Federico Pappalardo

San Raffaele Scientific Institute, Milano, Lombardy, Italy

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Publications (98)200.78 Total impact

  • 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
  • Circulation Cardiovascular Interventions 06/2013; 6(3):e34-6. · 6.54 Impact Factor
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    ABSTRACT: Multivalvular heart disease (MHD) accounts for approximately 15% of the patients undergoing valve surgery in the EuroHeart Survey and for 8.6% of all valvular surgical interventions. Most clinical studies on valvular heart disease are focused on single-valve disease and very few data stress the difficulties encountered in the diagnostic assessment and clinical decision making of multiple defects, also concerning the reciprocal hemodynamic influence or the overlap of surgical indications. Many fields related to multiple valve disease are not encountered in the European Guidelines on Valvular Heart Disease (ESC) or the American College of Cardiology/American Heart Association (ACC/AHA). Increasing age and new trends of mixed population have newly aroused interest in multivalvular heart disease in the developed countries, still in need of new clinical insights. According to the high comorbidities of candidates, the appropriate diagnostic framework necessary for the correct diagnosis and best clinical outcome may still be challenging. The paper reviews multivalvular heart disease (except congenital heart disease) from aetiology and background definition to surgical outcome, with special emphasis on echocardiographic assessment and clinical interpretation.
    Minerva cardioangiologica 04/2013; 61(2):229-242. · 0.43 Impact Factor
  • European Journal of Intensive Care Medicine 03/2013; · 5.17 Impact Factor
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    ABSTRACT: To evaluate the efficacy of methylene blue in raising mean arterial pressure in hypotensive patients. A meta-analysis of randomised controlled trials. We searched BioMedCentral, PubMed, Embase and the Cochrane Central Register of clinical trials. Inclusion criteria were random allocation to treatment and comparison of methylene blue versus any comparator. Exclusion criteria were duplicate publications, non-adult studies and no data on main outcomes. The primary end point was mean arterial blood pressure value 1 hour after the study drug administration; the secondary end points were mortality at the longest follow-up available, and cardiac index. Data from 174 patients in five randomised controlled studies were analysed. Mean arterial pressure rose in patients receiving methylene blue (weighted mean difference = 6.93 mmHg; 95% CI, 1.67 to 12.18; P for effect = 0.01; P for heterogeneity = 0.17; I2 = 41%). Only two studies reported the values of cardiac index with a non-statistically significant improvement in the methylene blue group (mean difference = 0.76 L/min/m2; 95% CI, ? 0.32 to 1.84; P for effect = 0.2). The overall mortality rate was 16% (14/88) among methylene bluetreated patients and 23% (20/86) in the control group (odds ratio = 0.65; 95% CI, 0.21 to 2.08; P for effect = 0.5). Methylene blue increases arterial blood pressure and systemic vascular resistances in vasoplegic patients without a detrimental effect on survival.
    Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine 03/2013; 15(1):42-8. · 1.51 Impact Factor
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    ABSTRACT: BACKGROUND: We investigated the impact of catheter ablation on ventricular tachycardia (VT) recurrences and survival in a large number of patients with structural heart disease treated in the setting of a dedicated multi-skilled unit. METHODS AND RESULTS: Since January 2007, we have implemented a multidisciplinary model, aiming for a comprehensive management of VT patients. Programmed Ventricular Stimulation (PVS) was used to assess acute outcome. Primary end-points were VT recurrence and the occurrence of cardiac and sudden cardiac death. Overall, 528 patients were treated by ablation (634 procedures, range 1-4); Among 482 tested with PVS after the last procedure, a Class A result (non-inducibility of any VT) was obtained in 371 pts (77%), class B (inducibility of non-documented VT) in 12.4% and class C (inducibility of index VT) in 10.6%. After a median follow-up time of 26 months VT recurred in 164 among 472 (34.1%) patients. VT recurrence was documented in 28.6% of patients with Class A result vs. 39.6% of patients with Class B and 66.7% with Class C result (log-rank p<0.001). The incidence of cardiac mortality was lower in Class A patients compared to those with Class B and Class C (8.4% vs. 18.5% vs. 22%, respectively, log-rank p=0.002). Based on multivariate analysis post-procedural inducibility of index VT was independently associated both with VT recurrence (HR=4.030, p<0.001) and cardiac mortality (HR=2.099, p=0.04). CONCLUSIONS: Within a dedicated VT unit, catheter ablation prevents long-term VT recurrences which may favourably affect survival in a large number of patients suffering from VT.
    Circulation 02/2013; · 15.20 Impact Factor
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    ABSTRACT: Increasing age and new trends of mixed populations have newly aroused interest in valvular heart disease in the developed countries still in need of new clinical insights. In the clinical setting of systemic diseases, the proper assessment of cardiovascular abnormalities may be challenging, and the characterization of valvular involvement might help to recognize the underlying disease and cardiac sequelae. Prompt identification of valvular lesions may, therefore, also be useful for differential diagnosis. This article reviews the cardiac involvement in systemic diseases from etiology and background definition to echocardiographic assessment and clinical interpretation. The authors have no funding, financial relationships, or conflicts of interest to disclose.
    Clinical Cardiology 02/2013; · 1.83 Impact Factor
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    ABSTRACT: OBJECTIVES: The 'edge-to-edge' technique (EE) can be used as a bailout procedure in case of a suboptimal result of conventional mitral valve (MV) repair. The aim of this study was to assess the long-term outcomes of this technique used as a rescue procedure. METHODS: From 1998 to 2011, of 3861 patients submitted to conventional MV repair for pure mitral regurgitation (MR), 43 (1.1%) underwent a rescue edge-to-edge repair for significant residual MR at the intraoperative hydrodynamic test or at the intraoperative transoesophageal echocardiography. Residual MR was due to residual prolapse in 30 (69.7%) patients, systolic anterior motion in 12 (27.9%) and post-endocarditis leaflet erosion in 1 (2.3%). According to the location of the regurgitant jet, the edge-to-edge suture was performed centrally (60.5%) or in correspondence with the anterior or posterior commissure (39.5%). The original repair was left in place. RESULTS: There were no hospital deaths. Additional cross-clamp time was 15.2 ± 5.6 min. At hospital discharge, all patients showed no or mild MR and no mitral stenosis. Clinical and echocardiographic follow-up was 97.6% complete (median length 5.7 years, up to 14.6 years). At 10 years, actuarial survival was 89 ± 7.4% and freedom from cardiac death 100%. Freedom from reoperation and freedom from MR ≥3+ at 10 years were both 96.9 ± 2.9%. At the last echocardiogram, MR was absent or mild in 37 patients (88%), moderate in 4 (9.5%) and severe in 1 (2.4%). No predictors for recurrence of MR ≥2+ were identified. The mean MV area and gradient were 2.8 ± 0.6 cm(2) and 2.7 ± 0.9 mmHg. NYHA I-II was documented in all cases. CONCLUSIONS: A 'rescue' EE can be a rapid and effective option in case of suboptimal result of 'conventional' MV repair. Long-term durability of the repair is not compromised.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 02/2013; · 2.40 Impact Factor