Antonio Spitaleri

Thrombotic complications during mechanical circulatory support (MCS) are infrequent but potentially devastating, often presenting prohibitive surgical risks. We report the case of a patient bridged with veno-arterial extracorporeal life support (V-A ECLS) and Impella CP, known as ECPELLA support, to HeartMate 3 left ventricular assist device (LVAD) and subsequent temporary right ventricular assist device (RVAD) implantation for severe biventricular failure. Postoperatively, despite therapeutic anticoagulation, a massive, mobile thrombus, most likely originating during ECPELLA support, was identified in the descending aorta. Given the patient’s critical hemodynamic stability on biventricular support and specific contraindications to systemic fibrinolysis (subacute cerebral lesions), open surgical thrombectomy was deemed too high-risk. Consequently, the patient underwent urgent percutaneous mechanical thrombectomy using the Inari FlowTriever system. The procedure, facilitated by a simultaneous, temporary reduction of both LVAD and RVAD flows to stabilize the thrombus position and maximize vacuum efficiency, resulted in the complete removal of a 14 cm thrombus without embolization or hemorrhagic complications. This report demonstrates that catheter-based aspiration thrombectomy can serve as a viable salvage strategy in complex MCS scenarios. It offers a crucial, minimally invasive alternative when conventional surgical and pharmacological options are precluded. Export

Introduction: Left ventricular assist device (LVAD) therapy may lead to an aortic regurgitation, limiting left ventricular unloading and causing adverse events. Whether concomitant aortic valve replacement may improve outcomes in patients with preoperative mild‐to‐moderate aortic regurgitation remains unclear.Methods: A retrospective propensity score‐matched analysis of adult patients with preoperative mild‐to‐moderate aortic regurgitation undergoing durable LVAD implantation between 01/01/2011 and 30/11/2021 was performed. Patients undergoing concomitant valve surgery other than biological aortic valve replacement were excluded, resulting in 77 with concomitant biological aortic valve replacement and 385 without.Results: Following 1:1 propensity score matching, two groups of 55 patients with and without biological aortic valve replacement were obtained, (mean age 59 ± 11 years, 92% male, 59.1% HeartWare). Aortic regurgitation was mild in 72.7% and 76.4% and moderate in 27.3% and 23.6% in non‐replacement and replacement cohorts respectively. The 30‐day survival was 89.1% vs. 85.5% (p = 0.59), 1‐year survival 69.1% vs. 56.4% (p = 0.19), and 2‐year survival 61.8% vs. 47.3% (p = 0.10) in the non‐replacement and replacement groups, respectively. After a mean follow‐up of 1.2 years, non‐replacement patients had a higher incidence of pump thrombosis (11 [20%] vs. 3 [5.5%], p = 0.022) and fewer major bleedings (2 [3.6%] vs. 11 [20%], p = 0.008).Conclusion: Compared with those treated conservatively, patients with mild‐to‐moderate aortic regurgitation undergoing concomitant aortic valve replacement during LVAD implantation have a similar survival up to 2 years on support. Patients with concomitant valve replacement had a higher risk of bleeding complications but fewer pump thromboses.

Background: Stroke after durable left ventricular assist device (d‐LVAD) implantation portends high mortality. The incidence of ischemic and hemorrhagic stroke and the impact on stroke outcomes of temporary mechanical circulatory support (tMCS) management among patients requiring bridge to d‐LVAD with micro‐axial flow‐pump (mAFP, Abiomed) is unsettled.Methods: Consecutive patients, who underwent d‐LVAD implantation after being bridged with mAFP at 19 institutions, were retrospectively included. The incidence of early ischemic and hemorrhagic stroke after d‐LVAD implantation (p = 0.015), hemolysis on mAFP support (HR 10.5, 95% CI 1.3–85.3, p = 0.028) and ECMELLA at d‐LVAD implantation (HR 5.0, 95% CI 1.4–18.7, p = 0.016) were associated with increased risk of hemorrhagic stroke after d‐LVAD implantation. Both early ischemic (HR 2.7, 95% CI 1.9–4.5, p < 0.001) and hemorrhagic (HR 3.43, 95% CI 1.49–7.88, p = 0.004) stroke were associated with increased 1‐year mortality.Conclusions: Among patients undergoing d‐LVAD implantation following mAFP support, tMCS characteristics do not impact ischemic stroke occurrence, while several factors are associated with hemorrhagic stroke suggesting a proactive treatment target to reduce this complication.

Mitral annular calcification is a chronic and degenerative process of the fibrous base of the mitral valve. Surgical management of mitral valve dysfunction with severe annular calcification remains technically demanding and, to date, the preferred approach is still a standard full sternotomy. We aimed to analyze and report our experience with mitral valve surgery addressing annular calcification via the minimally invasive approach through a right mini-thoracotomy. Data of patients with mitral valve disease and underlying annular calcification undergoing minimally invasive surgery from 2018 to 2022 were prospectively collected and retrospectively analyzed. The severity of mitral annular calcification was categorized with an angio-computerized tomography scan analysis as mild, moderate or severe according to calcium thickness, calcium distribution, and trigone and leaflet involvement using the Mitral Annular Calcification Computerized Tomography-score. During the study period, 27 patients with mitral valve disease and associated mitral annular calcification were enrolled. The most common etiology was advanced Barlow’s disease, which was encountered in 18 cases (67%). Mitral valve replacement was performed in 21 patients (78%). No intraoperative death, atrioventricular disruption, or circumflex coronary artery injury occurred. Conversion to sternotomy was necessary in a single case. Residual moderate periprosthetic leak requiring early reoperation and permanent heart block mandating permanent pacemaker implantation were reported in one and in three patients, respectively. No cases of stroke were reported. Two patients died, accounting for a 7.4% perioperative mortality. At a median follow-up of 9 months, one patient had residual moderate mitral regurgitation, whereas two patients required short-term reoperation and prosthetic valve (re)replacement. Minimally invasive mitral valve surgery via right mini-thoracotomy should be considered an and effective approach to be indicated also in patients with mild-to-severe mitral annular calcification. Routine angio-computerized tomography scan during work-up is a mandatory step to stratify the anatomical extension and severity of the mitral annular calcification.