The A-Med right heart support for off-pump coronary artery bypass grafting.

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) presents several advantages but, mainly due to the impaired diastolic filling of the right ventricle, the displacement of the heart can cause hemodynamic instability. The aim of this study was to investigate the possible role of the A-Med right heart support during OPCAB. METHODS: We report our early experience with the A-Med system (A-Med, West Sacramento, CA, USA) during OPCAB. The system consists of a coaxial cannula, a microcentrifugal pump and a control console. The coaxial cannula is passed through the right atrium with the tip of the cannula positioned in the main pulmonary artery. Thus the blood is actively removed from the right atrium and returned to the pulmonary artery. RESULTS: We successfully used this right heart support in 2 patients undergoing elective OPCAB. In both cases the system was used during the exposure of the proximal portion of the obtuse marginal branch. A mean pump flow of 3.2 l/min guaranteed normal cardiac output and hemodynamic stability during the exposure of the posterior target area. No complication occurred and the patients were discharged shortly after surgery. CONCLUSIONS: In our early experience the A-Med right heart support was safe and effective and allowed achievement of hemodynamic stability during exposure of the posterior areas of the left ventricle.

Open heart surgery in patients with dialysis-dependent renal insufficiency.

OBJECTIVE: Chronic renal failure (CRF) is commonly considered a significant factor for increased morbidity and mortality after cardiac surgery. METHODS: To assess the risk in our population we retrospectively analyzed 28 patients (16 men and 12 women, mean age 58.1+/-10.8 years) with end-stage renal disease (ESRD) undergoing cardiac surgery between 1989 and 2001. Sixteen (57.2%) patients had isolated coronary artery bypass grafting (CABG), nine (32.1%) had isolated valve replacement, and three (10.7%) underwent combined CABG and valve replacement. Preoperatively, 20 (71.4%) patients were on hemodialysis and eight (28.6%) on peritoneal dialysis. Mean preoperative duration of dialysis was 38.7+/-24.9 months (range, 3 to 93 months). RESULTS: There were two perioperative deaths (30-day mortality, 7.1%). Actuarial survival at 1, 2, 5, and 12 years was 0.85+/-0.7, 0.73+/-0.10, 0.65+/-0.12, and 0.54+/-0.14, respectively. Among 22 survivors, mean NYHA class was 1.7+/-0.8 (p < 0.001 vs. preoperatively) and mean CCS class was 1.6+/-0.6 (p < 0.001 vs. preoperatively). CCS/NYHA functional class IV (p = 0.01), urgent/emergency operation (p < 0.001), LVEF < 35% (p < 0.001) were strongly related to early and late mortality. CONCLUSIONS: Open-heart operations can be performed with acceptable short- and long-term results in patients with CRF on dialysis. Adequate preoperative management with identification of high-risk patients and a more aggressive approach before the onset of symptoms of cardiac failure are advisable.

[Leptospirosis. Description of a clinical case and review of the literature]. / Leptospirosi. Descrizione di un caso clinico e revisione della letteratura.

Leptospirosis is a world-wide diffused anthropozoonosis due to many strains of Leptospira. Initial symptoms may be mild, although in many cases severe systemic symptoms, including high fever, hypotension, etc. may be present since the beginning. In these latter circumstances, the diagnosis of leptospirosis can be very difficult because of the complexity of clinical picture especially when the history is lacking or incomplete. A case report of a 45 year-old man admitted to the hospital after severe jaundice and fever of unknown origin associated to altered mental status, renal failure and hypoxemia is presented. Because of the presence of septic shock and severe respiratory failure, the patient was transferred to the intensive care unit. The diagnostic hypothesis, based on clinical history, was confirmed by laboratory tests (leptospiral IgM antibodies detection). Therapeutical approach with the use of selected antibiotics (penicillin 24,000,000 U for day) and therapy of septic shock led to improvement of the patient's clinical conditions who was then transferred to a regular medical ward.

[Use of the laryngeal mask in general anesthesia. Clinical experience]. / Impiego della maschera laringea in anestesia generale. Esperienza clinica.

GOAL OF THE STUDY: To evaluate the use of the laryngeal mask during general anesthesia. STUDY DESIGN: We prospectively studied patients undergoing surgery with general anesthesia in spontaneous breathing. ENVIRONMENT: Urologic and general surgical ward, with standard monitoring equipment. PATIENTS: We studied consecutively 100 patients (ASA 1-3, 80 males, 20 females, age 64 +/- 15 years, range 19-98 years); 59 patients had a preexisting cardiopulmonary or metabolic disease. Monitoring included ECG, the arterial pressure (noninvasive), the CO2 capnography (EtCO2), the pulsossimetry (SpO2), the respiratory rate (RR) and the tidal volume/kg (TVi). The double product (DP = heart rate X systolic arterial pressure) was used as an index of cardiac stress. These parameters were recorded at 10-minute intervals throughout the procedure. RESULTS: The heart rate, the systolic arterial pressure remained stable during the anesthesia, whereas the DP significantly decreased at t10, t20, t30 and t40. The EtCO2 decreased slightly (from 41 +/- 6 to a 36 +/- 4 mmHg; p.n.s.), SpO2 did not change (from 97 +/- 2% to 96 +/- 2%; p:n.s.). The RR significantly increased at t30 and t40 and the TVi significantly increased during the first hour. No relevant complications have been reported. CONCLUSIONS: Anesthesia with laryngeal mask was not associated with any detrimental cardiovascular and respiratory effect.