Innovative use of Protek Duo during bilateral lung transplant with Veno-Arterial Extracorporeal Membrane Oxygenation assistance.

V-A ECMO during bilateral lung transplantation is routinely used when extracorporeal support is needed, in particular in case of patients affected by pulmonary hypertension. We report the case of a patient successfully transplanted with V-A ECMO assistance using a percutaneous double lumen cannula as venous drainage (Protek Duo, CardiacAssist Inc., Pittsburgh, PA) and central aortic cannulation. The double lumen cannula allowed an optimal drainage of the venous system and effective emptying of right heart chambers.

Effect of Preoperative Right Ventricular Dysfunction on Heart Transplantation Outcomes.

BACKGROUND: We investigated if the occurrence of preoperative right ventricular dysfunction is capable of influencing heart transplant results in terms of in-hospital mortality, incidence of primary graft dysfunction, and follow-up mortality. METHODS: We retrospectively analyzed 517 patients who underwent heart transplant between January 2000 and December 2020. We defined right ventricular dysfunction (RVD), as central venous pressure (CVP) > 15 mm Hg and CVP/pulmonary capillary wedge pressure ratio > 0.63. We identified 2 subgroups in our population: 33 patients with preoperative RVD and 484 patients without RVD. RESULTS: In-hospital mortality was 7.9%. Severe early graft failure occurred in 6.6% of patients, with 26 patients (5.1%) needing intra-aortic balloon pump and 17 patients (3.3%) needing extracorporeal membrane oxygenation support. Clinical variables that significantly influenced in-hospital mortality were age, peripheral artery disease, and bilirubin > 1.5 mg/dL, while hemodynamic variables influencing in-hospital mortality were CVP (odds ratio [OR], 1.09 [confidence interval {CI}, 1.03-1.15], P = .004], pulmonary artery systolic pressure (OR, 1.02 [CI, 1.00-1.04], P = .05), CVP/pulmonary capillary wedge pressure ratio (OR, 2.78 [CI, 1.14-6.80], P = .025), pulmonary vascular resistance (OR, 1.15 [CI, 1.01-1.32], P = .042), transpulmonary gradient (TPG) (OR, 1.11 [CI, 1.03-1.18], P = .003) , diastolic transpulmonary gradient (OR, 1.10 [CI, 1.02-1.20], P = .015], together with right ventricular dysfunction (OR, 3.56 [CI, 1.44-8.80], P = .011). On the other hand, clinical variables influencing the incidence of early graft failure were body mass index (calculated as weight in kilograms divided by height in meters squared) > 30, peripheral artery disease, bilirubin > 1.5 mg/dL, Model for End-Stage Liver Disease score excluding international normalized ratio before transplant, and preoperative extracorporeal membrane oxygenation support, while hemodynamic variables were pulmonary arterial systolic pressure (OR, 1.03 [CI, 1.00-1.05], P = .016), TPG (OR, 1.08 [1.01-1.17], P = .03), and right ventricular dysfunction (OR, 3.00 [CI, 1.07-8.40] P = .046). On the multivariable analysis, RVD and TPG were independent predictors of in-hospital mortality, while only TPG was a predictor of early graft failure. Follow-up mortality was 38.7% and was influenced by recipient age, recipient body mass index, and preoperative diabetes. Moreover, 1-, 5-, and 10-year survival of patients with preoperative RVD was significantly worse than patients without RVD (log-rank = 0.001). CONCLUSIONS: In our population, RVD influenced both in-hospital and long-term results after heart transplant. For these reasons, it appears crucially important to optimize preoperative right ventricular function to improve these patients' outcomes.

Therapeutic alternatives in chronic thromboembolic pulmonary hypertension: from pulmonary endarterectomy to balloon pulmonary angioplasty to medical therapy. State of the art from a multidisciplinary team.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease with a very complex pathophysiology differing from other causes of pulmonary hypertension (PH). It is an infrequent consequence of acute pulmonary embolism that is frequently misdiagnosed. Pathogenesis has been related to coagulation abnormalities, infection or inflammation, although these disturbances can be absent in many cases. The hallmarks of CTEPH are thrombotic occlusion of pulmonary vessels, variable degree of ventricular dysfunction and secondary microvascular arteriopathy. The definition of CTEPH also includes an increase in mean pulmonary arterial pressure of more than 25 mmHg with a normal pulmonary capillary wedge of less than 15 mmHg. It is classified as World Health Organization group 4 PH, and is the only type that can be surgically cured by pulmonary endarterectomy (PEA). This operation needs to be carried out by a team with strong expertise, from the diagnostic and decisional pathway to the operation itself. However, because the disease has a very heterogeneous phenotype in terms of anatomy, degree of PH and the lack of a standard patient profile, not all cases of CTEPH can be treated by PEA. As a result, PH-directed medical therapy traditionally used for the other types of PH has been proposed and is utilized in CTEPH patients. Since 2015, we have been witnessing the rebirth of balloon pulmonary angioplasty, a technique first performed in 2001 but has since fallen out fashion due to major complications. The refinement of such techniques has allowed its safe utilization as a salvage therapy in inoperable patients. In the present keynote lecture, we will describe these therapeutic approaches and results.

Impact of Predicted Heart Mass-Based Donor-Recipient Size Matching on Transplant Outcomes.

BACKGROUND: Currently, guidelines for appropriate donor sizing in recipients mostly focuses on donor-recipient body weight matching. The purpose is to retrospectively determine the impact of predicted heart mass (pHM)-based size matching on heart transplant (HT) outcomes. METHODS: According to our institutional registry, 512 consecutive adult patients underwent HT between January 2000 and August 2020. For each patient, pHM and donor-recipient pHM ratio were calculated. Patients were partitioned into quintiles in terms of pHM ratio: undersizing 2, undersizing 1, reference, oversizing 1, and oversizing 2, with mean pHM donor-recipient ratio of 0.81, 0.96, 1.04, 1.12, and 1.28, respectively. Severe early graft failure and 30-day, 90-day, 1-year, and 10-year mortality were analyzed as outcomes. RESULTS: Recipients of the most oversized group were mostly female (P < .001), had higher preoperative pulmonary vascular resistance (P = .009), had higher rate of mechanical circulatory support (P < .05), and showed a lower United Network for Organ Sharing score (P = .041); the respective donors were younger and more frequently male (P = .001). Ischemic time was similar in all groups (P = .358). Pulmonary vascular resistance (P = .023; odds ratio [OR], 2.38), preoperative mechanical circulatory support (P = .05; OR, 3.06), and United Network for Organ Sharing score (P = .033; OR, 1.76) were identified as risk factors for early mortality. Donor-recipient pHM ratio did not impact early graft failure (P = .871) and early mortality (P = .526). Survival analysis after adjustment for pHM ratio subgroups did not show any difference in outcomes. CONCLUSIONS: A wide range of pHM ratios seems to be safe. A careful allocation of organs, by considering a pHM ratio mismatch, may balance rescue preoperative clinical profiles and preserve HT outcomes.

Impact of prior sternotomy on survival and allograft function after heart transplantation: A single center matched analysis.

BACKGROUND: Orthotopic heart transplantation (OHT) remains the gold standard for the treatment of end-stage heart failure. The number of patients who have had at least one prior sternotomy while awaiting transplantation has increased over the years reaching 50% in the last ISHLT registry report. We analysed our institutional transplant activity focusing on prior-sternotomy setting to identify the real burden of this preoperative variable and its potential consequences. METHODS: Between 2000 and 2020, a total of 512 consecutive adult patients underwent OHT. We divided them into two groups according to the previous sternotomy variable: a prior sternotomy group (PS-group, n = 131, 25.6%) and a heart transplant as first sternotomy group (FS-group, n = 381, 74.4%). After propensity score matching, a total of 106 matched-pairs were identified for the final analysis. RESULTS: The overall 30-day mortality was similar in the two groups (7.5% vs. 5.7%, p = .58). The prior sternotomy was not an independent risk factor for 90-day mortality (odds ratio: 0.89, p = .81). In the matched sample, prior cardiac surgery was not predictive for any major postoperative complication: primary graft failure, AKI, bleeding, acute respiratory insufficiency, need for extra-corporeal life support (p > .05). The log-rank test revealed no significant difference between the two groups in the unmatched and matched pools (p = .93 and 0.69 respectively. At univariable analysis prior sternotomy was not associated with an increased risk of posttransplant mortality (hazard ratio: 0.87, p = .599). CONCLUSIONS: Despite it increases surgical complexity, the reoperation alone does not represent a proper risk factor and among different co-variates that may affect post-OHT outcomes.

A rescue transcatheter solution for early sutureless basal ring infolding.

We report the case of an 83-year-old woman treated with a "rescue" valve-in-valve transcatheter aortic valve implantation because of an early basal ring partial collapse of a sutureless valve, probably due to septal hypertrophy.

How Would the Authors Treat Their Own Temporary Left Ventricular Failure With Mechanical Circulatory Support?

In the last 20 years, mechanical circulatory supports (MCS) have overturned completely the outcomes and the clinical recovery of patients with isolated acute left ventricle failure (iALVF). This usually occurs more frequently than right-sided heart failure or biventricular dysfunction, and it mainly is caused by acute myocardial infarction. The primary role of MCS is to restore the tissue metabolism to preserve the vital organs' function but, on the other hand, they also have to relieve the workload stress on the heart. In this way, they allow not only the heart to recover from the acute event, but MCS also can stabilize the patient toward cardiac transplantation. The short-term MCS devices currently used in clinical practice are the intraaortic balloon pump, the Impella (Abiomed, Danvers, MA), and venoarterial extracorporeal membrane oxygenation (VA-ECMO), but the choice of the right and tailored device for each patient, as well as the timing to use it, is actually one of the most debated topics of MCS management.

Early outcome and mid-term survival after open arch repair using selective antegrade cerebral perfusion.

OBJECTIVES: The introduction of selective antegrade cerebral perfusion technique as method of cerebral protection improved the outcome of open arch surgery. The aim of this study was to report early outcomes using this technique. METHODS: Between 1997 and 2017, data were collected retrospectively for all patients who underwent surgical replacement of the aortic arch using selective antegrade cerebral perfusion (n = 938). To confirm the effectiveness of this cerebral protection method, early outcome and results were evaluated. RESULTS: The incidence of postoperative permanent neurological dysfunction was 6.4%. Overall hospital mortality was 11.9% (n = 112). On multivariable analysis, age >75 years, female gender, euroscore at increment of 1 point, chronic renal failure, extension of thoracic aorta replacement and CPB time emerged as independent risk factors for hospital mortality. The mid-term survival at 1, 5, 10 and 15 years was 92%, 78%, 60% and 49%, respectively. The competing risk analysis for permanent neurological dysfunction and aortic reoperations was performed excluding the patients who died during the hospital stay. The cumulative incidence of permanent neurological dysfunction and aortic reoperations was 2% at 3 years, 3% at 5 years, 6% at 10 years, 12% at 3 years, 15% at 5 years and 19% at 10 years, respectively. CONCLUSIONS: From the early 90s to the present day, the selective antegrade cerebral perfusion has confirmed to be a useful and "safe" method of brain protection in aortic arch surgery in terms of postoperative neurological complications.

Conventional and alternative sites for left ventricular assist device inflow and outflow cannula placement.

Left ventricular assist device (LVAD) therapy is a well accepted and effective strategy to treat advanced heart failure. The miniaturized third-generation centrifugal pumps HeartWare HVAD (Medtronic, Dublin, Ireland) and HeartMate 3 (Abbott, Illinois, USA) are the two most commonly implanted systems in the contemporary era. Their design has allowed clinicians to pioneer several alternate and less invasive implantation techniques to tackle a broad spectrum of clinical scenarios. A brief review and discussion of alternative surgical techniques for both inflow and outflow cannula insertion, in the contemporary LVAD surgery era, are herein reported.

Visceral malperfusion after Frozen Elephant Trunk in chronic aortic dissection: post-operative predictors and outcomes.

BACKGROUND: The aims of this study were to analyse the incidence of visceral malperfusion syndrome (MPS) following Frozen Elephant trunk operations in patients affected by chronic aortic dissection and the associated risk factors. METHODS: Between January 2007 and February 2019, 165 patients underwent surgery with FET for chronic aortic dissection. Post-operative computer tomography angiogram parameters (diameters, early post-operative false lumen enhancement and involving of aortic branches by the dissection) were collected and analysed to evaluate their impact on the occurrence of visceral malperfusion. RESULTS: Visceral (renal and mesenteric) MPS (with both clinical and radiological signs of MPS) was detected in 10 cases (6.1%). Post-operative visceral malperfusion was strongly related with in hospital mortality. The involvement of the visceral branches in the dissection was not a risk factor for visceral malperfusion occurrence, while a larger post-operative total aortic diameter at level of the coeliac trunk increased the risk of visceral MPS (OR 1.05; CI 1.002-1.102, p-value = 0.04). Furthermore, visceral MPS was associated to a complete thrombosis of the false lumen at level of the distal descending thoracic aorta. CONCLUSIONS: The development of post-operative MPS in frozen elephant trunk is strongly related to in-hospital mortality. The involvement of aortic branches by the dissection does not represent a real predictive risk factor for MPS, while early larger aortic diameters and false lumen thrombosis represent independent risk factors for MPS and in-hospital mortality.

The Triple-Layer Patch Technique for Postinfarction Ventricular Septal Rupture.

Postinfarction ventricular septal rupture (VSR) represents a well-known mechanical complication of myocardial infarction, determining cardiogenic shock with high mortality rates. Surgical correction requires significant expertise to avoid cardiac rupture, uncontrollable bleeding, residual shunts, heart failure, and death. In the last year, we observed a substantial increase of VSR at our hospital, related to the delayed presentation of people with acute chest pain to the emergency departments during the coronavirus disease 2019 pandemic. We discuss our innovative triple-layer patch technique in a recent consecutive series of 8 patients. This technique proved effective in all patients, with no residual shunt or cardiac rupture.

Postinfarction posterobasal ventricular septal defect closure with a triple-layer patch.

We present the case of a 65-year-old patient who developed a large posterobasal ventricular septal defect resulting from an extensive acute myocardial infarction involving the inferior and basal septum and wall. We repaired the interventricular lesion by verticalizing the cardiac apex to perform a left posterobasal ventriculotomy. We removed a great part of the residual infarcted tissue, leaving the residual scar in place. Our technique first involved creating a double-layer patch comprising heterologous pericardium and a non-collagen-impregnated Sauvage Dacron patch, fixed with single pledgeted U-stitches from the right side of the anterior septum; then we applied a third layer of heterologous pericardium on the left side of the septum in order to have only a pericardial surface in contact with blood on both ventricular sides. A running suture was used to complete the procedure from the middle to the posterior rim of the ventricular septal defect.  The final triple-layer patch allowed us to obtain a complete and durable closure of the defect. The subsequent closure of the left ventriculotomy was performed with a similar bilayer pericardium-Dacron patch (always leaving pericardium on the internal surface). This technique proved effective, guaranteeing resistance to suture stress, less risk of leakage, and reduced thrombogenicity.

An unusual case of Thoraflex displacement after blunt thoracic trauma during skiing.

We present a case of a patient, who had previously undergone a frozen elephant trunk procedure for acute non-A-non-B aortic dissection, and developed a traumatic new entry tear due to the displacement of the hybrid prosthesis while skiing. An emergency thoracic endovascular aortic repair was performed without postoperative complications.

Delayed-Onset Postoperative Paraplegia in Acute Type A Aortic Dissection.

In patients with operated type A aortic dissections, irreversible spinal cord injury (SCI) may result from several factors: prolonged circulatory arrest, extension of replacement, and hypoperfusion of segmental arteries secondary to aortic false lumen thrombosis. Careful neuroprotective strategies and shorter operative times are crucial to reduce SCI incidence. Despite optimal perioperative management, delayed-onset SCI occurs in rare cases in response to subacute aortic remodeling. This report describes the case of a 77-year-old woman who underwent ascending aorta and hemiarch replacement for type A aortic dissection and had delayed paraplegia that developed on postoperative day 12.

AVR in patients with anomalous course of the circumflex artery without prosthetic downsizing.

An anomalous origin of the left circumflex coronary artery that arises as a side branch of the right coronary artery and encircles the aortic annulus is usually an incidental finding. However, in patients undergoing aortic valve/root procedures, its existence can significantly complicate the surgical treatment. We report our operative strategy with three different prostheses without valve downsizing.