Andrea Montalto

By Cristiano Amarelli, Francesco Musumeci, Antonio Loforte, Andrea Montalto, Sveva Di Franco and Jaime Hernandez-Montfort

Cardiogenic shock (CS) still carries an unacceptably high mortality (30–60%), despite several therapeutic approaches; the SHOCK II trial questioned the benefit of intra-aortic balloon pump (IABP), while IMPRESS and CULPRIT-SHOCK trials confirmed heterogeneity in disease spectrum and patient selection for acute myocardial infarction-related CS requiring acute mechanical circulatory support (AMCS). The heterogeneity of devices employed as AMCS, including temporary micro-axial flow pumps (Impella), percutaneous bypass (TandemHeart), and extracorporeal life support (VA-ECMO), contributed to the actual dramatic scenario, where CS is defined clinically rather than hemodynamically. To date, the role of VA-ECMO is emerging as rapid strategy to mitigate mortality rates of severe refractory states, despite the lack of data regarding the best practices of management and flows control. VA-ECMO’s flow represents the “dose” of treatment and higher flows are less tolerated percutaneously requiring, to prevent deleterious pulmonary edema and ventricular distention, additional approaches such as pulmonary, left atrial, or left ventricular unloading. Any efforts have to be directed to (1) determine adequate management of patients on VA-ECMO, (2) define the safer duration of VA-ECMO support, and (3) establish algorithms and techniques to predict and obtain stable weaning from ECMO or ensure fast transition to durable VAD and/or heart transplant.

Part of the book: Advances in Extra-corporeal Perfusion Therapies

By Antonio Giovanni Cammardella, Federico Ranocchi, Antonio Lio, Amedeo Pergolini, Francesco Nicolò, Marina Comisso, Vitaliano Buffa and Francesco Musumeci

The introduction of transcatheter aortic valve implantation (TAVI) have changed the management of patients affected by severe aortic stenosis. Nowadays, TAVI procedure represents the treatment of choice in patients with severe AS inoperable or at high risk. MDCT is the technique of choice in preoperative planning: it provides information regarding aortic valve and vascular access. Particular attention should be paid on bicuspid valve morphology. The choice of valve is, basically, based on confidence and experience of the operator and center.

Part of the book: Cardiac Surgery Procedures

By Andrea Montalto and Francesco Musumeci

Significant advancements have been made in Cardiac surgery during the last decades, thanks to technological evolution. The enormous progress achieved has led to a relevant improvement in terms of surgical results, and at the same time, new ethical dilemmas have been addressed. Until the 90’s ethics in cardiac surgery mainly concerned significant moral problems caused by the introduction of extremely innovative techniques. However, today’s ethical issue focuses essentially on the doctor-patient relationship, other aspects of doctor’s practice concern relevant ethical perspectives. Ethics affects today the activity of the surgeon and the doctor in general. It is possible to distinguish clinical ethics, an ethics of health policies, and scientific research ethics. In the following chapter, we try to analyze the main ethical aspects concerning the application of cardiac surgical procedures.

Part of the book: Bioethics in Medicine and Society