Endoscopic Mitral Valve Repair in a Patient With Persistent Left Superior Vena Cava Draining Into the Coronary Sinus – Cannulation Technique and Surgical Management

Persistence of the left superior vena cava is often an incidental finding during cardiac surgical procedures. In minimally invasive valvular surgery, it may jeopardise venous drainage and myocardial protection. This How-To-Do-It paper describes the cannulation strategy in a case of minimally invasive mitral surgery in a patient with persistence of the left superior vena cava and absence of the anonymous vein detected with preoperative multimodality imaging

High-Versatility Left Ventricle Pump and Aortic Mock Circulatory Loop Development for Patient-Specific Hemodynamic in Vitro Analysis

The importance of experimental setups able to reproduce cardiac functions was well established in the field of clinical innovations. The mock circulatory loops acquired rising relevance, and the possibility to have a complete reproduction of different and specific fluid dynamic conditions within the setup is pivotal. A system with enough versatility to reproduce the physiologic range of both flows and pressures is required. This study describes the design of a versatile setup composed by a custom pulsatile left ventricular pump system and a 3D-printed mock circulatory loop for the in vitro analysis of a patient-specific case of an aortic complex. The performances of the pump were validated first with a set of test flow profiles. It was demonstrated that the system was able to cover a wide range of aortic and mitral flows. Second, the pump system was inserted within the full mock circulatory loop. A patient-specific case was reproduced, both in terms of flow and pressure profiles. A successful validation of the flow and pressure waveforms was obtained by using patient-specific in vivo data from magnetic resonance analysis

Extracorporeal life support for acute coronary syndrome complicated with cardiogenic shock requiring PCI: The impact of the shock team on outcomes

Objectives: To verify the impact on intra-hospital survival of the "Shock Team" in the decision to use Veno-arterial ECMO (VA-ECMO) as support in patients with acute coronary syndrome (ACS) in cardiogenic shock (CS), requiring percutaneous revascularization (PCI). Methods: Consecutive patients who from July 2013 to September 2020, presented to our Center for SCA and CS candidates for primary PCI, supported with VA-ECMO, were considered. The Shock Team is composed of the Hemodynamic Cardiologist, Clin- ical Cardiologist, Anesthesiologist, Cardiac Surgeon and Perfusionist. Over the years, the shared pre- or intra- procedural decision of how to mechanically support the circulation or not in patients with CS has been im- plemented. The retrospective analysis of consecutive patients has as primary end-point the frequency of Shock Team training, from the analysis of the conditions in which VA-ECMO was implanted, i.e. semi-elective (ECLS - Extracorporeal Life Support) or emergency (ECPR - Extracorporeal Cardio-Pulmonary Resuscita- tion), followed by the rate of weaning and survival from VA-ECMO. Results: Twenty-three patients (19 males, median age 63 years, range 59-66 years) were supported with femoral- femoral VA-ECMO. The Shock Team was formed in 11 cases. When Shock Team was formed (Group 1), VA- ECMO was implanted as ECLS in 7/11 cases, in the remaining as ECPR. In Group 2 (no pre-procedure Shock Team consultation), VA-ECMO was implanted as ECPR in 11/12 cases (92%) and intra-procedure. Pre- or intra-procedural IABP was implanted in all patients in Group 2. In Group 1, intra-hospital survival was 9/11 cases (82%) and in Group 2 3/12 cases (25%), in most of the latter with no possibility of weaning. Conclusions: In our case series, periprocedural Shock Team in patients with CS, allowed the establishment of mechanical support to the circulation in a semi-elective manner, with successful PCI and was associated with high survival. In contrast, in those in whom VA-ECMO is implanted as ECPR due to lack of shared decision, high intra-hospital mortality is observed. We therefore recommend in patients with ACS and CS the presence and consultation of the pre-procedural Shock Team

Elective institution of ECLS for primary PCI is associated with improved outcomes. A single center experience

Background/Purpose: The use of extracorporeal life sup- port (ECLS) in the cath lab has increased in recent years, as it provides adequate support during high‐risk angioplasty pro- cedures (HR‐PCI). Timing of ECLS initiation is crucial and we aim to elucidate the diffecences in early outcome between elective or rescue (ECPR) use of VA‐ECMO during HR‐PCI. Methods: We retrospectively reviewed the use of venous‐ar- terial ECMO (VA‐ECMO) as a support during HR‐PCI for acute coronary syndrome (ACS) with cariogenic shock (CS). Only the patients who met the criteria of the ELSO guide- lines were selected for receiving VA‐ECMO. The results of the group in which the VA‐ECMO was started electively be- fore or after the procedure were analyzed and compared with the group of patients in which it was started under cardiac massage after hemodynamic deterioration (ECPR) during the procedure. Results: From July 2013 to May 2017, 14 patients aged 60.1 ± 9.26 year received VA‐ECMO for ACS, with the clin- ical diagnosis of (CS). In seven patients the VA‐ECMO was initiated pre‐PCI or post‐PCI (sliding fast on inotropic sup- port), while in the other seven patients the VA‐ECMO was used as ECPR after hemodynamic collapse during the pro- cedure. The ECMO setup was percutaneously in all patients through the femoral vessels. All patients received culprit le- sion revascularization. Intra‐aortic balloon pump (IABP) was used in 11 patients (78.5%), preoperatively in 100% of theECPR group. We were able to wean four patients in the “elec- tive” group, while only three in the ECPR group; one patient was discharged on support and transplanted. The “elective group” had a lower mortality (2 [28.6%] vs 4 [57.1%]; “elec- tive” vs “ECPR” group). Conclusions: Elective use of VA‐ECMO for high‐risk PCI is associated, even in this small series, with improved in‐hospi- tal survival. Our results foster the pre‐PCI use of VA‐ECMO in HR‐PCI patients presenting with CS

The hemodynamic effect of Modified Blalock–Taussig Shunt morphologies: a computational analysis based on reduced order modeling

The Modified Blalock Taussig Shunt (MBTS) is one of the most common palliative operations in case of cyanotic heart diseases. Thus far, the decision on the position, size, and geometry of the implant relies on clinicians' experience. In this paper, a Medical Digital Twin pipeline based on reduced order modeling is presented for fast and interactive evaluation of the hemodynamic parameters of MBTS. An infant case affected by complete pulmonary atresia was selected for this study. A three-dimensional digital model of the infant's MBTS morphology was generated. A wide spectrum of MBTS geometries was explored by introducing twelve Radial Basis Function mesh modifiers. The combination of these modifiers allowed for analysis of various MBTS shapes. The final results proved the potential of the proposed approach for the investigation of significant hemodynamic features such as velocity, pressure, and wall shear stress as a function of the shunt's morphology in real-time. In particular, it was demonstrated that the modifications of the MBTS morphology had a profound effect on the hemodynamic indices. The adoption of reduced models turned out to be a promising path to follow for MBTS numerical evaluation, with the potential to support patient-specific preoperative planning

Patient blood management in cardiac surgery: The “Granducato algorithm”

Background: Patients undergoing cardiac surgery are subject to severe alterations of the coagulation system. The four cardiac surgery centers in Tuscany (Italy)structured and shared an algorithm (Granducato Patient Blood Management algorithm, G-PBMa)with predefined interventions for patient blood management. The aim of the study is to analyze the impact of that algorithm on the transfusion needs and bleeding-related outcomes in a large patient population. Methods: Multicenter retrospective observational study on 3839 patients undergoing cardiac surgery at the four cardiac centers in Tuscany. The G-PBMa was released at the end of 2015 and it was structured in three parts: pre-, intra-, and post-operative. The year 2014, before the G-PBMa (1955 patients)and the year 2016 (1884 patients)after the G-PBMa in place were compared. Logistic regression analyses were used. Results: The main changes introduced were the routine application of viscoelastic tests in bleeding patients (+72%)and the use of fibrinogen and prothrombin complex concentrate (+67%). The G-PBMa resulted in a significant reduction in the overall transfusion rate and in the transfusion rate of the separate blood products (relative risk for transfusions: 0.75, 95% confidence interval 0.65–0.85, P = 0.001). For preoperative hemoglobin values of between 8 and 10 g/dL, the absolute difference in RBC transfusion rate before and after the G-PBMa introduction ranged around 15%–17%. The G-PBMa introduction determined lower (P = 0.02)chest drain blood loss, lower (P = 0.001)postoperative acute kidney injury and shorter (P = 0.001)hospital stay. Conclusions: The G-PBMa was effective in reducing blood loss, transfusion requirements, and resulted in a better outcome