Extracorporeal Membrane Oxygenation for COVID-19 Respiratory Distress Syndrome: An Italian Society for Cardiac Surgery Report.

An increased need of extracorporeal membrane oxygenation (ECMO) support is going to become evident as treatment of SARS-CoV-2 respiratory distress syndrome. This is the first report of the Italian Society for Cardiac Surgery (SICCH) on preliminary experience with COVID-19 patients receiving ECMO support. Data from 12 Italian hospitals participating in SICCH were retrospectively analyzed. Between March 1 and September 15, 2020, a veno-venous (VV) ECMO system was installed in 67 patients (94%) and a veno-arterio-venous ECMO in four (6%). Five patients required VA ECMO after initial weaning from VV ECMO. Thirty (42.2%) patients were weaned from ECMO, while 39 (54.9%) died on ECMO, and six (8.5%) died after ECMO removal. Overall hospital survival was 36.6% (n = 26). Main causes of death were multiple organ failure (n = 14, 31.1%) and sepsis (n = 11, 24.4%). On multivariable analysis, predictors of death while on ECMO support were older age (p = 0.048), elevated pre-ECMO C-reactive protein level (p = 0.048), higher positive end-expiratory pressure on ventilator (p = 0.036) and lower lung compliance (p = 0.032). If the conservative treatment is not effective, ECMO support might be considered as life-saving rescue therapy for COVID-19 refractory respiratory failure. However warm caution and thoughtful approaches for timely detection and treatment should be taken for such a delicate patients population.

Safety and usefulness of composite grafts for total arterial myocardial revascularization: a prospective randomized evaluation.

OBJECTIVES: To evaluate the results of total arterial revascularization with composite grafts compared with the results of conventional coronary surgery, we enrolled 200 consecutive patient undergoing myocardial revascularization. METHODS: Patients were randomly assigned to 2 groups of 100 patients each: group 1 underwent total arterial revascularization, and group 2 received left internal thoracic artery on left anterior descending artery grafts plus additional saphenous vein grafts. The groups were comparable in terms of continuous and discrete variables and preoperative risk factors. RESULTS: There were no differences between group 1 and group 2 in terms of the number of grafted vessels (mean, 2.8 vs 2.9, respectively), crossclamping time (mean, 38 +/- 7 vs 40 +/- 6 min, respectively), intensive care unit stay (mean, 25 +/- 8 vs 24 +/- 7 hours, respectively), and hospital mortality (1% in both groups) nor were there any differences in postoperative complications. At the mean follow-up of 12 +/- 4 months, patients receiving total arterial revascularization (group 1) showed a better outcome in terms of angina recurrence (group 1 vs group 2: 2 vs 13 patients, P =.007), need of percutaneous transluminal coronary angioplasty reintervention (group 1 vs group 2: 0 vs 8 patients, P =.0012), and actuarial freedom from cardiac events (group 1 vs group 2: 96% vs 67%, P =.006). Angiography carried out in 72% in group 1 and in 68% in group 2 demonstrated a patency rate of 99% of saphenous vein grafts in group 1 and 89% of saphenous grafts in group 2. CONCLUSIONS: Total myocardial revascularization with composite arterial grafts provided superior clinical results and improved patient outcome, even in the short term to midterm. Arterial conduit-related benefits were clearly evident with respect to recurrence of angina and a higher graft patency rate.

Pulmonary valve lipoma presenting as syncope.

We report a case of a pulmonary valve lipoma presenting as syncope in a 28-year-old woman. Surgical excision of the mass was performed in urgency and the patient was discharged uneventfully.

Is total arterial myocardial revascularization with composite grafts a safe and useful procedure in the elderly?

OBJECTIVE: The aim of the study was to evaluate the mid-term results of total arterial myocardial revascularization (TAMR) with composite grafts in patients older than 70 years when compared to standard CABG technique, since the usefulness of TAMR in the elderly has not been demonstrated yet. METHODS: A prospective randomized study was designed with the following end-points: post-operative complications, death, recurrence of angina, graft occlusion, any cardiac event and reinterventions. One hundred and eighty-eight patients older than 70 years were enrolled and assigned to Group 1(G1)=94 pts, for total arterial revascularization or Group 2(G2)=94 pts, for standard CABG (LITA on LAD plus additional saphenous veins). The groups were comparable in terms of pre-operative characteristics and Euroscore (mean: G1=8.4 vs. G2=8.2). RESULTS: No differences between the groups were observed in terms of mean number of grafted vessels (G1=2.1 vs. G2=2.3), mean aortic cross-clamping time (G1=34+/-8 vs. G2=33+/-6min), mechanical ventilation time (G1=23+/-4 vs. G2=22+/-4hr), ICU stay (G1=40+/-10 vs. G2=39+/-9hr), post-operative complications and hospital mortality (G1=5.3% vs. G2=4.2%). At a mean follow-up of 12+/-4 months, cumulative incidence of angina recurrence was 2.1% in G1 vs. 11% in G2 (P=0.021). Angiographic evaluation showed 98.2% arterial patency in G1 vs. 86% saphenous vein graft patency in G2 (P<0.001). Multivariate analysis identified conventional CABG surgery as independent predictor of angina recurrence, graft occlusion and late cardiac events. CONCLUSIONS: Total arterial revascularization with composite grafts proved to be a safe and effective procedure also in the elderly. Composite arterial grafts provided superior clinical outcome with a lower rate of angina recurrence, graft occlusion and late cardiac events when compared to conventional CABG strategy.

Intraoperative microwave ablation in patients undergoing valvular surgery: midterm results.

AIM OF THE STUDY: To assess the safety and efficacy of intraoperative microwave ablation to restore sinus rhythm and systolic atrial function in patients undergoing valvular surgery. METHODS: Forty-one patients with atrial fibrillation (AF) underwent operations. The mean age was 61 years (range, 45- 76 years). AF was permanent in 30 patients and paroxysmal in 11. Associated cardiac procedures were mitral valve repair in 10 patients, mitral valve replacement in 12, and mitro-aortic valve replacement in 19. The microwave procedure (FLEX, AFx inc.) was performed to create an endocardial bilateral encircling isolation of the ostia of the pulmonary veins. RESULTS: There was no hospital mortality or morbidity. The mean follow-up period was 14.2 months. At follow-up, sinus rhythm was found in 34 patients (82.9%). Echocardiography results at follow-up showed no major or minor left atrial thrombosis and only a mild impairment of the systolic left atrial function. CONCLUSION: Intraoperative microwave ablation is a safe and effective treatment to restore sinus rhythm and a mildly impaired left atrial function in patients with AF undergoing cardiac surgery.

A novel approach to ventricular rupture: clinical needs and surgical technique.

Cardiac rupture is a life-threatening event that often occurs after myocardial infarction and is often associated with significant death. Pericardiocentesis provides hemodynamic short-term improvement; however, patients with cardiac rupture require an emergency operation. This report describes a new procedure used to repair left ventricle free wall rupture after myocardial infarction. The technique described repairs the rupture off-pump and without the need for suturing. Midterm results demonstrate the feasibility and durability of this procedure.

Diagnosing left ventricular aneurysm from pseudo-aneurysm: a case report and a review in literature.

Rupture of the free wall of the left ventricle (LV) is a catastrophic complication occurring in 4% of patients after myocardial infarction (MI) and in 23% of those who die of MI. Rarely the rupture is contained by an adherent pericardium creating a pseudo-aneurysm. This clinical finding calls for emergency surgery. If no ruptures are detectable and myocardium wall integrity is confirmed, we are in the presence of a true aneurysm, which can be treated by means of elective surgery. Differentiation between these two pathologies remains difficult. We report the case of a patient with a true aneurysm, initially diagnosed as pseudo-aneurysm at our institution; we have reviewed the literature on this difficult diagnosis and outlined characteristic findings of each clinical entity.

Unexpected limited chronic dissection of the ascending aorta.

We report a rare case of a limited chronic dissection of the ascending aorta that was accidentally discovered at operation performed for severe aortic stenosis and moderate to severe dilatation of the ascending aorta. Preoperative investigations such as transoesophageal echocardiography and cardiac catheterization missed the diagnosis of dissection. Intraoperative findings included a 3.5 cm eccentric bulge of the ascending aorta and a 5 mm circular shaped intimal tear comunicating with a limited hematoma or small dissection of the media layer. (The rarety of the report is that the chronic dissection is limited to a small area (approximatively 3.5 x 2.5 cm) of the ascending aorta).