Publications by authors named "Giuseppe Filiberto Serraino"

24 Publications

  • Page 1 of 1

Risk factors for acute kidney injury and mortality in high risk patients undergoing cardiac surgery.

PLoS One 2021 21;16(5):e0252209. Epub 2021 May 21.

Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy.

Background: Acute Kidney Injury (AKI) represents a clinical condition with poor prognosis. The incidence of AKI in hospitalized patients was about 22-57%. Patients undergoing cardiac surgery (CS) are particularly exposed to AKI because of the related oxidative stress, inflammation and ischemia-reperfusion damage. Hence, the risk profile of patients undergoing CS who develop AKI and who are consequently at increased mortality risk deserves further investigation.

Methods: We designed a retrospective study examining consecutive patients undergoing any type of open-heart surgery from January to December 2018. Patients with a history of AKI were excluded. AKI was diagnosed according to KDIGO criteria. Univariate associations between clinical variables and AKI were tested using logistic regression analysis. Variable thresholds maximizing the association with AKI were measured with the Youden index. Multivariable logistic regression analysis was performed to assess predictors of AKI through backward selection. Mortality risk factors were assessed through the Cox proportional hazard model.

Results: We studied 158 patients (mean age 51.2±9.7 years) of which 74.7% were males. Types of procedures performed were: isolated coronary artery bypass (CABG, 50.6%), valve (28.5%), aortic (3.2%) and combined (17.7%) surgery. Overall, incidence of AKI was 34.2%. At multivariable analysis, young age (p = 0.016), low blood glucose levels (p = 0.028), estimated Glomerular Filtration Rate (p = 0.007), pH (p = 0.008), type of intervention (p = 0.031), prolonged extracorporeal circulation (ECC, p = 0.028) and cross-clamp (p = 0.021) times were associated with AKI. The threshold for detecting AKI were 91 and 51 minutes for ECC and cross-clamp times, respectively. At survival analysis, the presence of AKI, prolonged ECC and cross-clamp times, and low blood glucose levels forecasted mortality.

Conclusions: AKI is common among CS patients and associates with shortened life-expectancy. Several pre-operative and intra-operative predictors are associated with AKI and future mortality. Future studies, aiming at improving prognosis in high-risk patients, by a stricter control of these factors, are awaited.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0252209PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8139497PMC
May 2021

Systematic review and meta-analysis of the clinical effectiveness of point-of-care testing for anticoagulation management during ECMO.

J Clin Anesth 2021 May 4;73:110330. Epub 2021 May 4.

Cardiac Surgery Unit, Dept. Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy.

Study Objective: Viscoelastic point-of-care (POC) tests are commonly used to provide prompt diagnosis of coagulopathy and allow targeted treatments in bleeding patients on ECMO. We evaluated the clinical effectiveness of point-of-care (POC) testing for anticoagulation management in patients on extracorporeal membrane oxygenation (ECMO).

Design: Systematic review and meta-analysis. Eligible studies evaluating the use of thromboelastography- or thromboelastometry-guided algorithms, anti-factor Xa and platelet function testing were selected after screening the literature from July 1975 to January 2020.

Setting: Patients on ECMO support.

Patients: Anticoagulation management on ECMO patients.

Interventions: Rotational thromboelastometry, thromboelastography, alone or combined with platelet function testing. Trials monitoring the anticoagulation effects during ECMO using an anti-factor Xa assay were included in the systematic review.

Measurements: The primary outcomes were bleeding events, surgical revisions, thrombosis events and ECMO circuit change/failure. Secondary outcomes were blood-product transfusions, cerebrovascular accidents, mortality on ECMO, ECMO duration, intensive care unit and hospital discharge rates, and in-hospital mortality.

Main Results: Thirty-one trials enrolling 1684 participants were included in the systematic review. Four trials enrolling 547 subjects were included in the meta-analysis. The use of a POC testing device resulted in improved detection of surgical bleeding (RR: 0.68, 95% CI 0.49 to 0.94, I = 0%; χ test for heterogeneity, P = 0.02). The use of POC-guided algorithms did not affect bleeding (RR:0.78, 95% CI 0.58 to 1.04, I = 47%; χ test for heterogeneity, P = 0.09), thrombosis events (RR:1.35, 95% CI 0.86 to 2.12, I = 37%; χ test for heterogeneity, P = 0.19), or ECMO circuit/change (RR:0.90, 95% CI 0.48 to 1.71, I = 28%; χ test for heterogeneity, P = 0.75).

Conclusion: Routine use of POC tests did not improve the main clinical outcomes beyond suggesting a diagnosis of surgical bleeding in ECMO patients.
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http://dx.doi.org/10.1016/j.jclinane.2021.110330DOI Listing
May 2021

Age, comorbidities, frailty: Who comes first?

J Card Surg 2021 Jul 6;36(7):2407-2409. Epub 2021 Apr 6.

Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy.

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http://dx.doi.org/10.1111/jocs.15543DOI Listing
July 2021

Sutureless in bicuspid valves: are there no more limits? Sutureless and Bicuspid.

Ann Thorac Surg 2021 Mar 9. Epub 2021 Mar 9.

Department of Experimental and Clinical Medicine, "Magna Graecia" University, Catanzaro, Italy.

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http://dx.doi.org/10.1016/j.athoracsur.2021.02.071DOI Listing
March 2021

Aortic Aneurysms, Chronic Kidney Disease and Metalloproteinases.

Biomolecules 2021 01 30;11(2). Epub 2021 Jan 30.

Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, I-88100 Catanzaro, Italy.

Metalloproteinases (MPs) are proteolytic enzymes involved in extracellular matrix deposition, regulation of cellular signals of inflammation, proliferation, and apoptosis. Metalloproteinases are classified into three families: Matrix-MPs (MMPs), A-Disintegrin-and-Metalloprotease (ADAMs), and the A-Disintegrin-and-Metalloproteinase-with-Thrombospondin-1-like-Domains (ADAMTS). Previous studies showed that MPs are involved in the development of aortic aneurysms (AA) and, concomitantly, in the onset of chronic kidney disease (CKD). CKD has been, per se, associated with an increased risk for AA. The aim of this review is to examine the pathways that may associate MPs with CKD and AA. Several MMPs, such as MMP-2, -8, -9, and TIMP-1 have been shown to damage the AA wall and to have a toxic effect on renal tubular cells, leading to fibrosis. Similarly, ADAM10 and 17 have been shown to degrade collagen in the AA wall and to worsen kidney function via pro-inflammatory stimuli, the impairment of the Renin-Angiotensin-Aldosterone System, and the degradation of structural proteins. Moreover, MMP-2 and -9 inhibitors reduced aneurysm growth and albuminuria in experimental and human studies. It would be important, in the future, to expand research on MPs from both a prognostic, namely, to refine risk stratification in CKD patients, and a predictive perspective, likely to improve prognosis in response to targeted treatments.
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http://dx.doi.org/10.3390/biom11020194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7912263PMC
January 2021

Quantitative and Qualitative Platelet Derangements in Cardiac Surgery and Extracorporeal Life Support.

J Clin Med 2021 Feb 6;10(4). Epub 2021 Feb 6.

Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands.

Thrombocytopenia and impaired platelet function are known as intrinsic drawbacks of cardiac surgery and extracorporeal life supports (ECLS). A number of different factors influence platelet count and function including the inflammatory response to a cardiopulmonary bypass (CPB) or to ECLS, hemodilution, hypothermia, mechanical damage and preoperative treatment with platelet-inhibiting agents. Moreover, although underestimated, heparin-induced thrombocytopenia is still a hiccup in the perioperative management of cardiac surgical and, above all, ECLS patients. Moreover, recent investigations have highlighted how platelet disorders also affect patients undergoing biological prosthesis implantation. Though many hypotheses have been suggested, the mechanism underlying thrombocytopenia and platelet disorders is still to be cleared. This narrative review aims to offer clinicians a summary of their major causes in the cardiac surgery setting.
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http://dx.doi.org/10.3390/jcm10040615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914426PMC
February 2021

Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Biomarkers for Cardiovascular Surgery Procedures: A Literature Review.

Rev Recent Clin Trials 2021 ;16(2):173-179

Department of Experimental and Clinical Medicine, University of Catanzaro, Catanzaro, Italy.

Background: Neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) have been studied so far as prognostic factors of cardiovascular diseases. Their role interplayed with endothelial inflammation has emerged as optimal predictors for major cardiovascular disease events and prognostic factors for post-procedural outcomes.

Methods: A review of the current literature was undertaken to investigate the relationship between NLR and PLR with percutaneous, cardiac surgery, and vascular surgery procedures.

Results: Our findings show that perioperative NLR and PLR levels are significantly correlated with patient morbidity and mortality rates.

Conclusion: These biomarkers have several attractive characteristics, as they are inexpensive and quickly available, and they can contribute to the early identification of patients at high risk for periprocedural adverse events.
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http://dx.doi.org/10.2174/1574887115999201027145406DOI Listing
January 2021

The Role of Prognostic and Predictive Biomarkers for Assessing Cardiovascular Risk in Chronic Kidney Disease Patients.

Biomed Res Int 2020 8;2020:2314128. Epub 2020 Oct 8.

Interuniversity Center of Phlebolymphology (CIFL), "Magna Graecia" University of Catanzaro, Catanzaro, Italy.

Chronic kidney disease (CKD) is currently defined as the presence of proteinuria and/or an eGFR < 60 mL/min/1.73m on the basis of the renal diagnosis. The global dimension of CKD is relevant, since its prevalence and incidence have doubled in the past three decades worldwide. A major complication that occurs in CKD patients is the development of cardiovascular (CV) disease, being the incidence rate of fatal/nonfatal CV events similar to the rate of ESKD in CKD. Moreover, CKD is a multifactorial disease where multiple mechanisms contribute to the individual prognosis. The correct development of novel biomarkers of CV risk may help clinicians to ameliorate the management of CKD patients. Biomarkers of CV risk in CKD patients are classifiable as prognostic, which help to improve CV risk prediction regardless of treatment, and predictive, which allow the selection of individuals who are likely to respond to a specific treatment. Several prognostic (cystatin C, cardiac troponins, markers of inflammation, and fibrosis) and predictive (genes, metalloproteinases, and complex classifiers) biomarkers have been developed. Despite previous biomarkers providing information on the pathophysiological mechanisms of CV risk in CKD beyond proteinuria and eGFR, only a minority have been adopted in clinical use. This mainly depends on heterogeneous results and lack of validation of biomarkers. The purpose of this review is to present an update on the already assessed biomarkers of CV risk in CKD and examine the strategies for a correct development of biomarkers in clinical practice. Development of both predictive and prognostic biomarkers is an important task for nephrologists. Predictive biomarkers are useful for designing novel clinical trials (enrichment design) and for better understanding of the variability in response to the current available treatments for CV risk. Prognostic biomarkers could help to improve risk stratification and anticipate diagnosis of CV disease, such as heart failure and coronary heart disease.
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http://dx.doi.org/10.1155/2020/2314128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568793PMC
May 2021

The Shaggy Aorta Syndrome: An Updated Review.

Ann Vasc Surg 2021 Jan 13;70:528-541. Epub 2020 Aug 13.

Department of Experimental and Clinical Medicine, University of Catanzaro, Catanzaro, Italy.

Background: Shaggy aorta (SA) depicts the severe aortic surface degeneration, extremely friable, and likely to cause spontaneous peripheral and visceral embolization or during catheterization, aortic manipulation, surgery, or minimally invasive procedures. This study aims to provide the most accurate and up-to-date information on this disease.

Methods: Potentially eligible studies to be included were identified by searching the following databases: CENTRAL Library, ClinicalTrials.gov, MEDLINE, and CINAHL, using a combination of subject headings and text words to identify relevant studies: (Shaggy aorta) OR (aortic embolization) OR (aortic embolism) OR (aortic thrombus) OR (aortic plaque). From a total of 29,111 abstracts, and after applying inclusion and exclusion criteria, we considered 60 studies for inclusion in this review.

Results: Appropriate measurement and assessment of the aortic wall are pivotal in the modern era, in particular when percutaneous procedures are performed, as SA has been identified as an independent risk factor for spinal cord injury, mesenteric embolization, and cerebral infarction after endovascular aortic repair. Furthermore, SA increases the rate of cerebral complications during transcatheter aortic valve implantation.

Conclusions: In conclusion, prompt diagnosis of SA syndrome and appropriate guidelines on the management of these conditions may help physicians to better assess the patient risk and to minimize the dreadful-related complications.
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http://dx.doi.org/10.1016/j.avsg.2020.08.009DOI Listing
January 2021

Diaphragmatic Dysfunction After Elective Cardiac Surgery: A Prospective Observational Study.

J Cardiothorac Vasc Anesth 2020 Dec 17;34(12):3336-3344. Epub 2020 Jun 17.

Anesthesia and Intensive Care, Padua Hospital, Department of Medicine - DIMED, University of Padua, Padua, Italy. Electronic address:

Objectives: To determine the incidence of postoperative diaphragm dysfunction as diagnosed by ultrasonography.

Design: Explorative prospective observational study.

Setting: University intensive care unit.

Participants: One hundred consecutive patients undergoing elective cardiac surgery.

Interventions: Diaphragm ultrasound was performed the day before surgery during unassisted breath (D-1), at the first spontaneous breathing trial attempt (D), 24 hours after surgery (D+1), and at intensive care unit (ICU) discharge (D). Diaphragm displacement, inspiratory and expiratory thickness, and the thickening fraction were measured at all timepoints.

Measurements And Main Results: Primary outcome was assessing the rate of postoperative diaphragm dysfunction, defined as a thickening fraction <20% at D. Secondary outcomes were the number of difficult-to-wean patients, the need for rescue noninvasive ventilation, the reintubation rate, and the ICU length of stay. Thirty-eight patients showed diaphragm dysfunction at D, which resolved over time. No differences in preoperative characteristics and comorbidities were found between patients who developed postoperative diaphragm dysfunction and patients without postoperative disorders. The duration of cardiopulmonary bypass (103 ± 34 v 55 ± 34 min; P < 0.001) was significantly associated with the development of postoperative diaphragm dysfunction. When compared with patients without postoperative diaphragm disorders, patients with diaphragm dysfunction were characterized by a higher rate of difficult weaning (32% v 5%; P < 0.001), lower extubation rate at 24 hours after surgery (50% v 92%; P < 0.001), and longer ICU length of stay (19 [16; 88] v 16 [15; 18] hours; P < 0.001).

Conclusions: The incidence of postoperative diaphragm dysfunction after elective cardiac surgery is high and might contribute to prolonging ICU length of stay.
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http://dx.doi.org/10.1053/j.jvca.2020.06.038DOI Listing
December 2020

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis.

Intensive Care Med 2020 06 23;46(6):1154-1169. Epub 2020 Apr 23.

Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands.

Despite increasing improvement in extracorporeal membrane oxygenation (ECMO) technology and knowledge, thrombocytopenia and impaired platelet function are usual findings in ECMO patients and the underlying mechanisms are only partially elucidated. The purpose of this meta-analysis and systematic review was to thoroughly summarize and discuss the existing knowledge of platelet profile in adult ECMO population. All studies meeting the inclusion criteria (detailed data about platelet count and function) were selected, after screening literature from July 1975 to August 2019. Twenty-one studies from 1.742 abstracts were selected. The pooled prevalence of thrombocytopenia in ECMO patients was 21% (95% CI 12.9-29.0; 14 studies). Thrombocytopenia prevalence was 25.4% (95% CI 10.6-61.4; 4 studies) in veno-venous ECMO, whereas it was 23.2% (95% CI 11.8-34.5; 6 studies) in veno-arterial ECMO. Heparin-induced thrombocytopenia prevalence was 3.7% (95% CI 1.8-5.5; 12 studies). Meta-regression revealed no significant association between ECMO duration and thrombocytopenia. Platelet function impairment was described in 7 studies. Impaired aggregation was shown in 5 studies, whereas loss of platelet receptors was found in one trial, and platelet activation was described in 2 studies. Platelet transfusions were needed in up to 50% of the patients. Red blood cell transfusions were administered from 46 to 100% of the ECMO patients. Bleeding events varied from 16.6 to 50.7%, although the cause and type of haemorrhage was not consistently reported. Thrombocytopenia and platelet dysfunction are common in ECMO patients, regardless the type of ECMO mode. The underlying mechanisms are multifactorial, and understanding and management are still limited. Further research to design appropriate strategies and protocols for its monitoring, management, or prevention should be matter of thorough investigations.
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http://dx.doi.org/10.1007/s00134-020-06031-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292815PMC
June 2020

Peri-procedural thrombocytopenia after aortic bioprosthesis implant: A systematic review and meta-analysis comparison among conventional, stentless, rapid-deployment, and transcatheter valves.

Int J Cardiol 2019 12 17;296:43-50. Epub 2019 Jul 17.

Cardio-Thoracic Surgery Dept., Heart & Vascular Centre, Maastricht University Medical Centre, and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands.

Background: Thrombocytopenia has been shown to occur soon after surgical biological aortic valve replacement (AVR), and recently reported also after transcatheter valve implantation (TAVI). The mechanism underlying this phenomenon is still unknown, and its clinical impact on the peri-operative outcome has been poorly investigated.

Methods: A systematic review and a meta-analysis of all available studies reporting data about peri-procedural thrombocytopenia on isolated bio-AVR, comparing rapid-deployment (RDV), stentless (stentless-AVR), and TAVI vs. stented (stented-AVR) valves, have been performed.

Results: Fifteen trials (2.163 patients) were included in the meta-analysis. Perioperative platelet reduction ranged from 35% to 55% in stented-AVR, from 60% to 77% in stentless-AVR, from 53% to 60% in RDV, and from to 21% to 72% in TAVI (apparently, balloon-expandable valves more frequently associated to thrombocytopenia). Stented-AVR required more red blood cells transfusion than stentless-AVR (P < 0.0001), whereas no difference has been found between RDV and stented-AVR. Platelet transfusion rate was very low in all surgical groups. No difference has been found in RDV and stentless-AVR vs. stented-AVR, in terms of reoperation for bleeding, and length-of-intensive care unit or hospital stay.

Conclusions: Thrombocytopenia-related major adverse events were mainly reported in TAVI patients, whereas clinically meaningless in surgical patients. Transient peri-procedural thrombocytopenia is common after bio-AVR, regardless of prosthesis's type or implant modality. It should receive appropriate monitoring and focused investigations.
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http://dx.doi.org/10.1016/j.ijcard.2019.07.056DOI Listing
December 2019

Perspective. Reoperative Bentall: choice of conduits.

Indian J Thorac Cardiovasc Surg 2019 Jun 13;35(Suppl 2):127-129. Epub 2017 Nov 13.

Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital Groby Road, Leicester, UK.

The Bentall procedure represents the gold standard in the treatment of patients requiring aortic root replacement. The most common indications for redo Bentall are structural degeneration or graft infection. Redo aortic root replacement can be performed with low perioperative morbidity and death. The choice of the best conduit is still up for debate but is mandatory to guarantee the best and most durable option for the patient. New options are available to reduce mortality in older or fragile patients and can modify the conduit choice.
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http://dx.doi.org/10.1007/s12055-017-0607-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525527PMC
June 2019

Bedside Emergency Percutaneous Extracorporeal Membrane Oxygenator with Bicaval Dual-Lumen Cannula.

Heart Surg Forum 2018 06 26;21(4):E290-E293. Epub 2018 Jun 26.

Cardiac Surgery Unit, University Magna Graecia of Catanzaro, V.le Europa, Germaneto, Catanzaro, Italy.

Background: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) support has emerged as a valuable rescue therapy in patients with severe acute lung failure. A new bicaval dual-lumen percutaneous cannula can be instituted with a single puncture of the right internal jugular vein under image guidance (fluoroscopy and/or trans-esophageal echocardiography) to support VV-ECMO. However, malpositioning of the dual-lumen catheter can jeopardize the efficacy of the ECMO therapy.

Case Report: We report an emergency VV-ECMO instituted at a patient's bedside in the intensive care unit. Percutaneous insertion of a dual lumen-cannula was performed on a young patient that had undergone cardiac surgery. The patient had developed a fulminant post-operative pneumonia, leading to respiratory failure and septic shock. The procedure was done at night, without any image guidance other than a post-insertion chest x-ray. We compared the oxygen saturation of arterial blood gas taken from both the outflow and inflow ECMO ends, and the saturations were used as indirect proof of correct cannula placement. The VV-ECMO was successfully removed after nine days, as the patient was clinically and radiologically recovered.

Conclusion: This case reports a dual-lumen cannula insertion in an emergency setting, with minimal image support. It confirms the efficacy and the safety of VV-ECMO in the treatment of post-operative acute respiratory failure.
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http://dx.doi.org/10.1532/hsf.1927DOI Listing
June 2018

Effects of cerebral near-infrared spectroscopy on the outcome of patients undergoing cardiac surgery: a systematic review of randomised trials.

BMJ Open 2017 Sep 7;7(9):e016613. Epub 2017 Sep 7.

Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK.

Objectives: Goal-directed optimisation of cerebral oxygenation using near-infrared spectroscopy (NIRS) during cardiopulmonary bypass is widely used. We tested the hypotheses that the use of NIRS cerebral oximetry results in reductions in cerebral injury (neurocognitive function, serum biomarkers), injury to other organs including the heart and brain, transfusion rates, mortality and resource use.

Design: Systematic review and meta-analysis.

Setting: Tertiary cardiac surgery centres in North America, Europe and Asia.

Participants: A search of Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature Plus from inception to November 2016 identified 10 randomised trials, enrolling a total of 1466 patients, all in adult cardiac surgery.

Interventions: NIRS-based algorithms designed to optimise cerebral oxygenation versus standard care (non-NIRS-based) protocols in cardiac surgery patients during cardiopulmonary bypass.

Outcome Measures: Mortality, organ injury affecting the brain, heart and kidneys, red cell transfusion and resource use.

Results: Two of the 10 trials identified in the literature search were considered at low risk of bias. Random-effects meta-analysis demonstrated similar mortality (risk ratio (RR) 0.76, 95% CI 0.30 to 1.96), major morbidity including stroke (RR 1. 08, 95% CI 0.40 to 2.91), red cell transfusion and resource use in NIRS-treated patients and controls, with little or no heterogeneity. Grades of Recommendation, Assessment, Development and Evaluation of the quality of the evidence was low or very low for all of the outcomes assessed.

Conclusions: The results of this systematic review did not support the hypotheses that cerebral NIRS-based algorithms have clinical benefits in cardiac surgery.

Trial Registration Number: PROSPERO CRD42015027696.
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http://dx.doi.org/10.1136/bmjopen-2017-016613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5595187PMC
September 2017

A computational fluid dynamics comparison between different outflow graft anastomosis locations of Left Ventricular Assist Device (LVAD) in a patient-specific aortic model.

Int J Numer Method Biomed Eng 2015 Feb 9;31(2). Epub 2015 Feb 9.

Bioengineering Unit, Magna Graecia University, Catanzaro, Italy.

Left ventricular assist devices (LVADs) are mechanical supports used in case of heart failure. Little is known as the height of the anastomosis in aorta might influence the hemodynamic. The aim of the study was to evaluate the fluid dynamic behavior due to the outflow graft placement of a continuous flow LVAD in ascending aorta and to identify the insertion site with the best hemodynamic profile. Computational fluid dynamic studies were carried out to analyze 4 different anastomosis locations in a patient-specific aorta 3D model coupled with a lumped parameters model: 1 cm (case 1), 2 cm (case 2), 3 cm (case 3) and 4 cm (case 4) above the ST junction. In cases 1 and 2, epiaortic vessels presented a steady flow, while in cases 3 and 4 the flow was whirling. Moreover, maximum velocity occurred before: brachiocephalic trunk (case 1), brachiocephalic and left carotid arteries (case 2), left carotid and left subclavian artery (case 3) and left subclavian vessel and upper wall of aortic arch (case 4). Maximum time averaged wall shear stress (TAWSS) was located in: the ascending aorta (cases 1 and 2), the inferior curvature of the arch (case 3); at the origin of epiaortic vessels (case 4). Furthermore, a flow recirculation (cases 1 and 2), a blood stagnation and chaotic flow (cases 3 and 4) occurred above the aortic valve. The results suggested that the placement of the outflow graft at 2 cm above the ST junction gave the most favorable hemodynamic profile.
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http://dx.doi.org/10.1002/cnm.2700DOI Listing
February 2015

Apicoaortic conduit and cerebral perfusion in mixed aortic valve disease: a computational analysis.

Interact Cardiovasc Thorac Surg 2013 Dec 20;17(6):950-5. Epub 2013 Aug 20.

Bioengineering Unit, Magna Graecia University, Catanzaro, Italy.

Objectives: The revival of the apicoaortic conduit has attracted new interest in this alternative treatment for severe aortic stenosis unsuitable for conventional valve replacement. However, doubts still exist about the perfusion of the epiaortic vessels after apicoaortic conduit implantation, especially when severe aortic stenosis is associated with aortic valve insufficiency. The aim of the study was to evaluate the perfusion of the epiaortic vessels (innominate artery, left carotid artery and left subclavian artery) in cases of mixed aortic valve disease before and after apicoaortic conduit implantation.

Methods: Starting from the data of a real patient with severe aortic stenosis and mild aortic insufficiency who underwent apicoaortic conduit implantation, we created a computational model where severe aortic valve stenosis was associated with different grades of aortic insufficiency (mild, medium and moderate).

Results: A total of six combinations were analysed. In all simulations, the more severe the concomitant aortic insufficiency, the more the flow through the epiaortic vessels was diminished. After apicoaortic conduit implantation, there was an absolute augmentation of the median output in each epiaortic vessel compared with the same combination of mixed aortic valve disease before implantation. Interestingly, retrograde flow from the conduit in the descending aorta was minimal and did not contribute to the improved output of the epiaortic vessels.

Conclusions: The computational analysis suggested a protective effect, rather than steal phenomenon, of the apicoaortic conduit towards the cerebral perfusion, even in cases of mixed aortic valve disease.
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http://dx.doi.org/10.1093/icvts/ivt379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3829496PMC
December 2013

Ventricular assist device driveline infection: treatment with platelet-rich plasma.

Ann Thorac Surg 2013 Aug;96(2):e37-8

Cardiac Surgery Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy.

We report a case of autologous platelet-rich plasma (PRP) application over the driveline site of a left ventricular assist device (LVAD) to treat an infection. The patient, a 47-year-old man with end-stage dilated cardiomyopathy, underwent Jarvik 2000 implantation through a median sternotomy. A pedestal with power supply and LVAD control was implanted into the mastoid bone. Retroauricular wound dehiscence occurred, and PRP was applied over the wound. Normal healing of the driveline exit site was observed. PRP can be used at a driveline exit site to either prevent or treat wound infection.
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http://dx.doi.org/10.1016/j.athoracsur.2013.01.093DOI Listing
August 2013

Ventricular assist device abdominal driveline infection: treatment with platelet-rich plasma.

J Thorac Cardiovasc Surg 2013 Jun 21;145(6):e69-70. Epub 2013 Mar 21.

Cardiac Surgery Unit, Magna Græcia University of Catanzaro, Catanzaro, Italy.

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http://dx.doi.org/10.1016/j.jtcvs.2013.02.072DOI Listing
June 2013

Late de novo aortic regurgitation with the Jarvik 2000 Flowmaker® left ventricular assist device.

Int J Artif Organs 2012 Dec;35(12):1080-2

Department of Cardiac Surgery, Magna Graecia University, 88100 Catanzaro, Italy.

Introduction: There is a worldwide trend towards a more liberal use of ventricular assist devices (VADs) as a definitive treatment for patients in end-stage heart failure. This has also led to a new set of complications related to the prolonged interaction between the native heart and the device.

Methods: We report a case of, late, de novo aortic regurgitation (AR), leading to acute pulmonary edema in a 56-year-old man, 20 months after the implantation of a left ventricular assist device (LVAD), the Jarvik 2000 Flowmaker®, as destination therapy for end-stage heart failure.

Results: The Jarvik 2000 was working well at check up at level 3 of assistance, i.e. generating a flow between 3-5 l/min at 10,000 rpm. The only new finding was a moderate, de novo, AR at trans-thoracic echocardiogram (TTE). The patient was assisted in intensive care with inotropic and diuretic support and made a good recovery. He remains under close follow up in NYHA class II with the same level of mechanical assistance and a more intensive diuretic therapy.

Conclusions: This case shows how dramatic the onset of de novo AR in patients with LVAD can be. The AR occurred despite the presence of the ILS (intermittent low speed) that allows the opening of the native aortic valve for 8 seconds every 64 and should, theoretically, preserve the native aortic valve. To our knowledge, this is the first report of de novo AR in a patient with the Jarvik 2000 axial flow device.
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http://dx.doi.org/10.5301/ijao.5000111DOI Listing
December 2012

What is the optimal anticoagulation in patients with a left ventricular assist device?

Interact Cardiovasc Thorac Surg 2012 Oct 3;15(4):733-40. Epub 2012 Jul 3.

Department of Cardiac Surgery, Magna Graecia University, Catanzaro, Italy.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there is an optimal antithrombotic management for patients supported with axial-flow left ventricular assist devices (LVADs). Altogether, more than 758 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. These included seven prospective and three retrospective cohort studies with a total of 538 patients with axial-flow left ventricular assist device (LVAD) (HeartMate II, Jarvik 2000, INCOR, Thoratec assist device) implanted across the world as destination therapy or bridge to transplantation. We conclude that there is a substantial alteration of the prothrombotic profile in patients with axial-flow LVADs. These abnormalities appeared to be reversible with the removal of the device and are likely to be responsible for the high incidence of non-surgical bleeding episodes reported. Warfarin seems to offer a lower thromboembolic risk compared with unfractioned heparin or low molecular weight heparin. There are reports that suggest that managing axial-flow LVAD without anticoagulation, after major bleeding complications, is possible but in all probability, these papers are subject to publication bias as poor outcomes are unlikely to have been reported. All patients with axial-flow LVAD, showed severely impaired platelet function at point of care tests. The use of warfarin (INR target 2.5), in association with aspirin at 100 mg/day, or with point-of-care tests titrated antiplatelet therapy to inhibit 70%, seems to have the best bleeding-thrombosis, and in many cases a very small dose of aspirin of 25 mg twice a day and a dose of clopidogrel of 35 mg/day, were sufficient to achieve a reduction of the maximum aggregation to less than 30%. Finally, we would like to emphasize that such recommendations are addressed only to patients with axial-flow LVAD.
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http://dx.doi.org/10.1093/icvts/ivs297DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445379PMC
October 2012

What do you do with the antiplatelet agents in patients with drug eluting stents who then receive a mechanical valve?

Interact Cardiovasc Thorac Surg 2012 Jul 28;15(1):115-21. Epub 2012 Mar 28.

Department of Cardiac Surgery, Magna Graecia University, Catanzaro, Italy.

Dual antiplatelet therapy (DAT) with aspirin and clopidogrel is a cornerstone of treatment during and after percutaneous coronary interventions with drug-eluting stent (DES) implantation. Oral anticoagulation (OAC) is the recommended treatment for patients with mechanical heart valves. When patients with DES need a mechanical heart valve or vice versa, we face the difficult choice of their antithrombotic therapy. Different institutions empirically follow a combination of OAC and single or DAT, the so-called triple antithrombotic therapy (TT) aiming to find the best balance between the thrombotic and bleeding risk for this subset of patients. A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there is an optimal antithrombotic management for patients with DES undergoing mechanical heart valve or vice versa. Altogether, more than 148 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that DES implantation in patients who could potentially need valve surgery in the future should be discouraged and bare-metal stent or an aortic bioprosthesis preferred. However, in high-risk patients with DES, the recommendation is to postpone elective surgery for 1 year and, if surgery cannot be deferred, continue aspirin during the perioperative period. Moreover, when OAC is given in combination with clopidogrel and/or low-dose aspirin, the target INR should be 2.0-2.5 (Class IIb, level of evidence C). As per the long-term management, antithrombotic management with DAT alone in mechanical aortic valve replacement might be possible, but there is not enough evidence to support it. The available evidence suggests that triple anticoagulation (OAC + DAT) is associated with the best clinical outcome compared with all the other possible strategies. The duration of TT should be 3 months after sirolimus DES implantation, and 6 months after paclitaxel DES implantation, followed by long-term therapy with OAC plus clopidogrel or aspirin with either PPIs, or H2-receptor antagonists (Class IIa Level of Evidence C).
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http://dx.doi.org/10.1093/icvts/ivs104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3380982PMC
July 2012

Pulsatile cardiopulmonary bypass with intra-aortic balloon pump improves organ function and reduces endothelial activation.

Circ J 2012 7;76(5):1121-9. Epub 2012 Mar 7.

Cardiac Surgery Unit, University of Magna Graecia, Campus “S.Venuta”, Viale Europa, 88100 Catanzaro, Italy.

Background: We aimed to evaluate if the use of an intra-aortic balloon pump (IABP) during cardioplegic arrest improves organ function and reduces endothelial activation in patients undergoing coronary artery bypass graft (CABG).

Methods And Results: Five-hundred and one CABG patients were randomized into 2 groups: (Group A n=270) linear cardiopulmonary bypass (CPB); and (Group B n=231) automatic 80 beats/min IABP-induced pulsatile CPB. We evaluated hemodynamic response, coagulation and fibrinolysis, transaminase, bilirubin, amylase, lactate, renal function (estimated glomerular filtration rate [eGFR], creatinine and any possibility of renal insufficiency or failure), respiratory function and endothelial markers (vascular endothelial growth factor [VEGF] and monocyte chemotactic protein-1 [MCP-1]). IABP, which induced surplus hemodynamic energy, was 21,387 ± 4,262 ergs/cm(3). Group B showed lower chest drainage, transfusions, international normalized ratio, and antithrombin III, together with higher platelets, activated partial thromboplastin time, fibrinogen and D-dimer. Transaminases, bilirubin, amylase, lactate were lower in Group B; there were better results for eGFR in Group B from ICU-arrival to 48 h, resulting in lower creatinine from ICU-arrival to 48 h. The necessity for renal replacement therapy was lower in Group B Stage-3. Group B P(a)O(2)/F(i)O(2) and lung compliance improved with aortic de-clamping on the first day with shorter intubation time. Group B showed lower VEGF and MCP-1.

Conclusions: Pulsatile flow by IABP improves whole-body perfusion and reduces endothelial activation during CPB.
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http://dx.doi.org/10.1253/circj.cj-11-1027DOI Listing
August 2012

Neurohormonal and echocardiographic results after CorCap and mitral annuloplasty for dilated cardiomyopathy.

Ann Thorac Surg 2009 Sep;88(3):719-25

Cardiac Surgery Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy.

Background: Restrictive mitral annuloplasty (RMA) can be an effective treatment for functional mitral regurgitation in congestive heart failure (CHF). Passive cardiac restraint is another surgical approach, but the midterm results are not well characterized.

Methods: Thirty patients with functional mitral regurgitation were prospectively randomized to RMA alone or cardiac restraint with the CorCap Cardiac Support Device (Acorn Cardiovascular Inc, St. Paul, MN) and RMA. Clinical, echocardiographic, New York Heart Association (NYHA) functional class, Short Form 36-Item Health Survey (SF-36) quality of life scores, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) results were analyzed.

Results: No hospital deaths or device-related complications occurred. The two groups had comparable morbidity (p = 0.34). Echocardiography showed a trend towards a slightly better functional improvement during follow-up in CorCap plus RMA patients (between groups, p = 0.001). Both groups showed improved results for SF-36, NYHA, and NT-pro.BNP; however, CorCap plus RMA patients had significantly better SF-36 at discharge (p = 0.003), postoperative NYHA (p = 0.05), and NT-pro.BNP (p = 0.001). Survival (p = 0.46), freedom from CHF (p = 0.23), and rehospitalization (p = 0.28) were comparable. Patients in whom CHF developed after postoperative day 1 had higher NT-pro.BNP values (p = 0.001 at all time-points).

Conclusions: Adjunctive application of CorCap with RMA correlated with better NT-pro.BNP at short-term follow-up together with slightly improved echocardiographic and functional results. This deserves further evaluation at midterm and long-term follow-up. Reduction of NT-pro.BNP at follow-up may be suggested as a prognostic index.
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http://dx.doi.org/10.1016/j.athoracsur.2009.05.050DOI Listing
September 2009