Federico Pappalardo

San Raffaele Scientific Institute, Milano, Lombardy, Italy

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Publications (118)333.65 Total impact

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    ABSTRACT: To determine if percutaneous tracheostomy is safe in critically ill patients treated with anticoagulant therapies. Single-center retrospective study including all the patients who underwent percutaneous dilatational tracheostomy (PDT) placement over a 1-year period in a 14-bed, cardiothoracic and vascular Intensive Care Unit (ICU). Patients demographics and characteristics, anticoagulant and antiplatelet therapies, coagulation profile, performed technique and use of bronchoscopic guidance were retrieved. Thirty-six patients (2.7% of the overall ICU population) underwent PDT over the study period. Twenty-six (72%) patients were on anticoagulation therapy, 1 patient was on antiplatelet therapy and 2 further patients received prophylactic doses of low molecular weight heparin. Only 4 patients had normal coagulation profile and were not receiving anticoagulant or antiplatelet therapies. Overall, bleeding of any severity complicated 19% of PDT. No procedure-related deaths occurred. PDT was proved to be safe even in critically ill-patients treated with anticoagulant therapies. Larger prospective studies are needed to confirm our findings.
    Annals of Cardiac Anaesthesia 07/2015; 18(3):329-34. DOI:10.4103/0971-9784.159802
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    ABSTRACT: Venovenous extracorporeal membrane oxygenation (VV ECMO) in acute respiratory distress syndrome (ARDS) is currently a widely used therapeutic strategy. However, patients are often still hypoxemic despite complete ECMO support. The major determinants of peripheral oxygen saturation (SpO2) during VV ECMO are pump flow, degree of recirculation, patient's systemic venous return and its oxygen saturation, hemoglobin concentration and residual lung function. Current guidelines state that the support can be considered adequate when the patient's SpO2 is equal or greater than 80%, but a possible objection could be that such a value of O2-tension may be too low and may worsen the patient's prognosis. Moving from the pathophysiology of hypoxemia during VV ECMO, this review focuses on recirculation of blood and on the possible strategies to minimize it, on the pharmacologic modulation of intrapulmonary shunt and on the questions related to management of ECMO flow and the risks and benefits of permissive hypoxemic states. Transfusional strategy during VV ECMO, administration of neuromuscular blocking agents and sedatives, therapeutic hypothermia, and prone positioning is also reviewed. The potential advantages of β-blockers are discussed. Finally, transition from VV ECMO to venoarterial ECMO (VA ECMO) or a hybrid configuration is also examined.
    ASAIO journal (American Society for Artificial Internal Organs: 1992) 05/2015; 61(3):227-36. DOI:10.1097/MAT.0000000000000207 · 1.39 Impact Factor
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    ABSTRACT: Dear Editor,The recent availability of the Avalon Elite® bicaval dual lumen catheter offers a potentially less invasive approach for the extracorporeal membrane oxygenation (ECMO) treatment of severe respiratory insufficiency as compared to the femorojugular approach [1]. Nevertheless, Avalon cannula placement is more demanding and no data have been published about its effectiveness in improving oxygenation and safety concerning hemolysis, which is also an important issue, being reported in 27 % of ECMO patients [2].In the last 2 years, we systematically adopted the bicaval dual lumen jugular approach for venovenous (VV)-ECMO treatment. Data about oxygenation and hemolysis have been collected and compared with an historical group of patients treated with the femorojugular approach (Table 1).Patients were supported with ECMO in case of severe hypoxia refractory to conventional treatment. During cannulation and 6 h after, patients were sedated. After cannulation, a respiratory rate of 10 ...
    Intensive Care Medicine 03/2015; 41(5). DOI:10.1007/s00134-015-3740-2 · 7.21 Impact Factor
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    ABSTRACT: To compare the surgical and percutaneous edge-to-edge (EE) repair in patients with severe left ventricular (LV) dysfunction and secondary mitral regurgitation (MR). We reviewed the prospectively collected data of the first 120 consecutive patients (age: 65 ± 9.8 years, EF: 28 ± 8.2%) treated with surgical (65 patients) or percutaneous (55 patients) EE repair for severe secondary MR in our institution. Age (P = 0.005) and logistic European System for Cardiac Operative Risk Evaluation (P < 0.0001) were significantly higher in the MitraClip group. LVEF (P = 0.37), end-diastolic (P = 0.83) and end-systolic (P = 0.68) volumes and systolic pulmonary artery pressure (SPAP) (P = 0.58) were similar. The follow-up was 100% complete [median: 4 years; interquartile range (IQR): 2.2-7.2]. The length of hospital stay was 10 days (IQR: 8-13) for surgery and 5 days (IQR: 3.9-7.8) for MitraClip (P < 0.0001). Hospital mortality (3 vs 0%, P = 0.49) and freedom from cardiac death at 4 years (80.8 ± 4.9% vs 79.1 ± 5.9%, P = 0.9) were not significantly different in the surgical and MitraClip group, respectively. Residual MR ≥ 2+ at hospital discharge was 7.6% for surgery and 29% for MitraClip (P = 0.002). At 4 years, freedom from MR ≥ 2+ (74.9 ± 5.6% vs 51.4 ± 7.4%, P = 0.01) and freedom from MR ≥ 3+ (92.8 ± 3.4% vs 68.1 ± 7%, P = 0.002) were both significantly higher in the surgical group. Multivariate analysis identified the use of MitraClip as an independent predictor of recurrence of MR ≥ 2+ [Hazard ratio (HR): 2.1, 95% confidence interval (CI): 1.1-3.9, P = 0.02] as well as of MR ≥ 3 (HR: 6.1, 95% CI: 1.5-24.3, P = 0.01). In the surgical group, no predictors of cardiac mortality were identified. In the MitraClip group, left ventricular end-diastolic diameter (HR: 1.1, 95% CI: 1-1.2, P = 0.005) and SPAP (HR: 1, 95% CI: 1-1.1, P = 0.005) were independent predictors of cardiac death at the follow-up. MitraClip therapy is a safe therapeutic option in selected high-risk patients with secondary MR and relevant comorbidities. The surgical EE provides higher efficacy both postoperatively and at the mid-term follow-up. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 02/2015; 19(suppl 1). DOI:10.1093/ejcts/ezv043 · 2.81 Impact Factor
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    ABSTRACT: IntroductionThe intra-aortic balloon pump is routinely used in cardiac surgery; however its impact on outcome is yet matter of debate and randomized trials were recently published. We perform an updated meta-analysis of randomized controlled trials that investigated the use of preoperative intra-aortic balloon pump in adult patients undergoing coronary artery bypass grafting.Methods Potentially eligible trials were identified by searching the Medline, Embase, Scopus, ISI Web of Knowledge and The Cochrane Library. Searches were not restricted by language or publication status and were updated in August 2014. Randomised controlled trials on preoperative intra-aortic balloon pump in patients undergoing coronary artery bypass grafting either with or without cardiopulmonary bypass were identified. The primary endpoint was mortality at the longest follow up available and the secondary endpoint was 30-days mortality.ResultsThe eight included randomized clinical trials enrolled 625 patients (312 to intra-aortic balloon pump group and 313 to control). The use of intra-aortic balloon pump was associated with a significant reduction in the risk of mortality (11 of 312 (3.5%) versus 33 of 313 (11%), risk ratio¿=¿0.38 (0.20 to 0.73), P for effect¿=¿0.004, P for heterogeneity¿=¿0.7, I-square¿=¿0%, with eight studies included). The benefit on mortality reduction was confirmed restricting the analysis to trials with low risk of bias, to those reporting 30-days follow up and to patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass.Conclusions Preoperative intra-aortic balloon pump reduces perioperative and 30-days mortality in high-risk patients undergoing elective coronary artery bypass grafting.
    Critical care (London, England) 01/2015; 19(1):10. DOI:10.1186/s13054-014-0728-1
  • Giulio Melisurgo · Silvia Ajello · Federico Pappalardo
    Journal of Cardiothoracic and Vascular Anesthesia 12/2014; DOI:10.1053/j.jvca.2014.08.019 · 1.48 Impact Factor
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    ABSTRACT: Weaning from venoarterial extracorporeal membrane oxygenation (VA ECMO) usually is performed without clear guidelines; yet, patients still die after removal of extracorporeal circulation because of inadequate heart or end-organ recovery. The aim of the study was to address the weaning procedure, analyzing the hemodynamic and echocardiographic picture of patients weaned and to identify predictors of poor outcome among this population. Observational study. University hospital. One hundred twenty-nine VA ECMO cases. None. Forty-nine patients (38%) were weaned, 7 (5.4%) were bridged to a ventricular assist device, and 6 (5.2%) were listed for heart transplantation. Weaned patients showed a significant increase of pulse pressure (35 [0-50] mmHg before ECMO, 59 [53-67] mmHg at weaning, 61 [51-76] mmHg after ECMO (p<0.001]) and reduction of dose of inotropes (inotropic score [as defined in the text] 20 [14-40] before ECMO, 10 [3-15] at weaning, and 10 [5-15] after ECMO, p<0.001). Left ventricular ejection fraction (LVEF) increased from 19 (0-22.5)% before ECMO to 35 (22-55)% after ECMO (p<0.001). A significant improvement of right ventricular (RV) function was observed in weaned patients (RV dysfunction from 52% to 21%, p<0.001). Among weaned patients, 15 (31%) died. Patients who died after weaning had longer ECMO duration compared to discharged patients (8 [5-11] v 4 [2-6] days, p = 0.01) and more transfusions (22 [10-37] v 7 [0.5-15] units, p = 0.02); survival was lower in patients with central ECMO (postcardiotomy) compared to peripheral ECMO (p = 0.045). Mortality was higher in those with persistence of RV failure, continuous venovenous hemofiltration, higher inotropic score, lower systolic pressure, or higher leucocyte count at weaning. Successful weaning from ECMO is a multifaceted process, which encompasses consistent recovery of myocardial and end-organ function; LVEF, though improved, is still low at weaning. Hospital survival is correlated significantly to the duration of ECMO support and to bleeding complications. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of cardiothoracic and vascular anesthesia 12/2014; DOI:10.1053/j.jvca.2014.12.011 · 1.48 Impact Factor
  • International Journal of Cardiology 11/2014; 180C:199-202. DOI:10.1016/j.ijcard.2014.11.155 · 6.18 Impact Factor
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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 11/2014; Publish Ahead of Print. DOI:10.2459/JCM.0000000000000228 · 1.51 Impact Factor
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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; 61(2). DOI:10.1097/MAT.0000000000000169 · 1.39 Impact Factor
  • International Journal of Cardiology 11/2014; 179. DOI:10.1016/j.ijcard.2014.11.047 · 6.18 Impact Factor
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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).
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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; 28(6). DOI:10.1053/j.jvca.2014.05.005 · 1.48 Impact Factor
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    ABSTRACT: BACKGROUND: To assess the long-term results of the edge-to-edge mitral repair performed without annuloplasty in degenerative mitral regurgitation (MR). METHODS AND RESULTS: From 1993 to 2002, 61 patients with degenerative MR were treated with an isolated edge-to-edge suture without any annuloplasty. Annuloplasty was omitted in 36 patients because of heavy annular calcification and in 25 for limited annular dilatation. A double-orifice repair was performed in 53 patients and a commissural edge-to-edge in 8. Hospital mortality was 1.6%. Follow-up was 100% complete (mean length, 9.2±4.21 years; median, 9.7; longest, 18.1). Survival at 12 years was 51.3±7.75%. At the last echocardiographic examination, MR ≥3+ was demonstrated in 33 patients (55%). At 12 years, freedom from reoperation was 57.8±7.21% and freedom from recurrence of MR ≥3+ was 43±7.6%. Residual MR >1+ at hospital discharge was identified as a risk factor for recurrence of MR ≥3+ (hazard ratio, 3.8; 95% confidence interval, 1.7-8.2; P=0.001). In patients with residual MR ≤1+ immediately after surgery, freedom from MR ≥3+ at 5 and 10 years was 80±6% and 64±7.58%, respectively. CONCLUSIONS: In degenerative MR, the overall long-term results of the surgical edge-to-edge technique without annuloplasty are not satisfactory. Early optimal competence (residual MR ≤1+) was associated with higher freedom from recurrent severe regurgitation.
    Circulation 09/2014; 130(11 Suppl 1):S19-24. DOI:10.1161/CIRCULATIONAHA.113.007885 · 14.95 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; 39(2). DOI:10.1111/aor.12335 · 1.87 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. DOI:10.1016/j.amjcard.2014.03.015 · 3.43 Impact Factor
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    Resuscitation 05/2014; 85:S109-S110. DOI:10.1016/j.resuscitation.2014.03.272 · 3.96 Impact Factor
  • Giulia Maj · Giulio Melisurgo · Michele De Bonis · Federico Pappalardo
    Resuscitation 04/2014; 85(10). DOI:10.1016/j.resuscitation.2014.03.309 · 3.96 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; 148(5). DOI:10.1016/j.jtcvs.2014.03.041 · 3.99 Impact Factor

Publication Stats

776 Citations
333.65 Total Impact Points

Institutions

  • 2012–2015
    • San Raffaele Scientific Institute
      Milano, Lombardy, Italy
  • 2014
    • University of Zurich
      Zürich, Zurich, Switzerland
  • 2012–2014
    • Università Telematica San Raffaele
      Milano, Lombardy, Italy
  • 2004–2013
    • Università Vita-Salute San Raffaele
      Milano, Lombardy, Italy
  • 2003–2013
    • University of Milan
      • Department of Mathematics
      Milano, Lombardy, Italy
  • 2004–2012
    • Ospedale di San Raffaele Istituto di Ricovero e Cura a Carattere Scientifico
      Milano, Lombardy, Italy