Antonio Loforte

By Antonio Loforte, Giacomo Murana, Mariano Cefarelli, Jacopo Alfonsi, Giuliano Jafrancesco, Francesco Grigioni, Lucio Careddu, Emanuela Angeli, Gaetano Gargiulo and Giuseppe Marinelli

Early graft failure (EGF) is a major risk factor for death after heart transplantation (Htx) accounting for >40% of deaths within 30 days postoperatively. According to the last International Society for Heart and Lung Transplantation (ISHLT) consensus statement, the graft dysfunction (GD) is to be classified into primary (PGD), in case of an unknown triggering factor or secondary (SGD) where there is a discernible cause such as acute rejection, pulmonary hypertension, or known surgical complications. The diagnosis of GD is to be made within 24 h after completion of Htx surgery and a severity scale for GD should include mild, moderate, or severe grades based on specified criteria. Mechanical circulatory support (MCS) for GD should be considered when medical management is not sufficient to support the newly transplanted graft. Currently, extra‐corporeal membrane oxygenation (ECMO) is widely accepted as treatment of severe EGF, given its easy and quick setup, the system versatility, the optimal end‐organ perfusion provided, and the possibility of both biventricular and lung assistance by usage of a low‐cost single pump.

Part of the book: Extracorporeal Membrane Oxygenation

By Antonio Loforte, Giuditta Coppola, Carlo Mariani, Gregorio Gliozzi, Francesco Grigioni and Giuseppe Marinelli

Cardiogenic shock (CS) still remains a leading cause of hospital death. The adoption of percutaneous ventricular assist devices (pVADs) as treatment of CS is an option which continues to rise. Several types of pVADs have been developed by time to provide full cardiac support with few related complications and easy implantation settings. pVADs are used to support the failing heart as a bridge to recovery, decision, durable device or heart transplantation. None of these devices adopted in the clinical practice is ideal for all patients. Disadvantages may be related to the risk of limb/arm ischaemia or cerebral stroke or haemolysis. The most important choice is to identify the best device for each patient depending on haemodynamics, clinical scenario and patient anatomical/pathological issues. This chapter discusses the current pVAD options to treat CS patients.

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

By Antonio Loforte

Part of the book: Heart Transplantation

By Sofia Martin-Suarez, Marianna Berardi, Daniela Votano, Antonio Loforte, Giuseppe Marinelli, Luciano Potena and Francesco Grigioni

In 1967, the first cardiac transplantation was performed in South Africa by Christiaan Barnard, becoming one of the most pioneering events of the human history, comparable to the first step on the moon, 2 years later. Even if Barnard became extremely famous because of this outstanding operation, behind this event there were years and years of studies, experimentations and hard work done by others, in particular by Lower and Shumway. The initial technique, still called ‘standard technique’ is the biatrial one. In the late 1980s, alternatives like the ‘bicaval technique’ were developed in order to get a more anatomical result. In the present chapter, we will throw the reader into the early years of the cardiac transplantation era, describing all the efforts made by the “fathers” of the cardiac surgery in order to standardize techniques inherited by the modern surgeons. Afterwards, we will present a review of the literature to answer the question if the biatrial technique should still be called “standard technique”.

Part of the book: Heart Transplantation

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 Loforte, Gregorio Gliozzi, Giulio Giovanni Cavalli, Carlo Mariani, Luca Botta, Nazzareno Galiè, Davide Pacini and Sofia Martin-Suarez

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare consequence of acute or chronic pulmonary embolism. Pulmonary endarterectomy (PEA) is the gold standard treatment: expert centers are able to offer this challenging procedure with low in-hospital mortality, excellent hemodynamic results, and significant improvement in exercise tolerance and quality of life. Despite careful preoperative selection and increasing technical experience in PEA, some patients may suffer from life-threatening complications requiring extracorporeal life support (ECLS). ECLS is necessary in case of heart failure, respiratory failure, or both. According to different indications and timing, cardiopulmonary failure after PEA should be managed with a tailored approach: veno-venous or veno-arterial support, and central or peripheral cannulation. In the present chapter, causes, management strategies, and outcomes of perioperative ECLS for PEA are discussed.

Part of the book: Extracorporeal Membrane Oxygenation Support Therapy