COVID-19 and the Brain: The Neuropathological Italian Experience on 33 Adult Autopsies.

Neurological symptoms are increasingly recognized in SARS-CoV-2 infected individuals. However, the neuropathogenesis remains unclear and it is not possible to define a specific damage pattern due to brain virus infection. In the present study, 33 cases of brain autopsies performed during the first (February-April 2020) and the second/third (November 2020-April 2021) pandemic waves are described. In all the cases, SARS-CoV-2 RNA was searched. Pathological findings are described and compared with those presently published.

Extracorporeal life support during and after bilateral sequential lung transplantation in patients with pulmonary artery hypertension.

The use of extracorporeal membrane oxygenator instead of standard cardiopulmonary bypass during lung transplantation is debatable. Moreover, recently, the concept of prolonged postoperative extracorporeal membrane oxygenator (ECMO) support has been introduced in many transplant centers to prevent primary graft dysfunction (PGD) and improve early and long-term results. The objective of this study was to review the results of our extracorporeal life support strategy during and after bilateral sequential lung transplantation (BSLT) for pulmonary artery hypertension. We review retrospectively our experience in BSLT for pulmonary artery hypertension between January 2010 and August 2018. A total of 38 patients were identified. Nine patients were transplanted using cardiopulmonary bypass (CPB), in eight cases CPB was followed by a prolonged ECMO (pECMO) support, 14 patients were transplanted on central ECMO support, and seven patients were transplanted with central ECMO support followed by a pECMO assistance. The effects of different support strategies were evaluated, in particular in-hospital morbidity, mortality, incidence of PGD, and long-term follow-up. The use of CPB was associated with poor postoperative results and worse long-term survival compared with ECMO-supported patients. Predictive preoperative factors for the need of intraoperative CPB instead of ECMO were identified. The pECMO strategy had a favorable effect to mitigate postoperative morbidity and mortality, not only in intraoperative ECMO-supported patients, but even in CPB-supported cases. In our experience, ECMO may be considered as the first choice circulatory support for lung transplantation. Sometimes, in very complex cases, CBP is still necessary. The pECMO strategy is very effective to reduce incidence of PGD even in CPB-supported patients.

[Extracorporeal membrane oxygenation for the treatment of refractory cardiogenic shock in adults: strategies, results, and predictors of mortality]. / Sistemi di ossigenazione a membrana extracorporea come trattamento per lo shock cardiogeno refrattario nella popolazione adulta: strategie, risultati e predittori di mortalità

BACKGROUND: The RotaFlow (Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany) and Levitronix CentriMag (Levitronix LCC, Waltham, MA, USA) veno-arterial extracorporeal membrane oxygenation (ECMO) support systems have been investigated as treatment for refractory cardiogenic shock. METHODS: Between 2004 and 2012, 119 consecutive adult patients were supported on RotaFlow (n=104) or CentriMag (n=15) ECMO at our Institution (79 men; mean age 57.3 ± 12.5 years, range 19-78 years). Indications for support were: failure to wean from cardiopulmonary bypass in the setting of postcardiotomy (n=47) and primary graft failure (n=26); post-acute myocardial infarction cardiogenic shock (n=11); acute myocarditis (n=3), and cardiogenic shock on chronic heart failure (n=32). RESULTS: A central ECMO setting was established in 64 (53.7%) patients while peripherally in 55 (46.2%). Overall mean support time was 10.9 ± 8.7 days (range 1-43 days). Forty-two (35.2%) patients died on ECMO. Overall success rate, in terms of survival on ECMO (n=77), weaning from mechanical support (n=51; 42.8%) and bridge to heart transplantation (n=26; 21.8%), was 64.7%. Sixty-eight (57.1%) patients were successfully discharged. Stepwise logistic regression identified blood lactate levels and creatine kinase-MB relative index at 72h after ECMO initiation, and number of packed red blood cells (PRBCs) transfused on ECMO as significant predictors of mortality. Central ECMO population had a higher rate of continuous veno-venous hemofiltration need and bleeding events compared with the peripheral setting. CONCLUSIONS: ECMO support provides encouraging results in different subsets of patients in cardiogenic shock. Blood lactate levels, creatine kinase-MB relative index and PRBCs transfused should be strictly monitored during veno-arterial ECMO running. Type of ECMO implantation, if peripheral or central, should be decided according to the specific patient subset.

Extracorporeal membrane oxygenation support in refractory cardiogenic shock: treatment strategies and analysis of risk factors.

Two centrifugal pumps, the RotaFlow (Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany) and Levitronix CentriMag (Levitronix LCC, Waltham, MA, USA), used in central or peripheral veno-arterial extracorporeal membrane oxygenation (ECMO) support systems have been investigated, in terms of double-center experience, as treatment for patients with refractory cardiogenic shock (CS). Between January 2006 and December 2012, 228 consecutive adult patients were supported on RotaFlow (n=213) or CentriMag (n=15) ECMO, at our institutions (155 men; age 58.3±10.5 years, range: 19-84 years). Indications for support were: failure to wean from cardiopulmonary bypass in the setting of postcardiotomy (n=118) and primary donor graft failure (n=37); postacute myocardial infarction CS (n=27); acute myocarditis (n=6); and CS on chronic heart failure (n=40). A peripheral ECMO setting was established in 126 (55.2%) patients while it was established centrally in 102 (44.7%). Overall mean support time was 10.9±9.7 days (range: 1-43 days). Eighty-four (36.8%) patients died on ECMO. Overall success rate, in terms of survival on ECMO (n=144), weaning from mechanical support (n=107; 46.9%), bridge to mid-long-term ventricular assist device (n=6; 2.6%), and bridge to heart transplantation (n=31; 13.5%), was 63.1%. One hundred twenty-two (53.5%) patients were successfully discharged. Stepwise logistic regression identified blood lactate level and MB isoenzyme of creatine kinase (CK-MB) relative index at 72 h after ECMO initiation, and number of packed red blood cells (PRBCs) transfused on ECMO as significant predictors of mortality on ECMO (P=0.010, odds ratio [OR]=2.94; 95% confidence interval [CI]=1.10-3.14; P=0.010, OR=2.82, 95% CI=1.014-3.721; and P=0.011, OR=2.69; 95% CI=1.06-4.16, respectively). Central ECMO population had significantly higher rate of continuous veno-venous hemofiltration need and bleeding requiring surgery events compared with the peripheral ECMO setting population. No significant differences were seen by comparing the RotaFlow and CentriMag populations in terms of device performance. At follow-up, persistent heart failure with left ventricle ejection fraction (LVEF)≤40% was a risk factor after hospital discharge. Patients with a poor hemodynamic status may benefit from rapid central or peripheral insertion of ECMO. The blood lactate level, CK-MB relative index, and PRBCs transfused should be strictly monitored during ECMO support. In addition, early ventricular assist device placement or urgent listing for heart transplant should be considered in patients with persistent impaired LVEF after ECMO.

Is time on cardiopulmonary bypass during cardiac surgery associated with acute kidney injury requiring dialysis?

It is commonly accepted that the longer the time on extracorporeal cardiopulmonary bypass (CPB), the higher is the likelihood of developing acute renal failure requiring dialysis (ARF-D). Nonetheless, previous works elicited conflicting evidence. We investigated the relationship between CPB duration and ARF-D occurrence. Data were extracted from a large observational study. All factors independently associated with ARF-D were detected. Overall, 11,092 case record forms were analyzed. At the univariate analyses, time on CBP was associated with an increase in the ARF-D risk (odds ratio of fifth vs. first quintile of CBP time: 3.84; 95% confidence interval: 2.58-5.7; P < 0.001). However, after adjusting for confounders, the association between time on CBP and ARF-D lost its statistical significance. In this large dataset, CBP time did not predict ARF-D occurrence. These results might suggest that an accurate risk assessment might be more important than time on CPB in determining ARF-D occurrence.

Moderately hypothermic cardiopulmonary bypass and low-flow antegrade selective cerebral perfusion for neonatal aortic arch surgery.

BACKGROUND: Although deep hypothermic circulatory arrest has been extensively used in neonates for aortic arch surgery, the brain and other organs might be adversely affected by prolonged ischemia and deep hypothermia. METHODS: Between December 1997 and January 2005, 70 consecutive neonates underwent Norwood stage I procedure for hypoplastic left heart syndrome (group A, n = 30), or aortic arch repair for interruption or coarctation with arch hypoplasia (group B, n = 40), with antegrade selective cerebral perfusion (ASCP). Mean weights were 3.0 +/- 0.2 kg and 2.8 +/- 0.07 kg, and mean ages were 10 +/- 3.5 days and 14 +/- 10.6 days in groups A and B, respectively. Only 2 patients were older than 30 days. Core body temperature was lowered to 25 degrees C, and mean pump flow during ASCP was initiated at 10 to 20 mL/(kg x min) and adjusted to guarantee a radial/temporal artery pressure of 30 to 40 mm Hg and venous oxygen saturation of more than 70%. Hematocrit was maintained at 30%. RESULTS: Early mortality was 17% (group A, 23%; group B, 12.5%; p = 0.19). Six late deaths occurred (3 in each group), and at 36 months, Kaplan-Meier overall survival was 64% +/- 9.2% in group A and 85% +/- 5.7% in group B. One patient had postoperative seizures. Age, weight, sex, prematurity, group A, and ASCP duration did not influence early mortality. CONCLUSIONS: Antegrade selective cerebral perfusion is a safe and effective procedure and might improve outcome of neonatal aortic arch surgery, minimizing neurologic impact without the need for deep hypothermia.

Outcome of cardiac surgery in low birth weight and premature infants.

OBJECTIVE: Low birth weight or premature infants may require early surgical treatment of congenital cardiac lesions because of their poor clinical status. Even thought early repair or palliation is carried out with incremental risk factor for morbidity and mortality, it has been demonstrated to be preferable to medical management and delayed surgery. This retrospective study was undertaken to evaluate early and mid-term results in infants, weighing less than 2500 g, who underwent surgery other than patent ductus arteriosus closure. METHODS: Since January 1993 to August 2002, 60 consecutive patients underwent early surgical treatment of congenital heart malformations at our institution. 27 patients were premature (born before 37 weeks of gestation). Ninety percent were severely symptomatic. Mean age at operation was 15.5 days (range 4-68 days). Mean weight was 2120 g (range 900-2500 g). Indications for surgery were: coarctation complex 11, transposition of great arteries 9, interrupted or severely hypoplastic aortic arch 9, hypoplastic left heart syndrome 7, truncus arteriosus 5, other 19. Thirty-five patients were operated on CPB, Deep Hypothermia with Circulatory Arrest was used in 9. Complete repair was achieved in 32 patients. Aortic arch reconstruction was required in 32 cases. RESULTS: There were nine early deaths (15%): heart failure (5), multiorgan failure (3), sepsis (1). Age, weight, prematurity, type of surgery and use of cardio pulmonary by-pass did not influence early mortality. Mean intensive care unit stay and duration of mechanical ventilation were 5.8 days and 75.5 h, respectively. Postoperative neurological complications did not occur in any patient. At follow-up (mean 48 months) there were nine late deaths. Kaplan-Meier survival at 60 months was 70%. CONCLUSIONS: Surgery for congenital heart disease can be performed in low weight critically ill infants with reduced, but still acceptable early and mid-term survival.

Intravenous flecainide for the treatment of junctional ectopic tachycardia after surgery for congenital heart disease.

BACKGROUND: Junctional ectopic tachycardia (JET) is a life-threatening arrhythmia producing severe hemodynamic dysfunction, which may complicate the postoperative course of surgery for congenital heart disease. Strict care and a fast and effective antiarrhythmic strategy are essential, because mortality largely depends on the duration of the arrhythmia. METHODS: Seven consecutive neonates with postoperative JET without any evidence of myocardial ischemia received intravenous flecainide after conventional therapies proved ineffective. Atrial pacing at the minimal rate for atrioventricular synchrony was followed by a 10-min intravenous infusion of 1.6 mg/kg flecainide, then continuous infusion of 0.4 mg/kg flecainide per hour. Treatment was considered effective based on restoration of sinus rhythm or a JET rate no higher than 170 bpm within 4 hours of flecainide loading. Overall mean flecainide infusion lasted 31.2 hours (range 25 to 53 hours). Side effects were assessed by monitoring plasma flecainide levels, electrocardiogram, arterial pressure, and central venous pressure. RESULTS: Flecainide was effective in all 7 patients after an infusion duration of 3.6 +/- 1.5 hours. Sinus rhythm was restored after 7.2 +/- 9.7 hours. After 4 hours of loading, heart rate fell from 219 +/- 14 to 136 +/- 7 bpm (p < 0.0001), arterial pressure increased from 69 +/- 8 to 93 +/- 10 mm Hg (p < 0.0001), while central venous pressure decreased from 8.0 +/- 1.6 to 5.2 +/- 1.9 mm Hg (p = 0.0007). No side effect or recurrence was noted. CONCLUSIONS: Flecainide can exert a fast antiarrhythmic effect on postoperative JET, and its infusion can be modulated to maintain the concentration within the therapeutic range, thus avoiding toxicity. We propose further consideration of flecainide for treatment of JET in neonates without myocardial ischemia.

Surgical management of double outlet right ventricle with intact ventricular septum.

A very rare case of double outlet right ventricle with intact ventricular septum and unrestricted pulmonary flow was successfully palliated with pulmonary banding and delayed bidirectional cavopulmonary anastomosis and mitral avulsion. This is the only case of pulmonary banding with mitral avulsion reported in the literature for this type of heart defect