Successful Recovery of Cardiac Function Following 20 min of a No-touch Period in a Donation After Circulatory Death: A Case Report.

BACKGROUND: Withdrawal of life-sustaining therapy (WLST) performed in the circulatory determination of death (DCD) donors leads to cardiac arrest, challenging the utilization of the myocardium for transplantation. The rapid initiation of normothermic regional perfusion or extracorporeal membrane oxygenation after death helps to optimize organs before implantation. However, additional strategies to mitigate the effects of stress response during WLST, hypoxic/ischemic injury, and reperfusion injury are required to allow myocardium recovery. METHODS: To this aim, our team routinely used a preconditioning protocol for each DCD donation before and during the WLST and after normothermic regional perfusion/extracorporeal membrane oxygenation. The protocol includes pharmacological treatments combined to reduce oxidative stress (melatonin, N -acetylcysteine, and ascorbic acid), improve microcirculation (statins), and mitigate organ's ischemic injury (steroids) and organ ischemia/reperfusion injury (remifentanil and sevoflurane when the heart is available for transplantation). RESULTS: This report presents the first case of recovery of cardiac function, with the only support of normothermic regional reperfusion, following 20 min of a no-touch period and 41 min of functional warm ischemic time in a DCD donor after the preconditioning protocol. CONCLUSIONS: Our protocol seems to be effective in abolishing the stress response during WLST and, on the other hand, particularly organ protective (and heart protective), giving a chance to donate organs less impaired from ischemia/reperfusion injury.

[Practical approach to the patient with fever in the intensive cardiac care unit: diagnostic framework and therapy notes]. / Approccio pratico al paziente con febbre in terapia intensiva cardiologica: inquadramento diagnostico e cenni di terapia.

The management of the patient with fever in the intensive cardiac care unit begins with a thorough evaluation of the patient, particularly symptoms, clinical history and physical examination, to provide information regarding the origin of the fever. The global evaluation of the patient should be integrated with blood and microbiological tests, in particular blood culture and swab. The laboratory, microbiologic or radiologic tests could be more or less detailed and targeted depending on the type of suspected infection and clinical conditions of the patient. When therapy is necessary, it is crucial to switch, as soon as possible, from broad spectrum antibiotic therapy to antibiotic therapy based on the results of the microbiological exams. Antibiotic therapy could be associated with antipyretic and specific organ support therapy when necessary.

[Management of elderly patients in the cardiac intensive care unit: how to balance between appropriateness and futility]. / Gestione del paziente anziano in unità di terapia intensiva cardiologica: tra appropriatezza diagnostico-terapeutica e futilità.

The number of elderly patients admitted to cardiac intensive care units (CICU) is significantly increasing. Nowadays, novel diagnostic and therapeutic tools allow to treat the vast majority of cardiac acute diseases, nonetheless care of elderly patients requires a careful clinical evaluation. A favorable proportion of cost-effectiveness is warranted, aimed at avoiding futile procedures or treatments. On the other hand, the availability of minimally invasive procedures carries forward old limits to treatments in elderly patients in CICU. It appears evident that age cannot per se represent a limit in the care of elderly people. The present review gives insights in the management of the most common cardiovascular disease settings in elderly patients in the CICUs, thus providing important tools in complex decision-making.

ANMCO POSITION PAPER: Role of intra-aortic balloon pump in patients with acute advanced heart failure and cardiogenic shock.

The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists, reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure.

[ANMCO Position paper: Current evidence on intra-aortic balloon pump in advanced acute heart failure]. / Position paper ANMCO: Ruolo del contropulsatore aortico nel paziente con insufficienza cardiaca acuta avanzata.

The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists (ANMCO), reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure. Data deriving from a national survey in Italian hospitals about IABP use are also provided.

Transfemoral transcatheter aortic valve implantation for treatment of severe aortic regurgitation in a patient with previous aortic valve-sparing operation according to David.

The regurgitation of the native aortic valve in patient with previous David operation may represent a clinical challenge because the morbidity and mortality risk of re-operation is not negligible. Here we describe the case of a patient suffering from late severe aortic regurgitation, many years after David operation, efficaciously treated with transfemoral transcatheter aortic valve implantation. To the best of our knowledge, this is the first description of such treatment in a patient with aortic regurgitation and previous David operation.

[The use of mechanical chest compression devices for both out-of-hospital and in-hospital refractory cardiac arrest]. / Utilizzo del massaggiatore automatico esterno nell'arresto cardiaco refrattario sul territorio e in ospedale.

The purpose of cardiopulmonary resuscitation after sudden cardiac arrest is to restore minimal blood flow to provide oxygen to the brain and other vital organs. Chest compressions and external defibrillation are the first line for circulatory support. Although early defibrillation is the main factor influencing survival, cardiopulmonary resuscitation must be characterized by high-quality external chest compressions. Unfortunately, the performance of manual chest compressions decreases during time and in hostile conditions. For these reasons, mechanical devices for chest compression are able to support rescuers during cardiopulmonary resuscitation. Commonly used mechanical chest compression devices in Europe include LUCAS and Autopulse. Routine utilization of mechanical chest compression devices cannot be recommended because randomized controlled trials, such as LINC and PARAMEDIC for LUCAS and CIRC for Autopulse, have not demonstrated their superiority compared with manual chest compressions. The aim of this review is to analyze recent data regarding utilization of mechanical chest compression devices, and to clarify advantages and limitations.

Life-threatening ventricular tachyarrhythmias in the cardiology department: Implications for appropriate prescription of telemetry monitoring.

BACKGROUND: in-hospital life-threatening ventricular arrhythmias (LT-VA) may complicate the course of cardiovascular patients. We aimed to assess the incidence, circumstances, determinants, and outcome of in-hospital LT-VA in order to help clinicians in prescribing appropriate levels of monitoring. METHODS: the study population consisted of all 10,741 consecutive patients (65 ± 15 years, 67.7% males) admitted to a cardiology department in 2009-2014. Terminally ill patients and those with primary arrhythmia diagnosis were excluded. The composite end-point included sudden arrhythmic death, ventricular fibrillation, unstable ventricular tachycardia and appropriate ICD shock unrelated to invasive interventions. RESULTS: the incidence of LT-VA was 0.6%, with no differences regarding age, gender and primary diagnosis of coronary artery disease between patients with and without LT-VA. The incidence of LT-VA was significantly higher (1.2% versus 0.1%, p<0.001) among urgent compared with elective admissions and among patients with left ventricular ejection fraction (LV-EF) <45% (1.7% versus 0.2%, p<0.001). At multivariable analysis, urgent admission and LV-EF <45%, but not primary diagnosis of coronary artery disease, remained independent predictors of LT-VA. At the time of the event, 97.1% fulfilled either class I or class II indications for telemetry monitoring according to the American Heart Association guidelines. Survival to discharge with good neurological status was 70.6%. CONCLUSIONS: acutely ill patients with heart failure and LV systolic dysfunction showed the highest rate of LT-VAs, regardless of the underlying cardiac disease (ischemic or non-ischemic). Current guidelines demonstrated high sensitivity in identifying patients at risk. These findings may favor proper utilization of telemetry monitoring resources.

Surviving out-of-hospital cardiac arrest: just a matter of defibrillators?

Out-of-hospital sudden cardiac arrest (OHCA) is a leading cause of death all over the world. Although the outcome of OHCA resulting from 'nonshockable' rhythms (asystole and pulseless electrical activity) is poor regardless of resuscitation efforts, 'shockable' rhythms such as ventricular tachycardia or fibrillation may carry a good prognosis if early defibrillation is performed. At present, simplified cardiopulmonary resuscitation techniques (hands-only cardiopulmonary resuscitation) and automated external defibrillators (AEDs) offer lay people the possibility to provide lifesaving treatment to OHCA victims in the critical minutes before the arrival of the emergency medical system. Programs aimed at increasing provision of cardiopulmonary resuscitation and use of AEDs by lay people have been set up in different countries, including Italy, and have contributed to improve survival rates. However, success of these programs critically depends on appropriate planning and design, and on cultural predisposition of witnesses to undertake immediate measures of resuscitation in the case of OHCA. Placement of a large number of AEDs may carry high costs and little benefits if it is uncoordinated and not preceded by educational campaigns to spread widely the 'culture of resuscitation' in the population.

At-admission risk stratification for in-hospital life-threatening ventricular arrhythmias and death in non-ST elevation myocardial infarction patients.

AIMS: Identification of patients with non-ST elevation acute myocardial infarction (NSTEMI) at higher risk of in-hospital life-threatening ventricular arrhythmias (LT-VA) and death is crucial for determining appropriate levels of care/monitoring during hospitalisation. We assessed predictors of in-hospital LT-VA and all-cause mortality in a consecutive series of NSTEMI patients. METHODS AND RESULTS: We prospectively studied 1325 consecutive patients (69.7% males, median age 70 (61-79) years) presenting with NSTEMI and undergoing continuous electrocardiographic monitoring. The primary study end-point was the occurrence of spontaneous (unrelated to coronary interventions) in-hospital LT-VA, including sustained ventricular tachycardia and ventricular fibrillation; the secondary end-point was in-hospital mortality from all causes. Of 1325 patients, 21 (1.5%) experienced LT-VA and 62 (4.7%) died from either arrhythmias (n=1) or other causes (n=61). Seven of the 20 patients who survived LT-VA subsequently died of heart failure. Independent predictors of in-hospital LT-VA were the Global Registry of Acute Coronary Events (GRACE) score >140 (odds ratio (OR)=7.5; 95% confidence interval (CI) 1.7-33.3; p=0.008) and left ventricular ejection fraction (LV-EF)<35% (OR=4.1; 95% CI 1.7-10.3; p=0.002). GRACE score >140 (OR=14.6; 95% CI 3.4-62) and LV-EF <35% (OR=4.4; 95% CI 1.9-10) also predicted in-hospital all-cause death. The cumulative probability of in-hospital LT-VA and death was respectively 9.2% and 23% in the 98 (7.4%) patients with GRACE score >140 and LV-EF<35%, while it was respectively 0.2% and 0% among the 627 (47.3%) with GRACE score ≤140 and LV-EF ≥35%. CONCLUSIONS: Simple risk stratification at admission based on GRACE score and echocardiographic LV-EF allows early identification of NSTEMI patients at higher risk of both in-hospital LT-VA and all-cause mortality.

Therapeutic hypothermia in Italian Intensive Care Units after 2010 resuscitation guidelines: still a lot to do.

BACKGROUND: Therapeutic hypothermia (TH) is one of three interventions that have demonstrated to improve patients' neurological outcome after cardiac arrest. The aim of this study was to investigate the effect of the 2010 resuscitation guidelines on TH implementation in various Italian Intensive Care Units (ICU). METHODS: A structured questionnaire was submitted to Italian ICU. The questionnaire was addressed to determine the procedures of TH in each ICU or, on the contrary, the reason for not employing the therapy. RESULTS: We obtained complete information from 770 of 847 Italian ICU (91%). Out of 405 Units included in the analysis only 223 (55.1%) reported to use TH in comatose patients after return of spontaneous circulation. The trend of TH implementation shows a stable increase, particularly after 2006 but there is no evident acceleration after the strong indication of the 2010 guidelines. There was a rise of about 3.4 times in the number of Italian ICU using TH as compared to the 2007 survey (an increase of 68% per year). One hundred and eighty-two (44.9%) units did not use TH mainly because of lack of equipment, economic issues or the conviction of the difficulty of execution. CONCLUSIONS: TH is still under-used in Italy (55.1%) even though the therapy is strongly recommended in the 2010 guidelines. However, the increase in the adoption of hypothermia has been significant in the past 5 years (68%/years) and the awareness of the efficacy is almost consolidated among intensivists, being logistic problems the leading cause for non-adoption.

[Combined treatment of refractory cardiac arrest by extracorporeal membrane oxygenation and therapeutic hypothermia]. / Trattamento combinato dell'arresto cardiaco refrattario mediante ossigenazione extracorporea a membrana e ipotermia terapeutica.

A 57-year-old man underwent myocardial revascularization for unstable angina. Cardiocirculatory arrest complicated the procedure and the patient was rapidly treated with advanced cardiac life support. After 26-min long resuscitation attempts, 5 DC-shock and cardioactive drug administration, an extracorporeal system was positioned and activated (extracorporeal membrane oxygenation, ECMO). After ECMO positioning, sinus rhythm was achieved after another DC-shock. Therapeutic hypothermia was started with a target temperature of 33°C. ECMO was removed after 12h, and therapeutic hypothermia was continued for 27h without any complications. The patient was discharged with good neurological outcome. This report shows the feasibility of treatment of a dramatic event such as refractory cardiac arrest, using modern and advanced techniques in the intensive cardiac care unit.

Impact of multivessel coronary artery disease on early ischemic injury, late clinical outcome, and remodeling in patients with acute myocardial infarction treated by primary coronary angioplasty.

OBJECTIVE: The mechanism through which multivessel coronary artery disease (MVD) adversely affects the outcome of patients with ST-elevation myocardial infarction (STEMI) is poorly characterized. We assessed whether the impact of MVD on outcome of STEMI patients is because of ischemic damage after primary percutaneous coronary intervention (PPCI) or to late ischemic events. METHODS: From August 2005 to 2007, 288 STEMI patients treated by (bare metal) stent-PPCI were prospectively enrolled. The ischemic injury early after PPCI (evaluated by multiparametric approach) and the incidence of late adverse cardiovascular events were compared between the two groups. RESULTS: Compared with single vessel coronary artery disease, MVD patients (n=134) were older, with higher prevalence of diabetes, prior MI, anterior MI and higher collateral score. Myocardial perfusion as assessed by myocardial blush and SigmaST-segment resolution was similar in the two groups as well as the infarct size and microvascular obstruction as assessed by Troponin I and by the delayed enhancement of cardiac magnetic resonance. At clinical (98% complete) and echocardiogaphic (94% complete) follow-up (median 32 months) MVD patients showed a higher incidence of re-MI (6.1 vs. 1.3%), and urgent revascularization (8.3 vs. 2.7%) and worse left ventricular remodeling than single vessel disease patients. At propensity adjusted analysis MVD was an independent predictor of re-MI (odds ratio: 5.7) and ventricular remodeling (odds ratio: 2.2). CONCLUSION: The impact of MVD on clinical outcome and remodeling of STEMI patients is not because of the extent of ischemic damage observed after PPCI, but to recurrent ischemic events during follow-up.