Federico Pappalardo

San Raffaele Scientific Institute, Milano, Lombardy, Italy

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Publications (105)220.16 Total impact

  • International journal of cardiology. 11/2014; 180C:199-202.
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    ABSTRACT: Italy is a country with high rates of immigration and the knowledge of immigrant health is very fragmentary. We provide a current picture of cardiovascular disease causes and clinical outcomes following heart surgery. A clinical and echocardiographic survey was conducted on 154 consecutive immigrants referred for heart surgery to San Raffaele Hospital in Milan between 2003 and 2011. Major causes of heart disease were rheumatic heart disease (RHD) (n = 64, 41%), nonrheumatic valvulopathies (n = 41, 27%), ischemic heart disease (IHD) (n = 25, 16%), congenital heart disease (n = 13, 9%) and miscellaneous (n = 11, 7%). Median age was 49 years [interquartile range (IQR) 7-81]; 55% of patients were male. Among valvulopathies, rheumatic mitral disease was predominant (n = 56, 53%) as both single and multivalvular disease (n = 46, 73%); myxomatous prolapse emerged as the second main pattern of mitral disease (n = 30, 33%). Among patients with IHD, 72% had a high cardiovascular risk. Surgery was scheduled in 138 patients (90%). Clinical follow-up was available in 96 patients (62%) [median time 62 months (IQR 15-123)], among whom 92 (96%) were alive, four patients (4%) had died and 58 (38%) were lost. Cardiovascular diseases represent a major health topic among immigrants in developed countries. RHD still is the predominant cause of hospitalization for heart surgery, nonrheumatic valvulopathies and IHD emerging as second and third causes, respectively. Data underline the need of reinforcement of prevention and care strategies in the matter of immigrant health and warrant the urgent attention of the international public health and research communities.
    Journal of cardiovascular medicine (Hagerstown, Md.). 11/2014;
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    ABSTRACT: Despite the consistent clinical data on the positive effects of LVADs in the treatment of refractory heart failure, unfortunately these devices yet show some limitations such as the risk of stroke, infection and device malfunction. The complex interplay between blood and the foreign material has a major role in the occurrence of these complications and biocompatibility of the inflow cannula would be pivotal in these terms. In the present study we carried out an in-depth physicochemical characterization of two commercially available LVADs by means of field emission gun scanning electron microscopy, energy dispersive X-ray and X-ray photoelectron spectra. Our results show that, despite both pumps share the same physicochemical concepts, major differences can be identified in the surface nature, morphology and chemical composition of their inflow cannulas.
    ASAIO journal (American Society for Artificial Internal Organs: 1992) 11/2014; · 1.39 Impact Factor
  • International journal of cardiology. 11/2014;
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    ABSTRACT: IMPORTANCE No effective pharmaceutical agents have yet been identified to treat acute kidney injury after cardiac surgery. OBJECTIVE To determine whether fenoldopam reduces the need for renal replacement therapy in critically ill cardiac surgery patients with acute kidney injury. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, double-blind, placebo-controlled, parallel-group study from March 2008 to April 2013 in 19 cardiovascular intensive care units in Italy. We randomly assigned 667 patients admitted to intensive care units after cardiac surgery with early acute kidney injury (Ն50% increase of serum creatinine level from baseline or oliguria for Ն6 hours) to receive fenoldopam (338 patients) or placebo (329 patients). We used a computer-generated permuted block randomization sequence for treatment allocation. All patients completed their follow-up 30 days after surgery, and data were analyzed according to the intention-to-treat principle. INTERVENTIONS Continuous infusion of fenoldopam or placebo for up to 4 days with a starting dose of 0.1 μg/kg/min (range, 0.025-0.3 μg/kg/min).
    JAMA. 09/2014;
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    ABSTRACT: Objectives Because of its reduced invasiveness, MitraClip (Abbott Vascular, Menlo Park, CA) therapy usually is reserved for patients with extreme left ventricular dysfunction or severe comorbidity contraindicating surgery. The appropriate post-procedural care in this high-risk population is yet to be defined. In this study, the postoperative course of such patients is reported, focusing on early complications and need for intensive care unit (ICU) management. Design, Setting, and Participants A retrospective analysis of patients with severe mitral regurgitation undergoing transcatheter mitral valve repair with the MitraClip system in the authors institution was performed. Interventions One hundred thirty patients underwent MitraClip implantation between 2008 and 2012. At the end of the procedure, all patients were admitted to the ICU. Measurements and Main Results Median ICU stay was 0.98 (0.82-1.87) days. Median mechanical ventilation time was 9.5 (6.8-14.1) hours. One hundred one patients (78%) required inotropic support and 13 patients (10%) suffered cardiogenic shock and required intra-aortic balloon pump support. No patient died during the procedure, but 3 patients died in the ICU. Three postoperative course profiles were identified: Fast-track, overnight stay, and critical illness. Twenty-four patients (18.5%) had an uneventful postoperative course, 89 patients (68.5%) suffered minor complications, and 17 patients (13.1%) required intensive care management and organ support. Preoperative serum creatinine (odds ratio [OR] 1.8; p = 0.014), cardiogenic shock (OR 34,8; p = 0.002), ventricular tachycardia (OR 2.8; p = 0.03), and intra procedural inotropes (OR 4; p = 0.001) were correlated with a complicated postoperative course. Conclusions A large number of patients undergoing MitraClip could be managed with a fast-track ICU course; however, it still is difficult to predict the postoperative course based on preoperative characteristics.
    Journal of Cardiothoracic and Vascular Anesthesia. 09/2014;
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    ABSTRACT: To assess the long-term results of the edge-to-edge mitral repair performed without annuloplasty in degenerative mitral regurgitation (MR).
    Circulation 09/2014; 130(11 Suppl 1):S19-24. · 15.20 Impact Factor
  • Simona Silvetti, Andreas Koster, Federico Pappalardo
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    ABSTRACT: Blood contact with surfaces of the extracorporeal circuit provokes the activation of the coagulation system. To improve biocompatibility of the extracorporeal circuit without increasing the risk of bleeding, coatings of artificial surfaces were designed; many of them involve the use of heparin. Data in the literature show that heparin-induced thrombocytopenia is a major issue in the extracorporeal membrane oxygenation scenario, and no relevant benefits have been shown comparing heparin and no-heparin coating.
    Artificial Organs 08/2014; · 1.96 Impact Factor
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    ABSTRACT: Afterload mismatch, defined as acute impairment of left ventricular function after mitral surgery, is a major issue in patients with low ejection fraction and functional mitral regurgitation (FMR). Safety and efficacy of MitraClip therapy have been assessed in randomized trials, but limited data on its acute hemodynamic effects are available. This study aimed to investigate the incidence and prognostic role of afterload mismatch in patients affected by FMR treated with MitraClip therapy. We retrospectively analyzed patients affected by FMR and submitted to MitraClip therapy from October 2008 to December 2012. Patients were assigned to 2 groups according to the occurrence of the afterload mismatch: patients with afterload mismatch (AM+) and without afterload mismatch (AM-). Of 73 patients, 19 (26%) experienced afterload mismatch in the early postoperative period. Among preoperative variables, end-diastolic diameter (71 ± 8 vs 67 ± 7 mm, p = 0.02) and end-systolic diameter (57 ± 9 vs 53 ± 7 mm, p = 0.04) were both significantly larger in AM+ group. An increased incidence of right ventricular dysfunction (68% vs 31%, p = 0.049) and pulmonary hypertension (49 ± 10 vs 40 ± 10 mm Hg, p = 0.0009) was found in AM+ group. Before hospital discharge, left ventricular ejection fraction (LVEF) became similar in both groups (31 ± 9% vs 33 ± 11%, p = 0.65). Long-term survival was comparable between the 2 groups (p = 0.44). A low LVEF in the early postoperative period (LVEF <17%) was significantly associated with higher mortality rate in long-term follow-up (p = 0.048). In conclusion, reduction of mitral regurgitation with MitraClip can cause afterload mismatch; however, this phenomenon is transient, without long-term prognostic implications.
    The American journal of cardiology. 06/2014; 113(11):1844-50.
  • Resuscitation 04/2014; · 4.10 Impact Factor
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    ABSTRACT: To assess the very long-term clinical and echocardiographic results of the edge-to-edge repair for mitral regurgitation (MR) due to isolated prolapse or flail of the anterior leaflet. From 1991 to 2004, 139 patients (age, 54 ± 14.4 years; left ventricular ejection fraction 56% ± 7.8%, New York Heart Association class I-II in 68.9%, atrial fibrillation in 20.1%) with severe degenerative MR due to isolated segmental prolapse or flail of the anterior leaflet were treated with the EE technique combined with annuloplasty. MR had resulted from prolapse or flail of the central scallop of the anterior leaflet (A2) in 105 patients (75.5%) and scallops A1 or A3 in 34 (24.4%). No hospital deaths occurred. At hospital discharge, MR was absent or mild in 130 patients (93.5%) and moderate (2+/4+) in 9 (6.4%). The clinical and echocardiographic follow-up data were 97.1% complete (mean length, 11.5 ± 3.73 years; median, 11; longest duration, 21.5). At 17 years, the actuarial survival was 72.4% ± 7.89%, freedom from cardiac death was 90.8% ± 4.77%, and freedom from reoperation was 89.6% ± 2.74%. At the last echocardiographic examination, recurrence of MR grade ≥3+ was documented in 17 patients (17 of 135, 12.5%). Freedom from MR grade ≥3+ at 17 years was 80.2% ± 5.86%. At multivariate analysis, the predictors of MR recurrence grade ≥3+ were residual MR greater than mild at hospital discharge (hazard ratio, 7.4; 95% confidence interval, 2.5-21.2; P = .0001) and the use of posterior pericardial rather than prosthetic ring annuloplasty, which was very close to statistical significance (hazard ratio, 2.8; 95% confidence interval, 0.9-8.7; P = .06). In patients with MR due to segmental anterior leaflet prolapse, the very long-term results of the edge-to-edge repair combined with annuloplasty were excellent.
    The Journal of thoracic and cardiovascular surgery 03/2014; · 3.41 Impact Factor
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    Federico Pappalardo, Enrico Ammirati, Stefano Ferrari
    Giornale italiano di cardiologia (2006) 03/2014; 15(3):133-7.
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    ABSTRACT: Anticoagulation with unfractionated heparin (UFH) in critically ill cardiac surgery patients has several limitations, including the risk of heparin-induced thrombocytopenia. The use of a direct thrombin inhibitor, such as bivalirudin, might either treat this complication or completely eliminate it. The aim of the present study was to analyze the use of bivalirudin in this setting, as either a secondary drug switching from heparin or as the primary anticoagulant, and to evaluate clinical outcomes. Propensity-matching retrospective analysis. A cardiac surgery intensive care unit. One hundred propensity-matched patients who received heparin or bivalirudin. Bivalirudin was administered as a first-line or second-line drug after heparin discontinuation in case of thrombocytopenia and suspicion of heparin-induced thrombocytopenia. Twenty-six patients (52%) received bivalirudin as a primary anticoagulant, while 24 patients (48%) received bivalirudin after switching from heparin. Bivalirudin treatment was associated with a reduction of major bleeding (p = 0.05) compared with the control group. Interestingly, in an intention-to-treat analysis, patients receiving primary bivalirudin showed significant reductions in minor bleeding (p = 0.04), and mortality (p = 0.01) compared with the secondary bivalirudin group and, similarly, compared with the rest of the study population (UFH and secondary bivalirudin patients, p = 0.01 and p = 0.05, respectively). Predictors of hospital mortality by multivariate analysis included urgent admission (odds ratio [OR] = 2.7; 95 confidence interval [CI], 1.03-7.2; p = 0.04), ;septic shock (OR = 8.0; 95 CI, 2.26-28.7; p<0.005) and primary therapy with UFH (OR = 19.2; 95 CI, 2.2-163.9; p = 0.007). Novel anticoagulant strategies might play a crucial role in critically ill cardiac surgery patients. In a propensity-matched population, results of the present study showed that primary bivalirudin anticoagulation may reduce bleeding complications and mortality.
    Journal of cardiothoracic and vascular anesthesia 01/2014; · 1.06 Impact Factor
  • Resuscitation 01/2014; · 4.10 Impact Factor
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    ABSTRACT: To investigate the ability of early urinary neutrophil gelatinase-associated lipocalin to predict postoperative complications in adult patients with ventricular dysfunction undergoing cardiac surgery. Prospective observational study. Single-center study, university hospital. Fifty-six adult high-risk cardiac surgical patients with preoperative cardiac failure. None. Demographic and clinical characteristics were obtained, and neutrophil gelatinase-associated lipocalin was measured at baseline and at several time points after surgery. Patient characteristics and neutrophil gelatinase-associated lipocalin levels were related to renal and patient outcome. On multivariate analyses, preoperative urinary neutrophil gelatinase-associated lipocalin was an independent predictor of length of intensive care stay (p = 0.004) and in-hospital stay (p = 0.04), but not of acute kidney injury or renal replacement therapy and was not associated with baseline renal function. In a cohort of high-risk cardiac surgery patients, preoperative urinary neutrophil gelatinase-associated lipocalin value provided prognostic information that was independent of the onset of acute kidney injury or of preoperative renal function.
    Journal of cardiothoracic and vascular anesthesia 11/2013; · 1.06 Impact Factor
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    ABSTRACT: Bivalirudin is a direct thrombin inhibitor that is increasingly used in patients undergoing mechanical circulatory support as it presents many advantages compared with unfractionated heparin. The aim of this study was to describe our experience with bivalirudin as primary anticoagulant in patients undergoing ventricular assist device (VAD) implantation. An observational study was performed on 12 consecutive patients undergoing VAD implantation at our institution. Patients received a continuous infusion of bivalirudin, with a starting dose of 0.025 µg/kg/h; the target activated partial thromboplastin time (aPTT) was between 45 and 60 s. Patients never received heparin during hospitalization nor had a prior diagnosis of heparin-induced thrombocytopenia (HIT). All patients received a continuous flow pump except one. Preoperative platelets count was 134 000 ± 64 000 platelets/mm(3) . Mean bivalirudin dose was 0.040 ± 0.026 mg/kg/h over the course of therapy (5-12 days). Lowest platelets count during treatment was 73 000 ± 23 000 platelets/mm(3) . No thromboembolic complications occurred. Two episodes of minor bleeding from chest tubes that subsided after reduction or temporary suspension of bivalirudin infusion were observed. Intensive care unit stay was 8 (7-17) days, and hospital stay was 25 (21-33) days. Bivalirudin is a valuable option for anticoagulation in patients with a VAD and can be easily monitored with aPTT. The use of a bivalirudin-based anticoagulation strategy in the early postoperative period may overcome many limitations of heparin and, above all, the risk of HIT, which is higher in patients undergoing VAD implantation. Bivalirudin should no longer be regarded as a second-line therapy for anticoagulation in patients with VAD.
    Artificial Organs 09/2013; · 1.96 Impact Factor
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    ABSTRACT: To comprehensively assess published peerreviewed studies related to extracorporeal membrane oxygenation (ECMO), focusing on outcomes and complications of ECMO in adult patients. Systematic review and meta-analysis. MEDLINE/PubMed was searched for articles on complications and mortality occurring during or after ECMO. Included studies had more than 100 patients receiving ECMO and reported in detail fatal or nonfatal complications occurring during or after ECMO. Primary outcome was mortality at the longest follow-up available; secondary outcomes were fatal and non-fatal complications. Twelve studies were included (1763 patients), mostly reporting on venoarterial ECMO. Criteria for applying ECMO were variable, but usually comprised acute respiratory failure, cardiogenic shock or both. After a median follow-up of 30 days (1st-3rd quartile, 30-68 days), overall mortality was 54% (95% CI, 47%-61%), with 45% (95% CI, 42%-48%) of fatal events occurring during ECMO and 13% (95% CI, 11%-15%) after it. The most common complications associated with ECMO were: renal failure requiring continuous venovenous haemofiltration (occurring in 52%), bacterial pneumonia (33%), any bleeding (33%), oxygenator dysfunction requiring replacement (29%), sepsis (26%), haemolysis (18%), liver dysfunction (16%), leg ischaemia (10%), venous thrombosis (10%), central nervous system complications (8%), gastrointestinal bleeding (7%), aspiration pneumonia (5%), and disseminated intravascular coagulation (5%). Even with conditions usually associated with a high chance of death, almost 50% of patients receiving ECMO survive up to discharge. Complications are frequent and most often comprise renal failure, pneumonia or sepsis, and bleeding.
    Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine 09/2013; 15(3):172-8. · 1.51 Impact Factor
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    ABSTRACT: Activated protein C is associated with a risk of bleeding and its effects on survival in septic shock patients are questionable. Protein C zymogen has no risk of bleeding and improves the outcome of patients with septic shock. We hereby describe the largest published case series of adult patients receiving protein C zymogen. A prospective study on 23 adult patients with severe sepsis or septic shock, two or more organ failures and at high risk for bleeding, treated with protein C zymogen (50IU/kg bolus followed by continuous infusion of 3IU/kg/h for 72h). The Z-test evidenced a significant reduction between the expected mortality (53%) and the observed mortality 30% (Z value=1.99, p=0.046) in our sample population. Protein C levels increased from 34±18% to 66±22% at 6h after PC bolus (p<0.001), and kept on increasing during 72h of administration (p<0.001 to baseline). Sequential Organ Failure Assessment (SOFA), score of organ dysfunction, decreased from baseline to 7 days after administration of protein C from 14±2 to 7±4 (p<0.001). No adverse event drug related was noted. Protein C zymogen administration is safe and its use in septic patients should be investigated through a randomized controlled trial.
    Medicina Intensiva 07/2013; · 1.32 Impact Factor
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    ABSTRACT: The Levitronix CentriMag is approved in Europe for 30 days as uni- or biventricular support in acute heart failure as a bridge to recovery, bridge to heart transplantation or to a long-term left ventricular assist device (LVAD). We report the case of a patient who was supported with the same Levitronix CentriMag pump for 119 days without changing any components of the circuit or the pump head because of an anatomical condition which precluded the feasibility of pump exchange and who did not experience any mechanical failure of the impeller but eventually died due to the rupture of the cannulae. This is the first report of failure of paracorporeal short-term LVAD due to disruption of one cannula with a properly functioning pump. doi: 10.1111/jocs.12149 (J Card Surg 2013;28:472-474).
    Journal of Cardiac Surgery 07/2013; 28(4):472-4. · 1.35 Impact Factor
  • Journal of cardiothoracic and vascular anesthesia 06/2013; · 1.06 Impact Factor