study and control groups: 9.1% (3 of 33 specimens) vs 8.3% (2 of 24) (P = .90). However, after the first month, the percentage of pneumonia-positive TBB specimens was significantly lower in the study group in the first year (months 3, 6, 9, and 12) of follow-up, at 1% (1 of 99) vs 6.4% (5 of 78) (P = .048), and in the first 2 years (months 3, 6, 9, 12, 18, and 24), at 0.8% (1 of 122) vs 6.5% (8 of 124) (P = .02). These data suggest the efficacy of combined prophylaxis to decrease the incidence of CMV-associated pneumonia after the first month in lung transplant recipients. The effect of combined prophylaxis after transplantation seems useful to prevent CMV-associated pneumonia not only in the first year after lung transplantation but also in the second year, which suggests a long-lasting immunologic role of prophylaxis.
Abstract: AIM: The aim of this paper was to report the authors' experience on biventricular epicardial pacing (BEP) as first-choice procedure concomitant to on-pump heart surgery for other definite indications. METHODS: BEP was performed in 13 consecutive patients with stage IV heart failure (HF) undergoing on-pump cardiac surgery for other definite indications. All patients were treated with optimized pharmacologic therapy, and showed complete left bundle branch block and reduced (<30%) left ventricular ejection fraction. RESULTS: In all patients, effective BEP was achieved. All patients were discharged alive; functional, ECG and echocardiographic parameters showed significant improvement, better observed at 4-month interval. However, a high mortality rate was noticed during follow up (about 70% at 6 months) with a significant number of sudden cardiac deaths. The absence of functional improvement in the mid-term period (4-month control) related to a poor prognosis. CONCLUSIONS: Epicardial lead placement during cardiac surgery of severe HF patients is safe and effective. A clear evaluation of the effect of BEP alone is precluded because of the interference of the concomitant indications for cardiac surgery and the absence of randomization. The high rate of sudden death noticed in this study raises the important question of whether implantation of a defibrillator would be warranted in such population.
Abstract: We describe a case of cardiogenic shock caused by a very late drug-eluting stent (DES) thrombosis. The patient underwent emergent coronary artery bypass grafting (CABG) and was discharged home 15 days after the operation. The incidence of stent restenosis had been reduced by the use of DES, but the Achilles' heel of DES is represented by a higher rate of stent thrombosis. In our case, the DES thrombosis occurred 5 years after its implantation, underlining the importance of prolonged dual antiplatelet therapy. Even though rare, this complication may be life-threatening. We believe that CABG provides better event-free survival than percutaneous coronary intervention in patients with multivessel coronary disease despite the use of DES.
Abstract: 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.
Abstract: Right ventricular dysfunction (RVD) after heart transplantation is a major complication, especially in patients with pulmonary hypertension (PH). Herein we have presented our initial experience with oral sildenafil for RVD following heart transplantation.
Abstract: The aim of this paper was to report the authors' experience on biventricular epicardial pacing (BEP) as first-choice procedure concomitant to on-pump heart surgery for other definite indications.
Abstract: Cyclosporine (CsA) renal toxicity is a well-known side effect. Various immunosuppressive strategies have been developed to minimize renal insufficiency. The use of everolimus associated with low levels of CsA can be an alternative strategy.
Abstract: Endothelial function measured with brachial ultrasound (BU) is a validated prognostic factor in heart failure patients. LVAD (left ventricle assist device) application is a promising surgical technique to treat refractory heart failure patients both as a bridge to heart transplantation or as destination therapy. Clinical recovery in such patients may be associated to normal endothelial function measured by BU but, as recently reported, only in pulsatile flow LVAD patients. The present paper report a case of normal endothelial function even in a axial LVAD patient.
Abstract: We present a case of a 71-year-old patient with arterial myocardial revascularization and postoperative course complicated with sternal wound diastasis and subsequent mediastinitis. The patient underwent double revision of the mediastinum: the first in 13th and the second in 27th with total sternectomy. Although the resulting external exposure of pericardial cavity and grafts is a contraindication for using vacuum-assisted closure (VAC), we used it after a 'depression induced ischemic test' (DIIT) to evaluate ischemic threshold. After the VAC therapy period (from 32nd to 112th postoperative day), the sternal wound was ready to close. We think that VAC-therapy is a safe and economic approach in the treatment of serious substance loss even with pericardial cavity and graft exposure.
Abstract: Pseudoaneurysms of the sovra-aortic trunks are uncommon lesions that usually have a post-traumatic etiology. The singular case of a patient who developed an innominate artery pseudoaneurysm (IAP) where a stent had been inserted 12 years earlier to manage severe innominate trunk stenosis is described. A chronic and large (8 cm in diameter) IAP was successfully treated in extracorporeal circulation and deep hypothermic circulatory arrest. The distal tract of the ascending aorta and the proximal aortic arch were substituted; total replacement of the innominate trunk with a singular 8-mm Dacron graft was necessary. We reviewed the literature about the reports of IAPs and the management of this singular lesion.
Abstract: Idiopathic pulmonary fibrosis (IPF) represents the second most frequent indication for lung transplantation after chronic obstructive pulmonary disease. Survival rate after transplantation is poorer compared with other lung diseases for reasons that are not completely clear. Medical therapy with anti-inflammatory drugs may improve symptoms and quality of life, but it does not influence the survival rate. Lung transplantation is the best therapy for end-stage IPF. The debate regarding the superiority of double lung transplantation (DLT) compared with single lung transplantation (SLT) is still ongoing. Until some years ago, SLT was almost uniformly utilized for this indication. In the most recent years, a larger application of DLT has been observed worldwide, probably related to higher 1-year and 5-year survivals. The unanswered question is whether it is ethical to use two lungs for the same patient, considering the donor shortage, when a single lung would suffice. Many reports have demonstrated that SLT offers acceptable pulmonary function and satisfactory early and intermediate survival. Probably DLT should be reserved for younger recipients, for those with concomitant or possible chronic infection of the contralateral lung, or cases of marginal donors. Further studies will be needed to formulate recommendations regarding the preferred surgical approach in IPF.
Abstract: Lung transplantation recipients are at high risk for herpesvirus infections. We evaluated the effect of combined cytomegalovirus (CMV) prophylaxis on CMV pneumonia, acute rejection episodes (ARE), lymphocytic bronchitis/bronchiolitis (LB), and obliterans bronchiolitis (OB) diagnosed in 180 transbronchial biopsies (TBB) of lung transplant recipients. At our center, 25 patients (control group; 1999-2002) received acyclovir for 12 months and 21 recipients (study group; 2003-2007) received combined CMV prophylaxis consisting of CMV-IG (Cytotect Biotest) for 12 months and ganciclovir or valganciclovir from postoperative day 21 for 3 weeks. Among the study group (since 2005), CMV shell vial viral culture and Epstein-Barr virus (EBV), human herpesvirus-6 (HHV-6), and HHV-7 DNA were determined on BAL specimens. In the study group, the number of LB was significantly lower than in the control group (2% vs 11%; P= .04). Similar results were obtained for ARE (6% vs 17%; P= .04). No difference was observed in OB (5% vs 5%; P= .53, NS). A reduction trend was found in CMV pneumonia (2% vs 7%; P= .23, NS). Logistic regression analysis showed a relationship between prophylaxis and a reduced prevalence of ARE (odds ratio [OR] 3.25, confidence interval [CI] 1.12-9.40; P= .03). Finally, in the study group, BAL EBV-DNA positivity and EBV-CMV coinfections were low (6% and 0%, respectively) compared with other herpesviruses and with the literature. Our data suggested the efficacy of combined CMV prophylaxis to prevent ARE and LB, 2 risk factors for chronic rejection, and a possible role to reduce the trend toward CMV pneumonia and EBV infections.
Abstract: Cardiac transplant vasculopathy is a limit to long-term survival in heart transplantation (H-Tx) recipients. PTCA results in our H-Tx population were retrospectively analyzed.
Abstract: 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 patient's 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.
Abstract: Use of minimally invasive approaches in cardiac surgery is increasing, obtaining a wide consensus and representing a challenging alternative technique for many surgeons. We report our experience of the treatment of ascending aorta disease using the Bentall-De Bono procedure through a minimally invasive approach.
Abstract: Exercise performance in heart-transplanted patients increases with respect to pre-transplantation but remains subnormal, and it does not improve with time after surgery. Possible causes include persisting denervation, and sympathetic vasoconstriction inducing functional vascular abnormalities that prevent adequate increase in blood flow to the exercising limbs. We tested the effects of physical training on baroreceptors-mediated control of heart rate and blood pressure in recently heart-transplanted subjects.
Abstract: We present the case of a 59-year-old male, admitted to hospital for cardiogenic shock due to massive infero-lateral myocardial infarction. Angiography showed occlusion of the right coronary artery and widespread critical lesions of both the anterior descending and circumflex artery. Echocardiography showed inferior akinesia with a large posterior ventricular septal defect (VSD). The haemodynamic instability induced us to use a left ventricular assist device (L-VAD) like Impella for easiness of its percutaneous implantation and for its duration. We obtained the stabilisation of the patient and the improvement of the clinical conditions. The location of the ventricular septal defect (VSD), from one side, and the serious and widespread coronaropathy (not suitable for any kind of revascularisation), from the other side, led us to choose heart transplantation for this patient. Heart transplantation was performed on the 12th day after myocardial infarction without complication and the patient was discharged on the 35th postoperative day. In our opinion, when the position of the VSD is unseemly and there coexists a widespread coronaropathy not eligible for revascularisation, heart transplantation may represent an efficacious alternative. Moreover, the use of L-VAD, reducing interventricular shunt and ensuring an adequate cardiac output, allows to obtain clinical stabilisation before heart transplantation.
Abstract: Postoperative wound infections generally cause considerable extra morbidity, mortality and costs. The prevalence of total wound infections after cardiac surgery, including both sternal wound and donor site infections, ranges from 1.3 to 12.8%. The present study was conducted to identify the incidence of wound infections following cardiac surgery, to identify the risk factors and evaluate the efficacy of present modes of management.
Abstract: In heart transplant recipients pulmonary neoplasms are among the most frequent solid tumors; they have a rapid and aggressive course, and therefore require an early diagnosis. We describe the role that diagnostic imaging plays in different diagnostic moments of this disease.
Abstract: We compared efficacy and safety of tacrolimus (Tac)-based vs. cyclosporine (CyA) microemulsion-based immunosuppression in combination with azathioprine (Aza) and corticosteroids in heart transplant recipients. During antibody induction, patients were randomized (1:1) to oral treatment with Tac or CyA. Episodes of acute rejection were assessed by protocol biopsies, which underwent local and blinded central evaluation. The full analysis set comprised 157 patients per group. Patient/graft survival was 92.9% for Tac and 89.8% for CyA at 18 months. The primary end point, incidence of first biopsy proven acute rejection (BPAR) of grade >/= 1B at month 6, was 54.0% for Tac vs. 66.4% for CyA (p = 0.029) according to central assessment. Also, incidence of first BPAR of grade >/= 3A at month 6 was significantly lower for Tac vs. CyA; 28.0% vs. 42.0%, respectively (p = 0.013). Significant differences (p < 0.05) emerged between groups for these clinically relevant adverse events: new-onset diabetes mellitus (20.3% vs. 10.5%); post-transplant arterial hypertension (65.6% vs. 77.7%); and dyslipidemia (28.7% vs. 40.1%) for Tac vs. CyA, respectively. Incidence and pattern of infections over 18 months were comparable between groups, as was renal function. Primary use of Tac during antibody induction resulted in superior prevention of acute rejection without an associated increase in infections.
Abstract: Video-assisted minimally invasive cardiac surgery (VAMICS) is currently performed with various indications. However, despite the increasing evidence of its effectiveness, new approaches have to be defined to simplify this procedure, minimize its potential complications and limit its costs, for a wider use in the surgical community. The limited access to the aorta is a key point in VAMICS and mandates specific clamping modalities with their own limitations, costs and drawbacks. The Portaclamp (Cardio Life Research SA, Louvain la Neuve, Belgium), a new autoguided extravascular aortic cross-clamping system, has been recently proposed to facilitate VAMICS. Herein, we describe the Portaclamp approach and report our indications and preliminary clinical experience so to define its role in VAMICS.
Abstract: The aim of this study was to compare the short- (< 30 days) and long-term (> or = 30 days) clinical outcomes of left internal mammary artery bypass grafting (LIMA-LAD) and directional coronary atherectomy plus stent implantation (DCA + stent) in the treatment of isolated proximal left anterior descending coronary (LAD) lesions. One hundred and twenty-six patients underwent LIMA-LAD and 132 consecutive patients underwent DCA + stenting. The primary endpoint was the incidence of short- and long-term major adverse cardiac events (MACE); the secondary endpoints included any periprocedural events and long-term target vessel revascularization (TVR). We found no significant between-treatment difference in the occurrence of short-term MACE, and the long-term MACE rate per 100 person-years was 3.0 in the LIMA-LAD group and 4.6 in the DCA + stent group. After 5-year follow-up, 79% of the patients in the DCA + stent group and 89% of those in the LIMA-LAD group were still MACE-free. The risk of any periprocedural events was six times lower in the DCA + stent group, and the risk of TVR was six times higher. We conclude that both procedures lead to good short- and long-term follow-up results in isolated proximal LAD disease. As fewer periprocedural events and more TVRs occur after DCA + stenting than after LIMA-LAD, they can be considered valuable alternatives to each other.
Abstract: New immunosuppressive strategies that can prevent both acute and chronic rejection are being investigated to achieve graft tolerance and to minimize side effects and toxicity that may lead to graft loss. Drug pharmacokinetics and pharmacodynamics, as well as pharmacogenetics, all play a role in customizing treatment to the individual patient. To improve patient compliance, new drug formulations are on trial, such as the modified- release oral form of tacrolimus MR4 for once daily administration, which seems to be equivalent to bid administration in terms of steady-state exposure. Monoclonal/polyclonal antibodies are increasingly used in the induction phase in protocols where steroids are discontinued early. However, discontinuing steroids carries a high risk of acute rejection or organ failure in some subgroups of patients. The supposed benefit of steroid discontinuation may not be enjoyed by all patients. Minimizing anticalcineurin agents may prove to be similarly or even more advantageous. The use of new drugs and new combinations has greatly improved short-term transplant outcomes. The new goal is, therefore, to improve long-term results and particularly to prevent chronic rejection, thus increasing patient and organ survival.
Abstract: Prolonged or intensive immunosuppressive therapy used after organ transplantation is complicated by an increased incidence of cancer. Striking differences in incidence are observed in heart and heart-lung transplant recipients when compared with renal transplant patients. The most significant increase was in the incidence of lymphomas in cardiac versus renal patients. Moreover, a two-fold greater increase of all neoplasms was found in cardiac recipients, with nearly a six-fold increase in visceral tumors. Several factors may account for these differences. In cardiac allograft recipients, intensive immunosuppression is frequently used to reverse acute rejection and the highest number of cardiac transplants was performed in the era of polypharmacy, usually consisting of triple therapy.
Abstract: A case of solitary septal metastasis from a clear cell carcinoma of the kidney is reported in a 55-year-old man who 5 years before had undergone right nephrectomy and adrenalectomy. Since then, he had been successfully treated by means of chemotherapy, radiation therapy, or operated on, at almost yearly intervals, for secondary pancreatic, pulmonary and cerebral single metastases. Diagnosis was obtained by routine computed tomography. The septal mass was surgically removed and the patient was discharged on the 4th postoperative day.
Abstract: Orthotopic heart transplantation (OHTx) represents the therapy of choice for end-stage heart disease not treatable with medical or conservative surgical approach. Heterotopic heart transplantation (HHTx) is a surgical procedure in which the graft is connected to the native heart in a parallel fashion and it was especially employed in precyclosporine era. The aim of this paper is to present our experience with HHTx.
Abstract: The limited number of suitable lung donors is the major obstacle to clinical application of lung transplantation. The "twinning procedure" may represent one strategy to optimize the use of the small pool of available grafts. From November 1991 to May 2003, 99 single lung transplants (SLTx) were performed including 46 (46%) cases of the "twinning procedure." We divided the study population into two groups: group A (recipients of the "first" lung) and group B (recipients of the "second" lung). The ischemia time was significantly different (A: 216 +/- 48 minutes, B: 310 +/- 89 minutes, P <.001). Differences were not observed in the incidence of graft failure (A: 2, B: 0, P = NS), in the length of mechanical ventilation (A: 12.8 +/- 29.4 days, B: 7.8 +/- 15.2 days, P = NS), or ICU stay (A: 18.8 +/- 50.6 days, B: 15.2 +/- 17.1 days, P = NS), or of hospitalization (A: 37.8 +/- 56.8 days, B: 31.4 +/- 31.7 days, P = NS). Three bronchial anastomotic complications occurred in each group. The incidence of infections (A: 0.015 events/patient/month, B: 0.011 events/patient/month, P = NS) and of treated acute rejections (A: 0.011 events/patient/month, B: 0.011 events/patient/month, P = NS) was similar in the two groups. One-year survival rates were 86% +/- 7% and 72% +/- 10% in group A and B patients, respectively (P = NS). In our experience the different ischemia times related to the twinning procedure did not increase the mortality or morbidity in the early and midterm period.
Abstract: Amyloidosis is a systemic disease. Heart transplantation in this subset of patients is contraindicated by the majority of authors. In our center, patients with heart failure due to amyloidosis have been evaluated for cardiac transplantation since 1991. The aim of this study was to analyze the outcome of these patients waiting for transplant and the effectiveness of this therapy.
Abstract: Jehovah's Witnesses, patients who refuse blood transfusions, are generally not considered as candidates for lung transplantation owing to the frequent requirement for transfusions. A successful procedure in a Jehovah's Witness is presented and to our knowledge this is the 2(nd) reported case. The patient, a 38-year-old female, type I diabetes, affected by idiopatic pulmonary fibrosis underwent left lung transplantation. From the same pulmonary bloc a twinning procedure was obtained by means of right lung transplantation in a 58-year-old man affected by the same pathology. Surgical strategies employed in achieving a successful outcome, ethical and moral aspects are discussed.
Abstract: In recent years port-access and endovascular extra-corporeal circulation techniques have allowed valvular and coronary operations to be performed by mini-thoracotomy. Experience with the technique suggested application to resection of ventricular aneurysms, which are usually approached through a median sternotomy with the use of traditional cardiopulmonary bypass.
Abstract: Bone loss has been reported as a complication after heart transplantation (HTx), and the increase in bone fractures is an effective problem. Treatment of osteoporosis has obtained mixed results. In this study we evaluate the effect of treatment with an oral bisphosphonate.
Abstract: Isolated valvular lesions consequent to non-penetrating trauma are rare. We present a case of a traumatic tricuspid valve rupture in a 51-year-old woman seriously involved in a motor vehicle accident 20 years earlier. She underwent tricuspid valve replacement performed via a minimally invasive thoracotomy in the right fourth intercostal space. The advantages of minimally invasive thoracotomy are discussed.
Abstract: We present here our experience of patent foramen ovale closure through a mini-invasive surgical technique. With the new surgical platform termed Heartport System, it is possible to install extra-corporeal circulation and to obtain cardioplegic arrest of the heart with endovascular techniques. This allows the operation of closure to be entirely performed through a micro-thoracotomy (Port-access surgery) in the right 4th intercostal space. Sixty-one patients underwent this surgical correction and seventeen of them (26%) had a diagnosis of patent foramen ovale, 12 with an history of cerebrovascular accidents. They are all alive and well after a mean follow-up of 16 months, with no recurrence of the inter-atrial communication and free from new neurological events. The post-operative course was uneventful with patients discharged on postoperative day 4. This technique shows a 100% efficacy, minimise surgical trauma, allows a quick recovery and offers excellent cosmetic results with no scarring. We believe that this procedure must be regarded as the "golden standard" for the closure of atrial septal defects
Abstract: Nonpenetrating chest trauma can cause cardiac rupture. Ventricles are affected more frequently than atria. Survival is rare and depends upon prompt diagnosis and immediate surgical intervention. We report the case of a 42-year-old man involved in a car accident with consequent right atrial rupture and pericardial tearing.
Abstract: Anthracycline cardiotoxicity can induce dilated cardiomyopathy (DCM). Nine patients (four men) experienced postchemotherapy DCM: age at time of tumour diagnosis ranged from 1-45 years (mean 13.5 +/- 19 years); interval time between tumour and HT was 3-23 years (mean 10.8 +/- 6.6) and age at HT ranged from 10-65 years (30.8 +/- 20.1). Interval between end of chemotherapy and beginning of cardiac symptoms was 5.71 +/- 4.6 years. Mean age at DCM diagnosis was 19.2 +/- 19.7 (range 1-50 years). Interval between start of chemotherapy and DCM ranged from 1 month to 10 years (mean 3.15 +/- 3.6 years). Tumours were Ewing sarcoma (7-year-old boy), paratesticular rabdomyosarcoma (1-year-old boy), Wilms tumor with pulmonary metastasis (3-year-old girl), bilateral breast carcinoma (45-year-old woman), uterine leiomyosarcoma (44-year-old woman), acute myelocytic leukemia (1.5-year-old boy and 17-year-old girl), and chronic myelocytic leukemia (5-year-old boy). All patients had high pulmonary resistance values. One patient with chronic myelocytic leukemia (14 year-old at HT) died due to graft failure on the first postoperative day. At follow-up (mean, 80.4 +/- 69.3 months) two patients died: a 32-year-old woman (acute myelocytic leukemia) 1 year after HT for sepsis and a 68-year-old woman who had breast adenocarcinoma recurrence 81 months after HT. The remaining patients are alive, in good condition with no difference in survival from other transplanted patients (P =.757). Patients with end-stage postchemotherapy DCM without evidence of tumour recurrence can safely undergo HT.
Abstract: Encouraging results in transplantation of other solid organs led to investigation of the use of tacrolimus in lung transplantation as a salvage immunosuppressant in persistent acute rejection.
Abstract: X-linked dilated cardiomyopathy (DCM) is a clinical phenotype of dystrophinopathy characterized by preferential myocardial involvement without overt signs of skeletal muscle disease. X-linked DCM is a familiar myocardial disease characterized by ventricular dilation resulting in progressive heart failure and/or sudden death, and it may be differentiated from other DCMs. The aim of this retrospective study was to assess that patients with end-stage X-linked DCM can safely undergo heart transplantation.
Abstract: Ascending aortic aneurysms without dilatation of the sinuses of Valsalva are generally handled by resection and replacement with a tubular graft or by tailoring aortoplasty. We propose an alternative treatment with a direct anastomosis of the two stumps of the aorta after complete aneurysm resection through an upper J ministernotomy.
Abstract: Dilated cardiomyopathy may result from an acute myocarditis. Little is reported in vivo documenting the progression from the acute inflammatory disease to the healing phase. We describe the consecutive light and electron microscopy studies performed on five myocardial sample series in a 47-year-old female patient who was referred to our hospital with acute myocarditis. She was sustained with left ventricular assist device (LVAD) for 63 days, and then she died of cerebral hemorrhage. The first three consecutive endomyocardial biopsies (days 2, 4, 36 from onset) documented the acute and early healing phase of the inflammatory disease. In the last two biopsies (days 50 and 64 from onset) active inflammation and myocyte necrosis were absent. The histopathological features were those commonly observed in most patients diagnosed with dilated cardiomyopathy, namely myocyte hypertrophy, nuclear size and shape irregularities, and interstitial fibrosis. Overall, the myocyte morphology significantly improved and LVAD support likely contributed to the structural recovery. The major conclusions to be drawn from this case are: 1) the aspecific pathologic findings of dilated cardiomyopathy patients may result from an acute myocardial inflammation; 2) immediate endomyocardial biopsy in patients with clinically diagnosed myocarditis minimizes the risk of missing the diagnosis of inflammatory disease; to this aim a precise definition of "early onset" is especially needed; 3) LVAD support may contribute to the morphological recovery of severely damaged myocytes.
Abstract: Mandatory use of prolonged immunosuppression in organ transplantation is complicated by an increased incidence of cancer. The current study represents a retrospective analysis of the incidence of neoplasms in our heart transplantation program.
Abstract: The port-access technique for cardiac surgery was recently developed at Stanford University in California as a less invasive method to perform some cardiac operations. The port-access system has been described in detail elsewhere. It is based on femoral arterial and venous access for cardiopulmonary bypass (CPB) and on the adoption of a specially designed triple-lumen catheter described originally by Peters, and subsequently modified and developed in the definitive configuration called the endoaortic clamp.
Abstract: We compared orthotopic heart transplantation (HT) by bicaval technique with the standard technique. Between January 1995 and December 1997, 117 patients underwent 118 HTs; 71 patients (15 women and 56 men) had 72 HTs by standard technique and 46 patients (9 women, 37 men) underwent HT using bicaval procedures. Preoperative parameters were similar in both groups; 5 patients who underwent the standard technique and no patients who underwent bicaval procedures required permanent pacemakers (p = NS). Isoproterenol infusion was significantly longer in the standard technique. Major perioperative arrhythmias (ventricular tachycardia and fibrillation, asystole) appeared in 8.2% and 7.0% of standard and bicaval HTs, respectively; atrial fibrillation appeared in 13.1% and 4.6%, respectively (p = NS). At 1 month, mitral and tricuspid regurgitation rates were higher in the standard group (p = NS); at 1 year only tricuspid regurgitation was still higher (p = NS). Right atrial pressure, Wood units, cardiac output, and cardiac index were examined (p = NS). At multivariate analysis, interaction between preoperative Wood units and transplant type was elicited for Wood units at 1 month and for right atrial pressure at 1, 3, and 6 months. In the high resistance subgroup, the patients who underwent bicaval procedures had higher resistances at 1 month. In the low resistance subgroup, right atrial pressure was higher in patients who underwent standard techniques at 1, 3, and 6 months follow-up. Thus, bicaval HT was found to be safe, without surgically related complications, it provoked significantly less blood loss, and required less isoproterenol use. No significant advantages were observed in conduction disturbances and major arrhythmias or regarding the need for temporary or permanent pacemakers.
Abstract: The connection between the donor and the recipient aorta is a potential source of early and late complications as a result of infection, compliance mismatch, and technical and hemodynamic factors. Moreover, the abrupt change in systolic pressure after heart transplantation involves the entire thoracic aorta in the risk of aneurysm formation. The aim of this study was to analyze the types of aortic complications encountered in our heart transplantation series and to discuss etiology, diagnostic approach, and modes of treatment.
Abstract: We report pharmacokinetic data on tacrolimus in 14 heart transplant patients (2 women, 12 men). The median age and the median body weight were 55.5 years (range, 23-61 years) and 67.0 kg (55-79 kg), respectively. All patients were maintained on a triple-drug protocol (tacrolimus, azathioprine, and prednisone), with a 7-day antithymocyte globuline induction. The first tacrolimus dose, administered orally 1 to 5 days posttransplant, ranged from 0.03 to 0.4 mg/kg (median = 0.052 mg/kg). The maintenance dose ranged from 0.03 to 0.13 mg/kg/day (administered in two equal doses) to achieve blood levels of 5 of 20 ng/ml, as determined by a microparticle enzyme immunoassay (MEIA). Whole blood samples were drawn just before, at 0.5 hour, and at 1, 2, 3, 4, 6, 8, 10, and 12 hours after the administration of the first dose; trough levels were measured thereafter. The mean oral clearance (CL/F) and apparent volume of distribution (Vd/F) averaged 0.21+/-0.08 L/hour/kg and 2.4+/-0.8 L/kg while the half-life averaged 8.7+/-3.5 hours. Tacrolimus accumulation index during chronic therapy (Rac = Cmin(steady state)/Cmin(first dose) normalized to the same dose) averaged 1.3. Eighty-eight percent of the trough blood levels measured in our patients were within 5 and 20 ng/ml. The incidence of rejection in the study population was extremely low: a prevalence of grade 2 rejection or more, of 0.4+/-0.8 episodes/ patient was observed after a follow-up period of 8.8+/-2.2 months. Only one patient experienced severe renal toxicity, probably because of his preoperative precarious hemodynamic status. Pharmacokinetic data suggest that maintenance tacrolimus daily dose should be equal to 0.1 mg/kg/day to obtain trough blood concentrations of approximately 10 ng/ml. Inter- and intra-patient variability of tacrolimus blood concentration should be expected and justify careful monitoring.
Abstract: The purpose of this article is to analyze patients affected with ischemic cardiomyopathy, older than 55 years, who have undergone heart transplantation. We conducted a retrospective analysis comparing clinical course and outcome in patients whose donor age was > or = 50 years (Group A) with patients who had younger donor heart (Group B). Group A was composed of 25 patients, 55 to 68 years old (27.4% of the patients), 20 males and 5 females; Group B was composed of 68 patients, 55 to 66 years old, 65 males and 3 females. Mean donor age in Group A was 54.7 years old (range 51-61), while in Group B it was 29.5 years old (range 9-49). Operative mortality was 16% (4 cases) and 12% in Group B (8 cases) p = ns. Total mortality in Group A was 24%, or 6 cases: 2 graft failures, 1 infection, 1 neoplasm, 1 multiorgan failure, 1 ischemic heart disease; in Group B it was 27%, or 18 cases: 2 cerebrovascular accidents, 4 graft failures, 3 infections, 5 neoplasms, 3 multiorgan failures, 1 acute rejection, p = ns. Coronarography was performed in 51 patients, 14 in Group A (10 cases normal, 3 with irregularities, and 1 case with a critical stenosis of the circumflex artery; 37 in Group B (32 cases were normal, 3 had irregularities and 2 had critical stenosis in a coronary artery). In conclusion, we emphasize that extending donor age in recipients older than 55 years of age does not determine a higher risk and mortality.
Abstract: Chronic rejection or transplant-associated coronary artery disease (TxCAD) is the most serious complication after human cardiac transplantation. Previous studies, using Western blotting, have shown formation of antibodies against endothelial antigens of 56 and 58 kDa, which are associated with early TxCAD. These antigens were later identified as being vimentin and its breakdown products. The aims of the present study were to devise a robust assay for detection of anti-vimentin antibodies and to compare antibody formation in patients taking different immunosuppressive drugs.
Abstract: Cardiac autonomic reinnervation after human cardiac transplantation has been demonstrated frequently but to date only for sympathetic efferents. Standard surgical techniques leave many parasympathetic branches intact in the original atria and thus with less stimulus to reinnervate the donor atria.
Abstract: Right ventricular endomyocardial biopsy is difficult to perform in patients who underwent heterotopic heart transplantation because of the complex vascular anatomy. The procedure is usually performed under fluoroscopic control. We present a case of a 59-year-old woman that after heterotopic heart transplantation underwent echo-guided endomyocardial biopsy. We report the technique discussing data obtained in other 11 patients heart transplanted in the heterotopic way. In conclusion we believe that echocardiographic guidance during endomyocardial biopsy allows a better choice of bite sites, reduces the risk of free wall perforation. Moreover is diminished the risk of X-ray exposure to both patient and operator.
Abstract: To discuss informed consent to heart transplantation in the case of an intensive care unit (ICU) patient: relatives' informed consent was refused by the patient himself whose cognitive ability appeared to be reasonable for the purpose.
Abstract: Tacrolimus (FK506) may represent a major advance in the management of allograft rejection after solid organ transplantation. In August 1994 a European heart transplantation pilot study was initiated to assess the efficacy and safety of tacrolimus when administered exclusively through an oral route.
Abstract: Our purpose was to establish whether patients on the waiting list for heart-lung or lung transplantation had different survival rates according to diagnosis and to determine the specific variables responsible for early death.
Abstract: Cardiac lipomas, extremely rare benign tumours, can develop in the pericardial surface or inside the cardiac chambers. We report three cases, 2 intracardiac (one in the left and right atrium at the level of the interatrial septum and the other in the right ventricle) and one epicardial at the level of the left atrial roof. All patients underwent surgery and are now asymptomatic.
Abstract: Between January 1991 and September 1995 at the Thoracic Organ Transplantation Centre of Pavia, 193 patients entered the waiting list for heart-lung or lung transplantation. Indications for heart-lung transplantation (HLT) were mainly primary or secondary pulmonary vascular diseases. Parenchymal lung diseases were the most frequent reasons for single- (SLT) or double-lung (DLT) transplantation. During the same period, 21 patients underwent HLT, 16 SLT and 14 DLT. Early deaths (within 30 days of surgery) occurred in 2 (10%) HLT, in 3 (19%) SLT, and in 3 (21%) DLT. Nineteen (90%) patients with HLT, 11 (69%) with SLT, and 10 (71%) with DLT survived up to 3 months; and 11 (52%) patients with HLT, 8 (50%) with SLT, and 5 (36%) with DLT survived up to 12 months. At the time of writing, the following patients are still alive: 10 (48%) with HLT, after a mean +/- SEM follow-up of 37.2 +/- 6 (range 28-46) months, 12 (75%) with SLT, after a mean follow-up of 16 +/- 11 (range 1-35) months, and finally 7 (50%) with DLT, after mean follow-up of 14 +/- 9 (range 1-23) months.
Abstract: Starting in January 1995, we performed heart transplantation, randomly using standard and bicaval techniques. In the latter technique, the anatomy of the right atrium is maintained, since the venae cavae are anastomosed. In 38 patients who received heart transplantation with bicaval anastomosis, 339 endomyocardial biopsies (EMB) were performed. EMB was done under echocardiographic control in 309 cases, whereas the remaining 30 were done under fluoroscopy. When EMB was echo-guided there was one major complication, namely right hemothorax in a 29-year-old man, who had had heart transplantation one week before, and this required surgical exploration. Other complications, correlated to venipuncture were: left hemothorax in a 65-year-old woman determined by arterial puncture, treated by means of chest tube drainage; pneumothorax (1 case). Echocardiographic guidance during EMB allows a better choice of biopsy site, reduces the risk of damaging cardiac structures and allows immediate monitoring of heart performance. Moreover the risk of X-ray exposure to both patient and operators is reduced. In any case, because the superior vena cava suture line is not visualized by two-dimensional echocardiography, if the bioptome cannot be introduced easily through superior vena cava, fluoroscopic control should be immediately applied, particularly in the early post-operative period when cicatrization is not complete.
Abstract: Tacrolimus (FK506) has recently become available clinically as an alternative to cyclosporine-based immunosuppression. This study reports the middle-term results of a prospective, randomized trial that compared FK506 with cyclosporine-based immunosuppression in heart transplant recipients.
Abstract: We have developed and applied in 7 cases an alternative "orthodromic" technique for Novacor left ventricular assist device implantation. After sternotomy, the pocket is tailored, dividing the insertion of the diaphragm to the lower ribs, for easier bleeding control. On cardiopulmonary bypass, the aorta is cross-clamped and cardioplegia administered. Apical cannulation is performed first on a dry, still field. The device is then easily deaired, with blood flowing in the physiologic direction. The aorta is declamped and the outflow conduit is anastomosed. Before the suture is tied, the final deairing is obtained. This technique allows extreme precision in apical cannulation, easier control of bleeding, and accurate deairing of the pump. The ischemic time is short and damage to the right ventricle negligible.
Abstract: 1. The human transplanted heart is initially denervated, hence any fluctuation present in the RR interval variability can be either due to reacquired innervation, or to the effect of some non autonomic activity, such as a direct effect of respiration on atrial (sinus node) stretch. 2. In order to distinguish between sympathetic, vagal and non autonomic factors we examined the effects of various physical and pharmacologic manoeuvres on the respiratory and non-respiratory components of heart rate variability. 3. We found that sinusoidal neck suction appears a useful, noninvasive tool to characterise the relative importance of the different factors, which can influence heart rate variability in the transplanted heart.
Abstract: Cardiomyoplasty (CMP) is a surgical therapy for dilated cardiomyopathy. In this procedure the "latissimus dorsi" is wrapped around the heart and chronically paced synchronously with ventricular systole. CMP has been performed in more than 500 cases worldwide, 42 cases in Italy, with variable degrees of success. Despite symptomatic improvement in the majority of patients surviving the procedure, objective hemodynamic effects have not been consistently demonstrated. The hemodynamic effect of CMP has been the subject of a great deal of experimental and clinical research over the past decade. This article discusses in detail the published results of experimental and clinical cardiomyoplasty, with particular emphasis on hemodynamic effects and limitations of the procedure.
Abstract: Single and bilateral lung transplantation represents the most recent success in the field of organ replacement. The procedure underwent a very long period of laboratory and clinical experimentation and it is still a high-risk procedure to be performed by a few highly specialized centers. At our Department of Cardiac Surgery, the preliminary experience in lung replacement was obtained by clinically applying heart-lung transplantation in patients with both vascular and parenchymal lung disease during 1991. In the following years, the indications for isolated lung transplantation were enlarged by some centers with good results; this consideration, together with the scarce availability of integral heart-lung blocks, led us to use single and bilateral lung transplantation initially for parenchymal disease and subsequently also for vascular disease. Since February 1992, 12 single lung transplantations and 12 bilateral lung transplantations have been performed at our Center. In this report the selection criteria, the preoperative characteristics and the perioperative variables of donors and recipients are discussed. Particular emphasis is given to immunosuppression treatment, diagnosis of rejection and airways suture complications. The conclusions summarize the present indications for the different types of lung transplantations according to the different preoperative diagnosis.
Abstract: 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.
Abstract: 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.
Abstract: To review experience with anesthetic management in ten patients undergoing dynamic cardiomyoplasty (CMPL), a new surgical technique that serves as an alternative to heart transplantation.
Abstract: After heart transplantation, respiration-synchronous fluctuations (0.18 to 0.35 Hz, high frequency [HF]) in RR interval may result from atrial stretch caused by changes in venous return, but slower fluctuations (0.03 to 0.15 Hz, low frequency [LF]) not due to respiration suggest reinnervation. In normal subjects, sinusoidal neck suction selectively stimulates carotid baroreceptors and causes reflex oscillations of RR interval.
Abstract: 1. Although the high-frequency fluctuations in R-R interval (respiratory sinus arrhythmia) observed in heart transplant recipients are not a reliable marker of reinnervation because of a previously shown direct mechanical effect of breathing, the presence of a non-respiration-related low-frequency oscillation reflects rhythms generated outside the heart, and thus could be neurally mediated. 2. To evaluate the presence of reinnervation, the spontaneous variability in R-R interval was investigated, supine and after passive tilting, in 23 heart transplant recipients (age 43 years, range 23-64 years) and in 25 normotensive control subjects by autoregressive spectral analysis of low- and high-frequency spontaneous fluctuations in R-R interval and respiration. The response of R-R interval to amyl nitrite inhalation was also evaluated in five heart transplant recipients and eight control subjects. 3. Detectable low-frequency oscillations, unrelated to respiration, were present in 13/23 heart transplant recipients, particularly in those who were transplanted at least 20 months earlier (11/14). The natural logarithm of the power of low-frequency fluctuations was markedly lower than in control subjects (0.75 +/- 0.21 versus 5.62 +/- 0.20 ms2, P < 0.001). The low-frequency but not the high-frequency fluctuations correlated with time since transplantation (r = 0.44, P < 0.05). The subjects with low-frequency fluctuations showed a sudden decrease in R-R interval with amyl nitrite linearly related to the decrease in mean blood pressure (r > or = 0.94). The slopes obtained in these heart transplant recipients were comparable (although of lower values) with those obtained in control subjects.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Although RR interval variability appears to be an ideal method for assessing reinnervation after heart transplantation, it has been shown that respiratory sinus arrhythmia is caused by the mechanical effect of respiration on the right atrium. The neck-suction induces heart rate changes only by means of nervous reflex and its hemodynamic effect is local and hence appears as a useful method for assessing reinnervation. We tested the presence of autonomic reinnervation in 18 heart transplant recipients, compared to 12 donor-age-matched controls. We measured the power of RR interval low- (LF, around 0.1 Hz) and respiratory fluctuations (HF) before and during rhythmic neck-suction stimulation at 0.1 Hz and at a frequency (0.20 Hz) similar to, but distinct from, that of respiration (controlled at 0.25 Hz), before and during 0.04 mg/kg atropine infusion, using autoregressive spectral analysis of RR interval, respiration and neck pressure signals. The relationship between pairs of signals at each frequency was quantitatively assessed by bivariate coherence function. All transplanted subjects showed low-amplitude HF, related to respiration. Detectable LF (whose power was lower than in controls: 1.15 +/- 0.39 versus 6.08 +/- 0.27 1n-ms2, p < 0.001), non coherent with respiration, were present in 11/18 transplanted subjects, and correlated with months since transplantation (r = +0.59, p < 0.05). HF neck suction induced the presence of a 0.20 Hz fluctuation in 12/12 controls, distinct from and greater than the 0.25 Hz respiratory component (7.28 +/- 0.26 versus 6.69 +/- 0.74 1n-ms2, p < 0.01); this was not seen in any of the transplanted subjects.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: 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.
Abstract: Syngeneic (Lewis-to-Lewis) and allogeneic (Brown Norway-to-Lewis) unilateral left lung transplants were performed between immature rats aged 6 wk (donors) and adult animals aged 4 mo (recipients). Transplanted animals were killed either 2 wk or 6 mo after operation. Right and left lungs were analyzed separately by quantitative light microscopic techniques, and findings were compared with control animals matched for age and strain. The immature transplanted left lung continued to grow to achieve its predicted adult number of alveoli. Six months after transplantation the alveoli and airways were larger than controls in allogeneic animals (P < 0.001) but were of normal size in syngeneic animals. After both syngeneic and allogeneic transplantation the recipient contralateral mature native right lung showed an increase in volume after 6 mo (P < 0.001), abnormal in a mature lung, due to an increase in size (P < 0.01 in allogeneic, P < 0.05 in syngeneic) and alveolar number (P < 0.02 in both). This study indicates that in rats, transplanted immature lungs can fulfill their growth potential even when transplanted into mature recipients.
Abstract: Transbronchial biopsy has become the procedure of choice for the diagnosis of acute lung rejection after transplantation, but the sensitivity of the technique in this setting remains unknown. In this study, 14 mongrel dogs underwent left lung transplantation, after which triple-drug immunosuppression was given for 5 days and then all immunosuppression was stopped. All animals had clear chest radiographs at this time. Transbronchial biopsy was performed in nine lung regions (two to six pieces of lung tissue were obtained per region, with a mean of 4.3 pieces per region) before the animals were killed 2 to 4 days later, at which time varying degrees of rejection had occurred. Rejection was graded histologically on a scale of 0 to 3 (0 = no rejection, 1 = mild rejection, 2 = moderate rejection, 3 = severe rejection) in each piece of lung tissue obtained at transbronchial biopsy. After the dogs were put to death, the true state of lung rejection was determined by histologic examination of the entire lung. We calculated the sensitivity of transbronchial biopsy with 95% confidence intervals. Five pieces of lung tissue were needed to yield a sensitivity of 92% (82%, 100%) to identify mild rejection in the entire lung with transbronchial biopsy. Three pieces of lung tissue were needed to yield a sensitivity of 92% (84%, 100%) to identify the presence of moderate to severe rejection in the entire lung (that is, rejection that requires pulse therapy) on transbronchial biopsy. These results indicate that three to five pieces of lung tissue that are suitable for diagnostic purposes obtained at transbronchial biopsy are adequate for the diagnosis of acute pulmonary rejection after lung transplantation.
Abstract: The transplanted immature rat lung has been shown capable of fulfilling its growth potential after left lung transplantation (LLTx) and concomitant right cardiac lobe resection (RCLR). However, unexpected findings in these studies included an abnormal rise in lung volume in the contralateral lung due to alveolar multiplication, and significant dilatation of the bronchi in the transplanted left lung. In the present study, the influence of surgical factors that could have contributed to these changes, i.e. RCLR, denervation, and anastomotic stenosis, were studied individually. Immature Lewis rats aged 4 and 6 weeks were used and (a) RCLR, (b) RCLR and right hilar stripping, and (c) RCLR and left pulmonary artery (PA) banding were performed in groups 1 (n = 12), 2 (n = 5) and 3 (n = 6), respectively. Animals were killed after 6 months and the lungs studied using quantitative morphometric techniques. In groups 1 and 2, right lungs did not show any significant increase in volume. Alveolar number and airway diameter in both lungs in all groups were not significantly different from controls. In group 3 both right and left lungs presented an increase in alveolar size (p less than 0.02 on the right and p less than 0.01 on the left). Changes seen after LLTx in the rat, such as alveolar multiplication, cannot be explained by compensatory growth (RCLR), denervation (RCLR and hilar stripping), or arterial stenosis at the anastomotic site (RCLR and left PA banding), but must be regarded as a consequence of transplantation per se. A role for neuropeptides in lung growth following transplantation is suggested.
Abstract: Endomyocardial biopsy is an essential procedure for the diagnosis and grading of rejection in heart transplant patients. Direct control of the bioptome positioning has classically been obtained by fluoroscopy. Starting in June 1988, at our institution an alternative approach involving the use of two-dimensional echocardiography was introduced in clinical practice. In 125 patients 1591 biopsies have been performed: 445 under echographic control and 1146 under fluoroscopic control with 3.6 and 4.5 samples/biopsy, respectively. The percentages of inadequate samples caused by biopsy site sampling were 0.4% and 1.3%, respectively, in the two groups. Cardiac perforation has occurred twice in the fluoroscopic group; it has not been observed in the echographic group. One case of iatrogenic tricuspid regurgitation was detected in each group. We now consider echocardiography the method of choice to guide the bioptome. We prefer it to fluoroscopy because it eliminates the risks of x-ray exposure, increases the number of sampling sites in cases of echocardiographic evidence of rejection, can be easily performed as a bedside procedure, allows choice and variation of sampling sites, and permits monitoring of cardiac complications during and after the procedure. A randomized clinical trial is probably needed to assess with statistical significance the superiority of the echographic-controlled biopsy.
Abstract: We report a case of one patient who underwent emergency retransplantation with a highly positive donor crossmatch. Standard immunosuppression was integrated by the addition of plasma exchange during extracorporeal circulation, polyclonal IgG, and cyclophosphamide for the first 30 days. After transplantation the clinical outcome was normal; immunosuppression induced a complete disappearance of the donor-specific antibody. In spite of the heavy immunosuppression, we did not observe any infectious complications. We suggest that a greater immunosuppression established soon after the transplant and adjusted on the basis of immunological monitoring may allow a heart transplant with a positive crossmatch.
