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A 73–year–old man comes to the cardiac surgery clinic, due to the onset of an arrhythmic storm. In 1999, the patient was diagnosed with dilated cardiomyopathy with finding of a pathogenic mutation of the MYH7 gene by NGS panel analysis. Because of severely reduced systolic function despite OMT and left conduction delay, he underwent CRT–D implant in class IA. The patient‘s course was characterized by multiple exacerbations and a worsening course of ventricular dysfunction (EF 20%), such as to configure a picture of advanced heart failure, INTERMACS III (frequent flyer). Approximately 6 months later, the patient was admitted with signs of hypoperfusion refractory to inotrope therapy and significant congestion. In consideration of age, frailty and irreversible renal dysfunction, the patient was excluded from the transplant list. Therefore, he was a candidate for mechanical support as destination therapy, through the implantation of the Heart Mate III. At admission, the patient was monitored with evidence of ventricular fibrillation (image 1) and relative hemodynamic stability. The vital parameters reported a BP of 90/76 mmHg, FC not evaluable and SpO2 of 80%. For this reason, in anesthesiological assistance, asynchronous external defibrillation (200 J) was performed with restoration of the pacing rhythm. The monitoring of the LVAD showed a series of alerts: a reduction of the Pump Flow and phases of reduction of the Pulse Index (image 2). Event monitoring of the CRT–D revealed that the patient developed an arrhythmic storm, with appropriate but ineffective several shocks. The 8 shocks were followed by the interruption of the device therapies, but the patient, despite the ventricular fibrillation, had preserved perfusion. Medical therapy was optimized (mexiletine add–on) and CRT–D was rescheduled.

Infection with HIV may lead to the development of cardiomyopathy as improved antiretroviral regimens continue to prolong patient life. However, advanced therapeutic options, such as heart transplant, have until recently been precluded to HIV-positive persons. A favorable long-term outcome has been obtained after kidney or liver transplant in HIV-positive recipients fulfilling strict virological and clinical criteria. We recently reported the first heart transplant in a HIV-infected patient carried out in our center. In this article, we detail the major challenges we faced with the management of antiretroviral and immunosuppressive treatments over the first 3 years post-transplant. The patient had developed dilated cardiomyopathy while on antiretroviral treatment with zidovudine, lamivudine and efavirenz. He was in WHO Stage 1 of HIV infection and had normal CD4+ count and persistently undetectable HIV-RNA. In spite of cardiac resynchronization therapy and maximal drug therapy, the patient progressed to end stage heart failure, requiring heart transplant. He was placed on a standard immune suppressive protocol including cyclosporine A and everolimus. Despite its potential pharmacokinetic interaction with efavirenz, everolimus was chosen to reduce the long-term risk of opportunistic neoplasia. Plasma levels of both drugs were monitored and remained within the target range, although high doses of everolimus were needed. There were no infectious, neoplastic or metabolic complications during a 3-year follow-up. In summary, our experience supports previous data showing that cardiac transplantation should not be denied to carefully selected HIV patients. Careful management of drug interactions and adverse events is mandatory.

In this study Bioelectrical Impedance Analysis was performed in 5 patients with end stage heart failure in whom a left ventricular assist device (Novacor) was successfully implanted. Whole body measurements of bioelectrical indices resistance and reactance were taken before surgery and 3, 7, 12, and 15 days after it. After surgery there was a significant decrease in reactance, indicating a shift of body fluids from intra- to extra-cellular space.