Emergency use of wearable left ventricular assist devices in patients not eligible for heart transplantation.

BACKGROUND: We reviewed our experience concerning the clinical outcomes of emergency implantation of left ventricular assist devices (LVAD) in patients not eligible for heart transplantation (HTX). PATIENTS AND METHODS: Between January 1998 and September 2006, 62 patients were referred for emergency HTX including 35 (55%) who received cardiac allografts; 9 (14%) died on the waiting list. The other 18 subjects (31%) did not meet listing criteria due to pulmonary hypertension with massive transpulmonary gradients (TPG), severe diabetes, or another factor; 7 patients had wearable LVAD implants and the remaining 11 who had contraindications both to HTX and to LVAD implantation remained on medical therapy. RESULTS: Twelve month actuarial survivals were 47% in LVAD G1 vs 1% in medical therapy G2 (P< .005). Four G1 patients died either due to cerebrovascular vascular episodes or to thromboembolic events. The beneficial use of LVAD in 3 patients led to consistent improvement in hemodynamic performance allowing listing for HTX. Two of them have been successfully transplanted; 1 is still waiting. Due to refractory heart failure, 90% of G2 died within the first months after evaluation. CONCLUSION: Our limited experience indicated that emergency use of LVAD ensued a satisfactory outcome allowing better actuarial survival.

Heart transplantation in older candidates.

UNLABELLED: Over the last few years significant changes have occurred in both donor and recipient profiles for heart transplantation (HTX). New therapeutic approaches to chronic heart failure have created a novel class of patients aged between 61 and 70 years. Although they are older than the conventional upper limit, they may undergo HTX using marginal donors. We retrospectively reviewed the outcomes of suboptimal donor implants in older recipients to examine negative prognostic factor. METHODS: Among 272 patients who underwent HTX at our institution from May 1994 to December 2005, 75 (26.5%) were 61 to 72 years (group 1). The remaining 197 (73.5%) denoted as group 2 ranged in age from 18 to 60 years. The Sex distribution, cause of end-stage heart failure, preoperative pulmonary hypertension, pre-HTX clinical status and mean follow-up did not show any significant difference between the two groups. However, group 1 patients had their organs retrieved from marginal donors (89%) vs group 2 (29%; P < .005). They were deceased mainly due to cerebrovascular events, (namely, 82% vs 27%, respectively, P < .005). RESULTS: All analyzed variables-actuarial survival, perioperative mortality, 12-month acute rejection freedom, 100-month chronic rejection freedom, infection freedom, neoplasia freedom, chronic renal failure freedom-did not show any significant difference. CONCLUSION: Advances in chronic heart failure medical therapy have generated a new class of HTX candidates aged between 61 and 70 years who benefitted from transplantation of organs retrieved from suboptimal donors.

Insulin-like growth factor-I ameliorates delayed kidney graft function and the acute nephrotoxic effects of cyclosporine.

BACKGROUND: Delayed graft function (DGF) is a relatively common complication after cadaveric renal transplantation. The adverse effect of DGF on long-term graft survival has lead to intensive efforts to reduce ischemic graft injury. In this study we examined the effects of a new protective treatment based on insulin growth factor (IGF)-I. We evaluated the impact of the treatment on renal recovery and on the nephrotoxicity that is a common side effect of mainstream immunosuppressants. Because therapy with IGF-I or the analog des(1-3)IGF-I is effective in treating experimental ischemic renal failure, these peptides may be useful as perspective clinical treatments. METHODS: We have addressed three areas relating to the potential use of IGF-I and its analog des(1-3)IGF-I. First, because of the immunogenic properties of IGF-I, we assessed the effect of des(1-3)IGF-I on the rejection of skin allografts in Lewis rats. Next we determined whether treatment with des(1-3)IGF-I influences the early function of transplanted kidneys in a model of DGF induced by a combination of warm and cold ischemia. Finally we tested whether IGF-I protects against acute cyclosporine nephrotoxicity. RESULTS: Des(1-3)IGF-I did not accelerate the rejection of the skin grafts (P=0.57). The administration of this peptide in a model of syngenic renal transplant improved the early function of the graft. Postoperative values of creatinine and blood urea nitrogen were significantly better (P<0.05) in treated animals. IGF-I also ameliorated the nephrotoxicity of cyclosporine, with better values of creatinine and blood urea nitrogen (P<0.05). CONCLUSIONS: In evaluating this study it should be recognized that the animal models studied, although widely used, differ from the human condition. However, IGF-I and des(1-3)IGF-I exhibit properties that strongly suggest their value in preventing clinical DGF, and they deserve further studies.

[Whole pancreatic transplantation and islet transplantation. Experiment notes]. / Trapianto di pancreas intero e trapianto di isole. Note sperimentali.

BACKGROUND: The results of pancreas transplantation have greatly improved in recent years. The path to further improvements goes through extensive experimental researches. METHODS: This study describes the effects of different procedures as hemodynamic asset and postoperative outcome. Twenty-nine swine underwent a total pancreatectomy, and were stratified into five groups. Group one (n = 5) served as control. Group two (n = 7) was autotransplanted. Group three (n = 6) and group four (n = 6) underwent allotransplantation; the first without immunosuppression and the second treated with cyclosporine and steroids. In group five (n = 5) Langerhans Islets transplantation was performed. RESULTS: Survival was different depending on which methodology was applied. The postoperative survival was 7 +/- 2 days in group one, 24 +/- 16 days in group two, 17 +/- 7 days in group three, 27 +/- 8 days in group four and 12 +/- 6 days in group five. CONCLUSIONS: The postoperative glucose control was normal in group two and group four while a severe diabetes appeared in group one (group 1 vs group 2: p < 0.05) and in group three during acute graft rejection after the 12th postoperative day (group 3 vs group 4: p < 0.05). Glycemia was slightly controlled in group five. The intraoperative hemodynamic status was evaluated at the time of pancreatectomy, harvesting, revascularization, and when surgery was over. Among the different parameters studied (mean arterial and pulmonary pressure, pulmonary wedge pressure, central venous pressure, cardiac output, oxygen extraction ratio, systemic vascular resistance, oxygen delivery and oxygen consumption), a statistically significant difference between group one and group five (p < 0.05) was observed.

[Treatment of the nephrotoxicity of immunosuppressive drugs with insulin-like growth factor-I]. / Trattamento della nefrotossicità da farmaci immunosoppressori con insulin-like growth factor-I.

BACKGROUND: Delayed graft function is a common and severe complication after cadaveric kidney transplantation. Besides a more complicated postoperative course, DGF can worsen the overall graft survival. In particular, DGF enhances the nephrotoxicity of mainstream immunosuppressants cyclosporine and FK506. This study evaluates a new therapeutical approach to the treatment of DGF related nephrotoxicity, based on the administration of IGF-I. METHODS: Sixty inbred Lewis rats underwent a bilateral clamping of the renal pedicles (20') as standard damage. The animals were stratified in six groups, according to the postoperative treatment. Group 1 served as control and received only the standard ischemic injury. Cyclosporine and FK506 were added in groups 3 and 5. Groups 2, 4 and 6 had the same treatment of groups 1, 3, 5 respectively, plus the administration of IGF-I. Blood samples were drawn daily to evaluate creatinine and BUN for 7 days. RESULTS: The rats treated with IGF-I had significantly better values compared to the respective controls (2-way ANOVA, p < 0.05). CONCLUSIONS: In conclusion, IGF-I improves the nephrotoxicity of mainstream immunosuppressants in this model. Its use is potentially beneficial for transplantation.

[The hemodynamic effects of the in-vivo administration of insulin-like growth-factor I]. / Effetti emodinamici della somministrazione in vivo dell'Insulin-like Growth Factor-I.

BACKGROUND: Recent studies have demonstrated that IGF-I has several biological activities that correlate with the GH axis, by acting as a cell protecting factor and a promoting compound in different tissues and organs. Our latest findings have demonstrated a potential application of IGF-I in the treatment of postischemic renal injury, which frequently appears after a kidney transplant. The beneficial effect of the renal postoperative recovery probably correlates with the regulation of the vascular tone, in which IGF-I plays a role with other cytokines. However, this rises the question whether IGF-I has any effect on the general hemodynamic status. This study was designed to underline the intraoperative hemodynamic effect of exogenous IGF-I in an experimental setting of renal transplantation in swine. METHODS: Twelve female swine underwent a left renal autotransplantation. At the reperfusion the animals were separated in two groups. Group one served as control. Group two received 400 micrograms of IGF-I (added to the flushing solution). The animals were kept under complete hemodynamic monitoring over the operation. RESULTS: Among the different parameters studied (mean arterial pressure, mean pulmonary arterial pressure, pulmonary wedge pressure, central venous pressure, cardiac output, oxygen extraction ratio, systemic vascular resistance, oxygen delivery and oxygen consumption), any statistically significant difference between group one and two were observed. CONCLUSIONS: While the clinical administration of IGF-I requires further studies, the in vivo administration of this peptide is apparently well tolerated, and does not cause any hemodynamic instability to the operation.

A survey of 1000 consecutive epidural catheter placements performed by inexperienced anesthesia trainees.

BACKGROUND: Education is the core activity of academic anaesthesia departments. One of the main difficulties appears to be the development of realistic high-quality 'training' practices that are safe for patients. The aim of this study was to determine the incidence of complications occurring after epidural catheter placement by inexperienced anaesthesia trainees and their possible relationship with the experience of the operator. METHODS: In a period covering 16 months, we performed a survey of 1,000 consecutive epidural placements performed by inexperienced anaesthesia residents under the direction of staff members in Padoa University Hospital, Italy. Neurological and cardiovascular complications as well as side effects were assessed and analyzed in terms of the experience levels of the trainees. RESULTS: Complications during epidural catheter placement included dural puncture (2.2%), epidural vascular damage (1.7%), and paresthesias (0.9%). Postoperative complications and side effects comprised local bleeding at the catheter insertion point (0.7%), catheter malfunction (0.4%), cardiovascular side effects (2.0%) and persistent postoperative paresthesias not caused by local anaesthetic infusion (1.7%). One patient suffered a transient radiculopathy. The overall incidence of complications was similar for each experience level examined. CONCLUSION: Epidural catheterization performed under supervision by inexperienced anaesthesia residents is not associated with a significantly greater number of complications than reported in the literature. Moreover, at the early stage of training, we could not demonstrate any correlation between the experience of the operator and the incidence of complications incidence.

Subarachnoid anesthesia for loco-regional antiblastic perfusion with circulatory block (stop-flow perfusion).

AIM: Loco-regional antiblastic perfusion with circulatory block (stop-flow perfusion, SFP) is a procedure designed to treat solid tumors of the limb and pelvis in an advanced stage, like melanoma, sarcoma of the soft tissues and colon-rectal cancer. The aim of this study was to evaluate if subarachnoid anesthesia could represent a safe and suitable anesthetic technique for this procedure. METHODS: Thirty SFP procedures were performed in the angiographic room, 15 for the treatment of lower-limb neoplasias and 15 for pelvic neoplasias. The patients (ASA I-III) had a mean age of 59.1 years (range: 19-81 years). The patients were given different dosages of bupivacaine (range: 10-20 mg) in hyperbaric solution at the concentration of 0.5% and 1% by lumbar subarachnoid injection at different levels (from T12-L1 to L3-L4). Standard monitoring was set up (ECG, pulse-oximetry, and non-invasive artery pressure). The use of any anesthetic and analgesic drug, eventually used in the intra- or postoperative period, was recorded. RESULTS: The lumbar puncture was approached at L1-L2 and L2-L3 levels in 80% of the cases. Doses of bupivacaine between 12 mg and 14 mg were administered in 2/3 of the cases. Bupivacaine was formulated in hyperbaric solution and administered at a concentration of 0.5% (8 patients) or 1% (22 patients). Complica-tions related to the anesthetic technique were absent. Intraoperative pain control was almost complete with one exception, when the procedure lasted unusually long. Pain control was satisfying immediately after the procedure as well: only in 3 cases were non-opiod analgesics administered within the first 6 h. CONCLUSIONS: Spinal subarachnoid anesthesia has proven to be an effective, safe, and easy-to-manage technique for carrying out SFP procedure in a non-conventional environment such as an angiographic room. It was free of serious side effects and well tolerated even in patients in poor general conditions.

[General anesthesia and undiagnosed cerebral metastasis. Clinical case]. / Anestesia generale e metastasi cerebrale misconosciuta. Caso clinico.

A case of late recovery from anesthesia in a patient undergoing bronchoscopy for surgical removal of metastatic bronchial mass is presented. The patient was comatose and a CT scan revealed the presence of bleeding inside a tumor, probably a metastasis, located in the right cerebellum. This report demonstrates that undetected cerebral metastases might lead to late recovery from anesthesia and underlines that accurate neurologic examination is mandatory in patients affected by tumors potentially spreading to the brain.

[Endotracheal tube and trachebronchial obstruction due to a large blood clot. Case report]. / Ostruzione del tubo endotracheale e dell'albero tracheobronchiale da parte di un voluminoso coagulo. Caso clinico.

A case of endotracheal tube and tracheobronchial acute obstruction caused by a large blood clot reproducing in part the trachea and the right bronchial tree is reported. The event has been anticipated by recurring hemoptyses whose source remained unknown despite any examination. Having established by simple manoeuvres that the obstruction was located at the endotracheal tube level, the tube was removed together with the blood clot without more invasive techniques like rigid or flexible bronchoscopy, embolectomy catheter of fibrinolytic agents. On the other side, those techniques should be used in case of obstruction located under the endotracheal tube. Albeit obstruction of endotracheal tubes due to blood clots is a frequent complication in critical care setting, this case is reported for the peculiar dimension and morphology of the clot, underlying that a precise diagnosis of the obstruction level allows the use of the most suitable technique for its removal.

Tracheal intubation under fluoroscopic control. X ray-guided orotracheal intubation in three cases of impossible direct laryngoscopy.

Three patients are described in whom it was impossible to visualise the larynx at direct laryngoscopy. Tracheal intubation was successfully and rapidly achieved with the aid of continuous fluoroscopy.