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Study objectives: The aim of this study was to evaluate the early and long-term outcomes in patients undergoing aortic root replacement (ARR) with the Bentall procedure. Design: Retrospective study. Setting: [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2007.06.038 Byline: Igor Vendramin (a), Gianluca Piccoli (b), Daniele Gasparini (b), Ugolino Livi (a) Author Affiliation: (a) Division of Cardiothoracic Surgery, Department of Cardiopulmonary Sciences, University of Udine Medical School, Udine, Italy (b) Division of Vascular and Interventional Radiology, Department of Radiologic Sciences, University of Udine Medical School, Udine, Italy. Article History: Received 8 June 2007; Accepted 22 June 2007

The aim of this study was to assess the clinical course and outcomes of all heart transplant recipients affected by coronavirus disease-2019 (COVID-19) who were followed at the leading heart transplant centers of Northern Italy.

We present a case of amyloidosis AL with isolated myocardial involvement. Because of a refractory heart failure picture, patient underwent orthotopic heart transplant (OHT). The replaced heart showed an important midwall infiltration. Ten months after he underwent autologous stem-cell transplantation (ASCT) with a favorable outcome. The case demonstrates that OHT followed by ASCT in highly selected patients with light chain amyloidosis is a life-saving procedure.

Factors at the level of family/healthcare worker, organization, and system are neglected in medication nonadherence research in heart transplantation (HTx). The 4‐continent, 11‐country cross‐sectional Building Research Initiative Group: Chronic Illness Management and Adherence in Transplantation (BRIGHT) study used multistaged sampling to examine 36 HTx centers, including 36 HTx directors, 100 clinicians, and 1397 patients. Nonadherence to immunosuppressants—defined as any deviation in taking or timing adherence and/or dose reduction—was assessed using the Basel Assessment of Adherence to Immunosuppressive Medications Scale©(BAASIS©) interview. Guided by the Integrative Model of Behavioral Prediction and Bronfenbrenner's ecological model, we analyzed factors at these multiple levels using sequential logistic regression analysis (6 blocks). The nonadherence prevalence was 34.1%. Six multilevel factors were associated independently (either positively or negatively) with nonadherence: patient level: barriers to taking immunosuppressants (odds ratio [OR]: 11.48); smoking (OR: 2.19); family/healthcare provider level: frequency of having someone to help patients read health‐related materials (OR: 0.85); organization level: clinicians reporting nonadherent patients were targeted with adherence interventions (OR: 0.66); pickup of medications at physician's office (OR: 2.31); and policy level: monthly out‐of‐pocket costs for medication (OR: 1.16). Factors associated with nonadherence are evident at multiple levels. Improving medication nonadherence requires addressing not only the patient, but also family/healthcare provider, organization, and policy levels. Multilevel factors, such as relation to the patient, healthcare provider, transplant center, and healthcare system, are associated with immunosuppressive drug nonadherence in heart transplant recipients, indicating a need for multilevel interventions to address nonadherence.

The 6-month, open-label, multicenter randomized trial is designed to compare primary safety endpoints in de novo heart transplantation and delayed everolimus initiation seems to provide a clinically relevant early safety benefit compared to immediate initiation without compromising efficacy. Supplemental digital content is available in the text.

Cardiovascular involvement is common in acromegaly and can lead to development of acromegalic cardiomyopathy, characterized by concentric biventricular hypertrophy with a progressive impairment of diastolic and systolic function. The onset of heart failure and arrhythmias are related to poor prognosis. We report on a case of a 48-year-old man with acromegalic cardiomyopathy caused by pituitary adenoma. Despite the successful trans-sphenoidal resection of the tumour, the patient was rehospitalized for ventricular arrhythmic storms that led to cardiogenic shock, which required mechanical hemodynamic support with intra-aortic balloon pump, venoarterial extracorporeal membrane oxygenation, and urgent heart transplantation.

Patients supported by continuous-flow left ventricle assist devices constitute a growing new population of chronic heart failure cases that are in need of structured cardiac rehabilitation. This article reviews some practical aspects of these devices and exercise-based rehabilitation that are specific to these patients, placing special emphasis on safety.An increasing number of patients with end-stage heart failure are being treated with continuous-flow left ventricular assist devices (cf-LVADs). These patients provide new challenges to the staff in exercise-based cardiac rehabilitation (CR) programs. Even though experience remains limited, it seems that patients supported by cf-LVADs may safely engage in typical rehabilitative activities, provided that some attention is paid to specific aspects, such as the presence of a short external drive line. In spite of initial physical deconditioning, CR allows progressive improvement of symptoms such as fatigue and dyspnea. Intensity of rehabilitative activities should ideally be based on measured aerobic capacity and increased appropriately over time. Regular, long-term exercise training results in improved physical fitness and survival rates. Appropriate adjustment of cf-LVAD settings, together with maintenance of adequate blood volume, provides maximal output, while avoiding suction effects. Ventricular arrhythmias, although not necessarily constituting an immediate life-threatening situation, deserve treatment as they could lead to an increased rate of hospitalization and poorer quality of life. Atrial fibrillation may worsen symptoms of right ventricular failure and reduce exercise tolerance. Blood pressure measurements are possible in cf-LVAD patients only using a Doppler technique, and a mean blood pressure ≤80 mmHg is considered “ideal.” Some patients may present with orthostatic intolerance, related to autonomic dysfunction. While exercise training constitutes the basic rehabilitative tool, a comprehensive intervention that includes psychological and social support could better meet the complex needs of patients in which cf-LVAD may offer prolonged survival.

A 40-year-old man underwent 4 aortic surgeries because of endocarditis and subsequent prosthesis dehiscence. At the last recurrence he presented with acute severe aortic regurgitation of a Pericarbon Freedom (LivaNova plc, London, UK) stentless bioprosthesis and a morphologically disarranged aortic root. He also presented with left ventricular dysfunction and a very low origin of the left coronary artery. Therefore, a fifth redo aortic valve replacement was considered at high surgical risk. Accordingly, before listing the patient for a heart transplantation, a transcatheter valve-in-valve implantation with the JenaValve (JenaValve Technology, GmbH, Munich, Germany) prosthesis was performed.

Cardiac stem cells (CSC) from explanted decompensated hearts (E‐CSC) are, with respect to those obtained from healthy donors (D‐CSC), senescent and functionally impaired. We aimed to identify alterations in signaling pathways that are associated with CSC senescence. Additionally, we investigated if pharmacological modulation of altered pathways can reduce CSC senescence in vitro and enhance their reparative ability in vivo. Measurement of secreted factors showed that E‐CSC release larger amounts of proinflammatory cytokine IL1β compared with D‐CSC. Using blocking antibodies, we verified that IL1β hampers the paracrine protective action of E‐CSC on cardiomyocyte viability. IL1β acts intracranially inducing IKKβ signaling, a mechanism that via nuclear factor‐κB upregulates the expression of IL1β itself. Moreover, E‐CSC show reduced levels of AMP protein kinase (AMPK) activating phosphorylation. This latter event, together with enhanced IKKβ signaling, increases TORC1 activity, thereby impairing the autophagic flux and inhibiting the phosphorylation of Akt and cAMP response element‐binding protein. The combined use of rapamycin and resveratrol enhanced AMPK, thereby restoring downstream signaling and reducing IL1β secretion. These molecular corrections reduced E‐CSC senescence, re‐establishing their protective activity on cardiomyocytes. Moreover ex vivo treatment with rapamycin and resveratrol improved E‐CSC capacity to induce cardiac repair upon injection in the mouse infarcted heart, leading to reduced cardiomyocyte senescence and apoptosis and increased abundance of endogenous c‐Kit+CSC in the peri‐infarct area. Molecular rejuvenation of patient‐derived CSC by short pharmacologic conditioning boosts their in vivo reparative abilities. This approach might prove useful for refinement of CSC‐based therapies. StemCells2014;32:2373–2385

Purpose In congestive heart failure (CHF) patients, a profound cardiac autonomic derangement, clinically expressed by reduced heart rate variability (HRV), is present and is related to the degree of ventricular dysfunction. Implantation of a left ventricular assist device (LVAD) can progressively improve HRV, associated with an increased circulatory output. Data from patients studied at different times after LVAD implantation are controversial. The aims of this study were to assess cardiac autonomic function in the early phases after axial-flow LVAD implantation, and to estimate the potential relevance of recent major surgical stress on the autonomic balance.Methods HRV (time-domain; 24-h Holter) was evaluated in 14 patients, 44.8 ± 25.8 days after beginning of Jarvik-2000 LVAD support; 47 advanced stage CHF, 24 cardiac surgery (CS) patients and 30 healthy subjects served as control groups. Inclusion criteria: sinus rhythm, stable clinical conditions, no diabetes or other known causes of HRV alteration.Results HRV was considerably reduced in LVAD patients in the early phases after device implantation in comparison to all control groups. A downgrading of HRV parameters was also present in CS controls. Circadian oscillations were highly depressed in LVAD and CHF patients, and slightly reduced in CS patients.Conclusions In CHF patients supported by a continuous-flow LVAD, a profound cardiac dysautonomia is still evident in the first two months from the beginning of circulatory support; the degree of cardiac autonomic imbalance is even greater in comparison to advanced CHF patients. The recent surgical stress could be partly linked to these abnormalities.

Purpose To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR).Methods Apattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database.Results In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90).Conclusion Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

Currently, it is unknown whether defects in stem cell growth and differentiation contribute to myocardial aging and chronic heart failure (CHF), and whether a compartment of functional human cardiac stem cells (hCSCs) persists in the decompensated heart. To determine whether aging and CHF are critical determinants of the loss in growth reserve of the heart, the properties of hCSCs were evaluated in 18 control and 23 explanted hearts. Age and CHF showed a progressive decrease in functionally competent hCSCs. Chronological age was a major predictor of five biomarkers of hCSC senescence: telomeric shortening, attenuated telomerase activity, telomere dysfunction-induced foci, and p21Cip1and p16INK4aexpression. CHF had similar consequences for hCSCs, suggesting that defects in the balance between cardiomyocyte mass and the pool of nonsenescent hCSCs may condition the evolution of the decompensated myopathy. A correlation was found previously between telomere length in circulating bone marrow cells and cardiovascular diseases, but that analysis was restricted to average telomere length in a cell population, neglecting the fact that telomere attrition does not occur uniformly in all cells. The present study provides the first demonstration that dysfunctional telomeres in hCSCs are biomarkers of aging and heart failure. The biomarkers of cellular senescence identified here can be used to define the birth date of hCSCs and to sort young cells with potential therapeutic efficacy.

Aortic dissection is a fearful complication with extremely high mortality in young patients with Marfan syndrome. Successful aortic emergency surgery increases the life expectancy of these patients, yet it does not prevent disease progression and late complications. Therefore, long-term imaging follow-up of both reconstructed and chronically dissected aortic segments is mandatory. This case report illustrates the potential role of real-time three-dimensional echocardiography as a supplement to conventional postoperative follow-up in aortic dissection that provides valuable spatial and functional information.

Objective This study was carried out with the aim of presenting our experience with minimally invasive mitral surgery and compare the endoaortic clamp with the external aortic clamp (EAC) techniques.Methods Between December 2002 and May 2009, 139 patients (75 men, aged 63 ± 11 years) underwent video-assisted mitral valve surgery through right thoracotomy. Twelve (9%) patients were operated without clamping the aorta, 32 (23%) patients (group A) were operated on by using the endoaortic clamp, and 95 (68%) patients were operated on by using the EAC (group B). There was no significant difference between groups A and B regarding preoperative variables.Results Intraoperative procedure-associated problems were experienced in three group A patients (9.3%, two aortic dissections with conversion to sternotomy; one conversion due to bad exposure) and in two group B patients (2%, one conversion to sternotomy for bleeding and one for ascending aorta hematoma). At a mean follow-up of 32 months, 121 patients (97%) were in New York Heart Association class I–II, with satisfactory echocardiographic results. There was one in-hospital and six late deaths (three noncardiac, two cardiac, and one valve related). Five-year actuarial survival was 88% ± 8%. There were three reoperations, one early (<30 days) after complex mitral valve repair, with a 5-year freedom from reoperation of 97% ± 2%. Postoperative levels of myocardial cytonecrosis enzymes as well as the extracorporeal circulation time were significantly lower in group B patients (P < 0.05).Conclusions Intraoperative procedure-associated complications with endoclamping combined with an apparently better myocardial protection forced us to change our practice to the more simple and economic EAC technique.

Pharmacokinetic modeling supports trough monitoring of everolimus, but prospective data comparing this approach versus mycophenolate mofetil (MMF) in de novo cardiac transplant recipients are currently unavailable.

To evaluate the surgical results in patients with acute type A aortic dissection and cerebral malperfusion.

A more rapid and aggressive course of hepatitis B virus (HBV)-related and hepatitis C virus (HCV)-related infection in organ transplant recipients has been described. Interferon alfa is the most accepted drug for treating HBV and HCV chronic infections. However, the use of interferon alfa-N3 has been contraindicated in heart transplant (HTx) recipients because of the hypothesized greater risk of triggering acute cellular rejection. The aim of this clinical pilot study was to evaluate tolerability, safety, and efficacy of natural leukocyte interferon alfa in the treatment of chronic HBV and HCV in HTx recipients.

Abstract. Patients with cardiovascular disease have cognitive function disturbances that are still evident after heart transplantation (HT). The aim of this study was to evaluate cerebral function in transplant patients and to assess whether cyclosporine therapy was responsible for cerebral abnormalities 1 year after transplantation. Six HT patients, eight liver transplant (LT) patients, and ten age-matched healthy controls underwent regional cerebral blood flow (rCBF) assessment by the ^99mTc-hexamethyl-propylene-amineoxime (^99mTc-HM-PAO) single-photon emission computed tomography (SPECT) technique. The rCBF was correlated with cyclosporine blood levels. rCBF in HT and LT patients was similar to that of controls in all regions assayed, except for the frontal inferior region of HT patients, where it was significantly lower than in controls. No correlations between rCBF and cyclosporine blood levels were found in either HT or LT patients. In conclusion, the cerebral abnormalities seen in patients after HT but not after LT may be due to long-standing cerebral hypoperfusion resulting from severe heart disease, whereas cyclosporine does not account for such functional alterations.

BackgroundStentless aortic valves are associated with a significant decrease in left ventricular hypertrophy. This study examined the time course and factors affecting left ventricular mass regression (LVMR) after aortic valve replacement (AVR) with Cryolife O’Brien (CLOB) (Cryolife International, Atlanta, Ga) stentless valves. MethodsBetween 1993 and 2000, 130 consecutive patients underwent AVR with CLOB. Mean age was 71.3 ± 6.3 years. Sixty-four (49.2%) were male. Mean body surface area (BSA) was 1.7 ± 0.2 m2. Mean valve size implanted was 23.6 ± 2.0 mm. All patients were monitored with serial echocardiograms; the first study was performed preoperatively, and subsequent controls were at 6 months, 1, 2, 3, 4, 5, 6, and 7 years, respectively. Left ventricular mass was calculated by the Devereux formula and indexed by BSA. ResultsAnalysis of variance showed a significant reduction in the left ventricular mass index (LVMI) over time (P<.001). Most LVMRs occurred within the first 6 months, and after 1 year LVMI had decreased by 37.5% with further, but not statistically significant, reductions at later examinations. We found that baseline BSA >1.75 m2, male sex, arterial blood pressure ≥150 mm Hg, left ventricular ejection fraction ≤35%, New York Heart Association functional class ≥III, non–sinus rhythm, and prevalent aortic incompetence to be factors influencing LVMR. LVMR was not related to postoperative effective orifice area ≤0.85 cm/m2and prosthetic size. ConclusionsAVR with a CLOB valve is followed by a significant LVMR that occurs soon after surgery. It is influenced by several patient-related factors: most of them can be predicted preoperatively. (Am Heart J 2001;142:556-62.)

Background. The Cryolife O’Brien (CLOB) is a composite stentless bioprosthesis constructed from noncoronary leaflets of three porcine aortic valves. This study aimed to investigate early and midterm results after aortic valve replacement with CLOB xenograft.

Introduction:The results of cardiac surgery in patients affected by autoimmune connective tissue diseases (ACTD) have not been extensively reported. Accordingly, we sought to assess the outcomes of ACTD patients after cardiac surgery, focusing on postoperative complications and survival at short and long term.Methods:Since 2008, 1002 cardiac surgical patients affected by ACTD (rheumatoid arthritis (RA) 59%, autoimmune vasculitis 14%, autoimmune inflammatory disease 12%, psoriatic arthritis 9%, and systemic lupus erythematosus (SLE) 6%), were retrospectively analysed in two centres. Demographics, clinical characteristics and specific treatment were recorded. Type of surgery, postoperative complications, early and late mortality were analysed.Results:Median age was 71 (22-92) years, and 48% were female. Most patients presented severe comorbidities (shown in the table) and required urgent surgery in 17% of cases, most frequently CABG (56%). Perioperative mortality was 2% but 60% of patients developed postoperative complications (mainly acute renal failure 15%). Patients affected by systemic inflammatory autoimmune diseases needed longer time of mechanical ventilation (p<0.01), while those with vasculitis more frequently had pneumonia (p=0.05). SLE patients had higher 30-day mortality (7%, p=0.04). Survival at 1, 5 and 10 years was 97±1%, 82±1% and 59±2%, respectively, and most common causes of death were not cardiac related (75%). By multivariate analysis, RA (HR 1.30, 1.00-1.70) was a risk factor for late mortality while both SLE and vasculitis were risk factors for re-operation (p=0.04 and p<0.01, respectively), at a median follow up of 59 months (1-184).Conclusions:Cardiac surgery in ACTD patients can achieve satisfactory short- and long-term results despite higher rate of postoperative complications, mainly renal failure and infections.

Severe left ventricular failure in ischemic heart disease may contraindicate conservative surgical procedures. To redefine therapeutic indications, the clinical and angiographic data of 143 patients (137 men and 6 women) with ischemic heart disease and a left ventricular ejection fraction less than 0.30 who were seen by us between June 1985 and December 1990 were retrospectively analyzed. Patients were divided into three groups according to therapy: medical only, 72 (group 1); myocardial revascularization, 20 (group 2); and heart transplantation, 51 (group 3). Clinical status was poorer in group 3, with congestive heart failure as predominant symptom; angina was more frequent in group 2. No difference was noted in hemodynamic variables. Four early deaths (20.0%) occurred in group 2 and 7 (13.7%) in group 3. Follow-up ranged from 1 to 64 months (mean, 22 ± 19 months), with an actuarial survival of 28% ± 9%, 80% ± 8% and 82% ± 5% at 5 years in groups 1, 2, and 3, respectively. Even though postoperative New York Heart Association class was better in group 3 (1.0 versus 2.3 in group 2; p< 0.01), the difference in survival was not significant. Although in patients with ischemic heart disease and low left ventricular ejection fraction heart transplantation offers the best clinical results, considering the donor shortage, we conclude that myocardial revascularization may still be performed with good midterm results.

A 46‐year‐old man with alcoholic dilated cardiomyopathy underwent heart transplantation on November 14, 1985. It was the first cardiac transplant in Italy and at that time no HIV antibody screening test was available in this country. The patient remained in good health for 6 years postoperatively, with only one episode of rejection (type 3A). In June 1992 he died of fulminant complications of AIDS and severe chronic rejection. Neither the patient nor the organ donor belonged to any of the known risk groups for HIV infection; a retrospective analysis revealed that perioperative blood transfusions had been the vectors of transmission.

In view of possible clinical use of the pulmomary homograft for right ventricular outflow tract reconstruction a comparative study with the aortic counterpart was performed. Samples of aortic and pulmonary walls from 10 cadaveric hearts were assessed for viability and morphologic characteristics before and after storage in nutrient-antibiotic solution. The viability, as evaluated by an autoradiographic technique, was similar in both aortic and pulmonary specimens at the time of dissection, after 2 weeks, and after 4 weeks of storage. The histologic examination showed no changes in the structure of the media in all samples up to 4 weeks of storage. The total calcium content per gram of tissue in the pulmonary media was on an average less than half of that in the aortic counterpart We conclude that the pulmonary homograft is preserved the same as the aortic homograft and, accordingly, it becomes available for clinical application. Moreover, a lesser content of elastic tissue and a lower amount of total calcium may, in all likelihood, make the pulmonary wall less prone to calcification.

Successful orthotopic heart transplantation was performed in a 38-day-old child with a fetal echocardiographic diagnosis of a left ventricular mass and in a 40-year-old woman with cardiac murmur since childhood and an echocardiographic diagnosis of asymmetric septal hypertrophy. Pathologic examination of the removed hearts, consisting of gross, histologic, immunohistochemical, and ultrastructural studies, led to the final diagnosis of cardiac fibroma. Both patients were alive and in good condition at 35 and 28 months, respectively, after operation. (J Thorac Cardiovasc Surg1993;106:1208-12)

We report our experience with 30 children under 15 years of age treated surgically for congenital mitral valve disease from March 1972 to July 1986. Valve reconstruction was possible in 26 patients (87%), whereas in four the valve was replaced with a mechanical prosthesis. Five patients died in the hospital (16.6%), four after conservative operations and one after mitral valve replacement. There was only one late death in a child in chronic congestive heart failure. Three patients, treated conservatively, required valve replacement 2, 22, and 24 months, respectively, after the operation. Follow-up data reveal that 22 of 24 patients are asymptomatic 5 months to 15 years after operation. Two-dimensional echocardiographic studies were performed in 19 patients treated conservatively, 17 of whom are asymptomatic. Eleven of them have no signs of mitral regurgitation or stenosis, six show only mild mitral incompetence, and two have moderate mitral regurgitation or stenosis. Peak pulmonary artery pressure is within normal limits in all. Our results indicate that mitral valve reconstructive procedures for congenital valve dysplasia may be effective and reliable in children despite the frequent severity of valve malformation. Although no major prosthesis-related complications were observed in the present series, we believe that mitral valve repair should always be attempted in the pediatric population to avoid the drawbacks of the currently available prostheses.

Chronic shortage of donor organs for heart transplantation led us to extend donor age limits. To verify the effectiveness of such a policy we have compared the results of heart transplantation in 45 patients with donors more than 40 years of age (group 1) with those of 72 patients older than 50 years of age who had heart transplantation with younger donors (group 2) between November 1985 and December 1992. The two groups were comparable in terms of mean recipient age, recipient and donor sex, and indication for heart transplantation. Mean donor age was 46 ± 4 years (range 41 to 59 years) in group 1 and 23 ± 7 years (range 8 to 39 years) in group 2 (p< 0.001). In group 1 cerebrovascular accidents were more common as the cause of donor death (60 % versus 16 %, p= 0.001), and no difference was found in ischemic time (144 ± 47 minutes versus 140 ± 48 minutes, p= not significant). There were 6 early (<30 days) deaths in group 1(13 %) and 10 in group 2 (14%; p= not significant). Fatal acute graft failure was more prevalent, but not significantly so, in group 1 (10 % versus 5.5 %, p= not significant). Mean follow-up was 29 ± 20 months (range 3 to 78 months) in group 1 and 30 ± 20 months (range 3 to 80 months) in group 2 (p= not significant). At 5 years actuarial survival was 80% ± 6 % in both groups with comparable graft performance at echocardiographic and hemodynamic control studies. A significant difference was found in freedom from any type of coronary artery abnormality between group 1 (49 % ± 13 %) and group 2 (77 % ± 8 %) at 5 years (p< 0.05); however, freedom from coronary stenotic lesions only was similar. Major conduction disturbances have occurred more frequently in patients of group 1 (37 % versus 12 %; p= 0.003) without any difference in the need for permanent pacing. Donors older than 40 years of age can be accepted for heart transplantation with early and long-term results comparable with those obtained with younger donors. The impact of a higher incidence of coronary abnormalities on late performance of older grafts must be assessed at longer follow-up. Our results indicate that, because of the current organ shortage, extension of donor age ,limits is justified, even up to the sixth decade of life in selected cases.

From 1977 to 1983, 32 consecutive patients, ranging in age from 15 days to 24 years, underwent operations for double-outlet right ventricle. Twenty patients had a palliative operation either to increase (12 cases) or to reduce (eight cases) pulmonary blood flow: Ten of them have subsequently undergone total repair, and in another six correction was delayed because of possible incremental operative risk factors, such as multiple ventricular septal defects or the need for an extra cardiac conduit. Four patients with multiple, complex associated intracardiac anomalies are currently considered to have uncorrectable defects. A total of 22 patients underwent correction either primarily (12) or after palliation (10). Intraventricular tunneling was performed in 16 patients with a subaortic ventricular septal defect and in one with a doubly committed ventricular septal defect. Seven of these had pulmonary stenosis and five had reconstruction of the right ventricular outflow by means of a patch (three) or a conduit (two); among this group, five also had enlargement of the ventricular septal defect. In three patients with a subpulmonary defect and in one with a remote ventricular septal defect, all of them without pulmonary stenosis, total repair was achieved by a Senning, a Mustard, or an arterial switch operation. Finally, the only patient with atrioventricular discordance and pulmonary stenosis had insertion of a left ventricle–pulmonary artery conduit. No operative deaths were observed after palliation, but one patient died of intra pulmonary hemorrhage after total repair (4.5%). Major postoperative complications included detachment of the ventricular septal defect patch in one patient and late progression of pulmonary vascular obstructive disease in another. No late deaths have been recorded. Surgical repair of double-outlet right ventricle can be accomplished with gratifying early and late results, the risk of operative death being below 5%. The outcome in patients with subaortic ventricular septal defect appears particularly favorable, despite the extensive intracardiac procedures required for total correction. An early intervention is recommended to prevent development of pulmonary vascular obstructive disease and to avoid massive cardiac hypertrophy and fibrosis, which may cause late rhythm disturbances and impede the intracardiac repair.

Several modifications of the Fontan principle are currently applied to the treatment of tricuspid atresia with low mortality. The use of these modifications in other malformations has most frequently been associated with less satisfactory results. At our institution, from June 1977 to October 1986, 35 consecutive patients, whose ages ranged from 8 months to 20 years (median age 3.4 years), underwent a modified Fontan procedure. Twenty patients with a median age of 3.2 years (group I) having tricuspid atresia (16 patients) or hypoplastic right heart syndrome (four patients) were treated by means of a right atrium-pulmonary artery anastomosis (12 patients) or right atrium-subpulmonary chamber connection (eight patients). Fifteen patients (group II) with a median age of 3.6 years, having a single left ventricle (10 patients), left atrioventricular valve hypoplasia or atresia (three patients), or double-outlet right ventricle (two patients), underwent right atrium-pulmonary artery anastomosis, together with a repositioning of the atrial septum to the right of the right atrioventricular valve, which thus left intact the inlet to the ventricle(s). The operative mortality rate was 25% in group I and 0% in group II. One patient in group I and one in group II died late postoperatively. All the 28 survivors are free of symptoms 3 months to 9 years after correction. According to our results, low risk can be associated with modified Fontan procedures in the treatment of complex heart malformations other than tricuspid or pulmonary atresia. Preserving the integrity of the entire inlet to the ventricle(s) by repositioning the interatrial septum, as done in group II malformations, might be helpful in improving the quality of the repair.

Patients with heart failure suffered by a complex syndrome, where the filling of the ventricle or ejection of the blood is impaired. In this setting, the exercise capacity decreases for many reasons, one of them being the insufficient oxygen transfer due to reduced cardiac output and anemia. Ventricular assist device has emerged as a durable and safe therapy for patients with end-stage heart failure. The benefits of cardiac rehabilitation in ventricular assist device patients are enormous: the first aim is to progressively reduce the physical and functional impairments of these patients, so that they will be able to resume meaningful daily activities.

Supplemental Digital Content is available in the text.