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Background: Pyro-electrohydrodynamic jetting (p-jet) has emerged recently as a promising technique for biosensing applications, through the concentration of highly diluted biomolecules in fluorescent spots at microscale. However, a great challenge still remains in optimizing the binding strategy for the sensing interface, enabling the detection of low abundance proteins through immunofluorescence protocols. Indeed, the surface of reaction can be functionalized with different chemical groups able to bind the target molecule with a strong interaction, prior to the p-jet spots decreasing the possibility to lose sensitivity after the common rinsing steps., Results: Here, we characterize the immobilization of a model protein, specifically the bovine serum albumin (BSA), in the concentrated p-jet spots to demonstrate the reliability of the technique for highly sensitive immunodetection assays. We first performed spectroscopic measurements on BSA deposited through pipette spots at relatively high concentrations and we achieved a higher efficiency in case of the covalent bond by using the carbonate buffer and the epoxy-based slides. We then tested the covalent setting in case of the p-jet spots with highly diluted samples of pre-labelled BSA. A significant concentration-dependent behavior of the signal was obtained down to picogram levels. Finally, an immunofluorescent protocol was settled with the p-jet spots and a Limit of the Detection (LOD) of 0. 27 pg/mL was reached., Significance: The demonstration here that the p-jet spots are compatible with immunodetection procedures and provide a LOD down to 0.27 pg/mL, launches the p-jet technique towards the development in future of a point-of-care (POC) diagnostic tool. This would become a major force in analytical chemical laboratories. The identification of highly diluted biomarkers from peripheral body fluids would help clinicians performing early diagnosis, overcoming the limitations of the traditional immunochemistry tests, such as the enzyme-linked immunosorbent assay (ELISA)., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

TiO 2 nanoparticles loaded with pistachio shell lignin (8 % and 29 % w/w) were prepared by a hydrothermal wet chemistry approach. The efficient interaction at the molecular level of the biomacromolecule and inorganic component was demonstrated by X-ray diffraction (XRD), transmission electron microscopy (TEM), UV-Visible (UV-Vis), Fourier transform infrared (FT-IR), dynamic light scattering (DLS), and electron paramagnetic resonance (EPR) analysis. The synergistic combination of lignin and TiO 2 nanoparticles played a key role in the functional properties of the hybrid material, which exhibited boosted features compared to the separate organic and inorganic phase. In particular, the hybrid TiO 2 -lignin nanoparticles showed a broader UV-Vis protection range and remarkable antioxidant performance in aqueous media. They could also better protect human skin explants from the DNA damaging effect of UV radiations compared to TiO 2 as indicated by lower levels of p-H2A.X, a marker of DNA damage, at 6 h from exposure. In addition, the samples could protect the skin against the structural damage occurring 24 h post UV radiations by preventing the loss of keratin 10. These results open new perspectives in the exploitation of food-waste derived phenolic polymers for the design of efficient antioxidant materials for skin photoprotection in a circular economy perspective., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Sustainable active food packaging is essential to reduce the use of plastics, preserve food quality and minimize the environmental impact. Humic substances (HS) are rich in redox-active compounds, such as quinones, phenols, carboxyl, and hydroxyl moieties, making them functional additives for biopolymeric matrices, such as poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHBV). Herein, composites made by incorporating different amounts of HS into PHBV were developed using the electrospinning technology and converted into homogeneous and continuous films by a thermal post-treatment to obtain a bioactive and biodegradable layer which could be part of a multilayer food packaging solution. The morphology, thermal, optical, mechanical, antioxidant and barrier properties of the resulting PHBV-based films have been evaluated, as well as the antifungal activity against Aspergillus flavus and Candida albicans and the antimicrobial properties against both Gram (+) and Gram (-) bacterial strains. HS show great potential as natural additives for biopolymer matrices, since they confer antioxidant, antimicrobial, and antifungal properties to the resulting materials. In addition, barrier, optical and mechanical properties highlighted that the obtained films are suitable for sustainable active packaging. Therefore, the electrospinning methodology is a promising and sustainable approach to give biowaste a new life through the development of multifunctional materials suitable in the active bio-packaging., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Melanin is a multifunctional biological pigment that recently emerged as endowed with anti-inflammatory, antioxidant, and antimicrobial properties and with high potentialities in skin protection and regenerative medicine. Here, a biomimetic magnesium-doped nano-hydroxyapatite (MgHA) was synthesized and decorated with melanin molecules starting from two different monomeric precursors, i.e. 5,6-dihydroxyindole-2-carboxylic acid (DHICA) and dopamine (DA), demonstrating to be able to polymerize on the surface of MgHA nanostructures, thus leading to a melanin coating. This functionalization was realized by a simple and green preparation method requiring mild conditions in an aqueous medium and room temperature. Complementary spectroscopy and electron imaging analyses were carried out to define the effective formation of a stable coating, the percentage of the organic compounds, and the structural properties of resulting melanin-coated nanostructures, which showed good antioxidant activity. The in vitro interaction with a cell model, i.e. mouse fibroblasts, was investigated. The excellent biocompatibility of all bioinspired nanostructures was confirmed from a suitable cell proliferation. Finally, the enhanced biological performances of the nanostructures coated with melanin from DHICA were confirmed by scratch assays. Jointly our findings indicated that low crystalline MgHA and melanin pigments can be efficiently combined, and the resulting nanostructures are promising candidates as multifunctional platforms for a more efficient approach for skin regeneration and protection., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Giuseppe Vitiello reports financial support was provided by University of Naples Federico II., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

A coupled 3D hydrodynamic-ecological model was applied to the Santa Marta Coastal Area (SMCA, Colombian Caribbean) to provide insights into the role of external stressors (e.g. wastewater outfall and upwelling) on the water quality and benthic - pelagic coupling. The model was calibrated and validated based on benthic metabolic measurements, satellite-derived chlorophyll-a (Chl-a) and sea surface temperature (SST) maps, field and literature water quality data. The model was able to reproduce the complex dynamics and fast transitions of temperature, nutrients, and phytoplankton, including the stratification and mixing periods during the non-upwelling (NUPW) and upwelling (UPW) seasons. Wide and fast changes in the temperatures and the highly flushed environment prevented excess phytoplankton growth and nutrient accumulation in the benthic and pelagic compartments. The model proved to be a reliable research tool to analyze the interactive effects of upwelling and untreated wastewater on the functioning of a tropical bay., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Hybrid Melanin-TiO 2 nanoparticles are promising bioinspired antibacterial agents for biomedical coatings and food-packaging fields. However, due to a very low colloidal stability, they showed a high tendency to self-aggregate and rapidly precipitate, making not easy their use in aqueous medium to produce homogeneous antimicrobial coatings or nanocomposites. A valid strategy to improve their dispersion is the combination with a hydrophilic water-soluble polymer such as poly-vinyl-alcohol (PVA), which is a good choice to improve the colloidal stability of nanoparticles and to modulate their agglomeration. In this work, we propose an in-situ synthetic approach based on the hydrothermal route, by which the hybrid Melanin-TiO 2 nanoparticles were prepared starting from the inorganic and organic precursors in the presence of PVA. Combined approach of TEM, XRD, TG/DSC, EPR and DLS techniques allows for assessing the PVA role in the formation of hybrids and on their morphological features as well as colloidal stability and aqueous dispersion. Antibacterial tests demonstrated the biocide activity of PVA/Melanin-TiO 2 nanoparticles against Escherichia coli bacterial cultures, which resulted partially influenced by the PVA content. This study provides key information on the mutual influence of organic/inorganic components on the functional properties of the final hybrid nanocomposites, contributing to define a much more far-reaching implementation in the synthesis of bioinspired polymer-based nanocomposites., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Developing advanced materials for wound dressings is a very challenging, yet unaddressed task. These systems are supposed to act as temporary skin substitutes, performing multiple functions, including fluid absorption and antimicrobial action, supporting cell proliferation and migration in order to promote the skin regeneration process. Following a global bioinspired approach, in this study, we developed a multifunctional textile for wound dressing applications. Biodegradable polyhydroxybutyrate/poly-3-caprolactone (PHB/PCL) mats were fabricated by electrospinning to mimic the extracellular matrix (ECM), thus providing structural and biochemical support to tissue regeneration. Furthermore, inspired by nature's strategy which exploits melanin as an effective weapon against pathogens infection, PHB/PCL mats were modified with hybrid Melanin-TiO 2 nanostructures. These were combined to PHB/PCL mats following two different strategies: in-situ incorporation during electrospinning process, alternately ex-post coating by electrospraying onto obtained mats. All samples revealed huge water uptake and poor cytotoxicity towards HaCat eukaryotic cells. Melanin-TiO 2 coating conferred PHB/PCL mats significant antimicrobial activity towards both Gram(+) and Gram(-) strains, marked hydrophilic properties as well as bioactivity which is expected to promote materials-cells interaction. This study is going to provide a novel paradigm for the design of active wound dressings for regenerative medicine., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Purpose: Radiation therapy dose escalation using stereotactic body radiation therapy may significantly improve both local control (LC) and overall survival (OS) for patients with inoperable pancreas cancer. However, ablative dose cannot be routinely offered because of the risk of causing severe injury to adjacent normal organs. Stereotactic magnetic resonance (MR)-guided adaptive radiation therapy (SMART) represents a novel technique that may achieve safe delivery of ablative dose and improve long-term outcomes., Methods and Materials: We performed a single institution retrospective analysis of 35 consecutive pancreatic cancer patients treated with SMART in mid-inspiration breath hold on an MR-linear accelerator. Most had locally advanced disease (80%) and received induction chemotherapy (91.4%) for a median 3.9 months before stereotactic body radiation therapy. All were prescribed 5 fractions delivered in consecutive days to a median total dose of 50 Gy (BED 10 100 Gy 10 ), typically with a 120% to 130% hotspot. Elective nodal irradiation was delivered to 20 (57.1%) patients. No patient had fiducial markers placed and all were treated with continuous intrafraction MR visualization and automatic beam triggering., Results: With median follow-up of 10.3 months from SMART, acute (2.9%) and late (2.9%) grade 3 toxicities were uncommon. One-year LC, distant metastasis-free survival, progression-free survival, cause-specific survival, and OS were 87.8%, 63.1%, 52.4%, 77.6%, and 58.9%, respectively., Conclusions: To our knowledge, this is the first report of 5-fraction pancreas SMART delivered on an MR-linear accelerator. We observed minimal severe treatment-related toxicity and encouraging early LC. Prospective confirmation of feasibility and long-term clinical outcomes of dose intensified SMART is warranted., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Humic acids (HAs) provide an important bio-source for redox-active materials. Their functional chemical groups are responsible for several properties, such as metal ion chelating activity, adsorption ability towards small molecules and antibacterial activity, through reactive oxygen species (ROS) generation. However, the poor selectivity and instability of HAs in solution hinder their application. A promising strategy for overcoming these disadvantages is conjugation with an inorganic phase, which leads to more stable hybrid nanomaterials with tuneable functionalities. In this study, we demonstrate that hybrid humic acid/titanium dioxide nanostructured materials that are prepared via a versatile in situ hydrothermal strategy display promising antibacterial activity against various pathogens and behave as selective sequestering agents of amoxicillin and tetracycline antibiotics from wastewater. A physicochemical investigation in which a combination of techniques were utilized, which included TEM, BET, 13 C-CPMAS-NMR, EPR, DLS and SANS, shed light on the structure-property-function relationships of the nanohybrids. The proposed approach traces a technological path for the exploitation of organic biowaste in the design at the molecular scale of multifunctional nanomaterials, which is useful for addressing environmental and health problems that are related to water contamination by antibiotics and pathogens., (Copyright © 2020 Elsevier Inc. All rights reserved.)

In this work the flammable/explosive behavior of mixtures of flammable dusts is investigated. In particular, minimum ignition temperature, minimum ignition energy, maximum pressure and deflagration index have been measured at varying the relative content of dusts in the mixtures. The thermal behavior of these mixtures has been also studied by means of DSC analysis coupled to chemical analysis performed by HPLC and ATR-FTIR. Depending on the mixtures, a synergistic behavior has been found due to physical and/or chemical reactions. For some mixtures, the more severe behavior has been attributed to the presence of a eutectic point (niacin/anthraquinone, ascorbic acid/niacin), in other cases, to chemical reactions with the formation of volatiles (ascorbic acid/irganox 1222, ascorbic acid/glucose). On this basis, we propose a new classification of dusts mixtures in three mixtures safety classes (MSC): MSC 0 (no synergistic effect, ideal behavior); MSC 1 (deviation from ideality, safety parameters included between those of the pure dusts) and MSC 2 (at least 1 parameter with more sever value than those of pure dusts)., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Developing safe and high efficiency contrast tools is an urgent need to allow in vivo applications of photoacoustics (PA), an emerging biomolecular imaging methodology, with poor invasiveness, deep penetration, high spatial resolution and excellent endogenous contrast. Eumelanins hold huge promise as biocompatible, endogenous photoacoustic contrast agents. However, their huge potential is still unexplored due to the difficulty to achieve at the same time poor aggregation in physiologic environment and high PA contrast. This study addresses both issues through the design of a biocompatible photoacoustic nanoprobe, named MelaSil_Ag-NPs, relying on silica-templated eumelanin formation as well as eumelanins redox and metal chelating properties to reduce Ag + ions and control the growth of generated metal nanoparticles. This strategy allowed self-structuring of the system into a core-shell architecture, where the Ag core was found to boost PA signal, despite the poor eumelanin content. Obtained hybrid nanoplatforms, showed stable photoacoustic properties even under long irradiation. Furthermore, conjugation with rhodamine isothiocyanate allowed particles detection through fluorescent imaging proving their multifunctional potentialities. In addition, they were stable towards aggregation and efficiently endocytosed by human pancreatic cancer cells (BxPC3 and Panc-1) displaying no significant cytotoxicity. Such numerous features prove huge potential of those nanoparticles as a multifunctional platform for biomedical applications., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Eco-friendly hybrid Eumelanin-TiO 2 nanostructures, recently obtained through in situ methodology based on hydrothermal route, have shown a striking antimicrobial activity, after exposure to oxidative environment, even under visible light induction condition. Nevertheless, the role of each component in defining the efficacy of these biological properties is far from being clearly defined. Furthermore, the effect of oxidative step on hybrids structure has not yet addressed. This study aims at elucidating the role of the ratio between eumelanin precursor, 5,6-dihydroxyindole-2-carboxylic acid (DHICA), and TiO 2 , for its polymerization in defining morphology and structural organization of TiO 2 -melanin nanostructures. Furthermore, tests on a Gram-negative Escherichia coli DH5α strain under UV irradiation and even visible light allowed to assess the contribution of each component, as well as of the TiO 2 -DHICA charge transfer complex to overall biological performance. Finally, results of biocide characterization were combined with spectroscopic evidences to prove that oxidative treatment induces a marked structural modification in melanin thus enhancing overall antimicrobial efficacy., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Understanding the mechanisms involved in the interaction of biological systems with inorganic materials is of great importance and interest in both fundamental and applied disciplines in several different fields such as astrobiology, ecology, biology, biotechnology, engineering, and medicine. In this context, this paper investigates the interaction of biomacromolecules with submicrometric silica gel particles (NP) obtained through the Stöber method. Surprisingly, particles size reduction is observed after their dispersion into two different reconstituted growth media (RPMI and M254). This effect was related to the nature of the Stöber particles and the mechanism of their formation. The experimental results can be explained arguing that a biomacromolecule corona rapidly forms on NP incubated in both RPMI and M254 growth media. The results suggest that hydrolytic attack at incompletely condensed internal surface valence sites as well as interactions between NPs surface and the components of the growth media reverse the aggregation process, giving smaller disaggregated particles surrounded by a biomacromolecule corona. Moreover it was assessed that, at longer incubation time, the particles slightly grow probably due to interlocking of biomacromolecules in the corona. Furthermore, experimental results confirm that formation of this corona is a competitive and dynamic process. The present paper shows that the described effects (as size changes) are strongly dependent on the nature of the growth medium., (Copyright © 2015 Elsevier B.V. All rights reserved.)

A large number of recent literature data focus on modification/modulation of surface chemistry of inorganic materials in order to improve their functional properties. Melanins, a wide class of natural pigments, are recently emerging as a powerful organic component for developing bioinspired active material for a large number of applications from organoelectronics to bioactive compounds. Here we report the use of the approach referred as "chimie douce", involving in situ formation of the hybrids through reactions of precursors under mild conditions, to prepare novel hybrid functional architectures based on eumelanin like 5,6 dihydroxyindole-2-carboxylic acid (DHICA) polymer and TiO2. Two synthesis procedures were carried out to get DHICA-melanin coated TiO2 nanoparticles as well as mixed DHICA/TiO2 hybrid nanostructures. Such systems were characterized through EPR, FT-IR and fluorescence spectroscopy, thermogravimetric analysis (TGA), X-ray diffraction (XRD), and TEM microscopy in order to assess the effect of synthesis path as well as of DHICA content on structural, morphological and optical properties of TiO2 nanostructures. In particular, EPR, FT-IR spectra and TGA analysis confirmed the presence of DHICA-melanin in these samples. TEM measurements indicated the formation of the nanoparticles having relatively narrow size distribution with average particle size of about 10nm. DHICA-melanin does act as a morphological agent affecting morphology of hybrid nanostructures. XRD analysis proved that TiO2 hybrid nanoparticles kept anatase structures for DHICA-melanin contents within the range of investigated compositions, i.e. up to 50% wt/wt., (Copyright © 2012 Elsevier B.V. All rights reserved.)

We report on a facile method towards a synthesis of novel hybrid heparin silica nanoparticles involving a modification of the Stober method. Tetrapropyl orthosilicate (TPOS) was used instead of the traditional TEOS or TMOS; by this way we could overcome the solubility problems of heparin in ethanol and exploit the good solubility of heparin in proper isopropanol-water mixtures. Aminopropyl triethoxysilane (APTS) was also used to have a good link of heparin to silica particles. SEM, DLS, FTIR and NMR proved that we did find conditions in which heparin conjugated silica particles were produced. Thermogravimetry allowed to evaluate the heparin/silica weight ratio to be 0.61. The efficiency of heparin binding to the particles was appreciated to be 35wt.%., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: We aimed to evaluate the relationship between serum leptin and the leptin/body mass index (BMI) ratio with prevalent cardiovascular disease (CVD), and their influence on all-cause and CVD-related mortality in patients on hemodialysis (HD)., Methods: 118 stable HD patients (50 women, median [interquartile range] age, 65.1 [54.7-72.2] years) were studied. All patients had baseline measurement of serum leptin concentrations. Relationships between leptin and all-cause and CVD mortality were studied by means of survival analysis and Cox regression analysis., Results: The leptin/BMI ratio was similar in patients with and without CVD at baseline (0.65 [0.29-2.23] vs. 0.68 [0.29-1.49] ng·m2/ml·kg, respectively, NS). Multiple logistic regression analysis showed that there was not an independent association between leptin/BMI ratio and prevalent CVD. During the follow-up time, 52 (44.1%) patients died. CVD was the cause of death in 27 out of 52 (51.9%) deceased patients. Survival analysis and Cox proportional multivariate regression analysis showed that there were no significant relationships between leptin levels or the leptin/BMI ratio and all-cause and CVD-related mortality., Conclusion: These results do not support that, in stable HD patients, serum leptin concentrations and the leptin/BMI ratio are related with prevalent CVD. Leptin/BMI ratio seems not to be a risk factor for mortality in these patients.

Anorexia, defined as the loss of the desire to eat, is relatively common in hemodialysis (HD) patients, occurring in one-third of cases. The pathogenesis is essentially unknown. It has been proposed that uremic toxins as middle molecules, inflammation, altered amino-acid pattern, leptin, ghrelin, and neuropeptide Y are involved. Anorexia reduces oral energy and protein intakes, thus contributing to the development of malnutrition and cachexia. Unquestionably, it contributes to poor quality of life. The clinical relevance of anorexia as an independent prognostic factor in HD patients is a matter of debated issue. The treatment of this debilitating condition is based on a therapeutic strategy which may include daily dialysis sessions and nutritional counseling. Normalization of plasma branched-chain amino acids through branched-chain amino acids supplementation may decrease anorexia and improve energy and protein intake. The role of megestrol acetate as appetite stimulant needs to be validated through adequate randomized trials. Subcutaneous ghrelin administration and melanocortin-receptor antagonists appear promising therapeutic interventions.

Background: This study was aimed at evaluating the determinants of postoperative dialysis-requiring acute renal failure and at identifying eventual correlations between the different etiologic mechanisms and postoperative prognosis., Methods: We evaluated the preoperative and intraoperative features of the 69 out of 6,542 consecutive cardiac surgery patients who developed postoperative dialysis-requiring acute renal failure at our Institution during a 10-year period., Results: Age, valvular and aortic surgery, hypertension, extracardiac vasculopathy, timing of surgery, cardiopulmonary bypass time, and preoperative creatinine level greater than 2.0 mg/dL were identified as predictors by multivariate analysis. In a second analysis, patients were divided in two groups according to the preoperative creatinine level: group A (preoperative creatinine 2.0 mg/dL or less; 38 cases) and group B (preoperative creatinine 2.1 mg/dL or more; 31 cases). The two groups significantly differed in preoperative and intraoperative characteristics and in postoperative outcome: group A patients were younger, had a lower incidence of cardiac and vascular risk factors and comorbidities, were mainly operated on urgent or emergent basis for valvular or aortic pathologies, had longer cardiopulmonary bypass and cross-clamp time, and worse in-hospital outcome but higher midterm survival. Group B patients were older, had a higher prevalence of comorbidities, required more often in-hospital or after-discharge dialysis, had lower in-hospital mortality, but reduced midterm survival., Conclusions: Postoperative dialysis-requiring acute renal failure can be the result of two different pathophysiological pathways: complicated perioperative course due to urgent-emergent surgery or main intraoperative technical complications in patients with preoperative normal renal function and uncomplicated perioperative course associated with reduced preoperative kidney function. The two patient groups significantly differ in baseline preoperative features, as well as in in-hospital and in midterm outcome.

Background: To define the long-term results of 331 standard Hancock porcine bioprostheses implanted in the mitral position between 1973 and 1980., Methods: Of 331 patients (225 male patients, 68%), mean age 49+/-10 years (range 14 to 69 years), 88% were in New York Heart Association functional class III or IV and 77% were in atrial fibrillation. Follow-up time extended more than 20 years (mean 13.9 years, range 0.3 to 24.7 years) for a total of 4,601 patient-years., Results: Overall operative mortality was 6.3%. At 5, 10, 15, and 20 years, the actuarial survival rate of patients were 71%+/-2%, 46%+/-3%, 30%+/-3%, and 22%+/-2%, respectively. Actuarial estimates of freedom from structural valve deterioration were 95%+/-1%, 67%+/-3%, 32%+/-3%, and 14%+/-3%; from reoperation were 96%+/-1%, 72%+/-3%, 36%+/-4%, and 18%+/-4%; from thromboembolism were 89%+/-2%, 82%+/-3%, 74%+/-4%, and 51%+/-2%; and from anticoagulant-related hemorrhage were 98%+/-1%, 96%+/-1%, 91%+/-1%, and 86%+/-4%. Estimates of freedom from all valve-related mortality at 5, 10, 15, and 20 years were 89%+/-2%, 76%+/-3%, 64%+/-4%, and 48%+/-4%. Multivariate analysis showed younger age to be a significant risk factor for reoperation. Age at operation did not correlate with structural valve deterioration., Conclusions: The long-term results with the standard Hancock bioprosthesis implanted in the mitral position appear satisfactory, particularly up to 15 years from implantation. Protection from stroke, anticoagulant hemorrhage, and endocarditis was good.

Background: This study seeks to define the long-term results after Biocor PSB stentless aortic valve replacement (AVR) in elderly patients, including the effects of No-React treatment., Methods: We reviewed the outcomes of 106 consecutive patients, aged 70+/-6 years, having Biocor PSB (93 standard, 13 No-React) AVR between October 1992 and October 1996., Results: There were three early deaths (3%) and 15 late deaths (15%), during a mean follow-up of 5.8+/-1.6 years. At 8 years, survival was 82%+/-4% and freedom from cardiac death was 94%+/-3%. Freedom from valve failure was 92%+/-4% at 8 years (No-React: 92%+/-8% at 4 years). Replacement of the xenograft was required in 5 patients. Freedom from reoperation was 91%+/-4% at 8 years (No-React: 92%+/-8% at 4 years). Four bleeding and two embolic events were recorded: overall valve-related event-free survival was 81%+/-7% at 8 years (No-React: 76%+/-12% at 4 years). Age of long-term survivors averaged 77+/-5 years and their New York Heart Association status was 1.3+/-0.6 (versus 2.9+/-0.6 preoperatively, p = 0.01)., Conclusions: Satisfactory freedom from cardiac events and from valve deterioration added to uniform improvement in functional status despite advanced age and high prevalence of comorbid conditions make AVR with the Biocor PSB xenograft a valid long-term therapy for the elderly. No-React treatment does not influence xenograft durability.

Background: Aortic root replacement remains a challenging surgical procedure. A variety of techniques and prosthetic devices have thus far been used. In order to assess the performance of the Carboseal (Sultzer Carbomedics, Inc, Austin TX) composite graft, review of the experience with composite root replacement was undertaken., Methods: Between January 1979 and December 1998, 273 patients underwent composite aortic root replacement. One-hundred-six received the Carboseal composite prosthesis (group 1) and 84 other types of composite grafts (group 2). Demographic and operative variables were similar in the 2 patient groups, except for an older mean age in group 1 (58+/-12 versus 50+/-12 years, p = 0.001)., Results: Operative mortality was lower in group 1 patients (3 of 106, 3% versus 10 of 84, 12%, p = 0.04). Follow-up of survivors was longer in group 2 due to more recent adoption of the Carboseal grafts (93+/-57 versus 36+/-23 months, p = 0.01). Late mortality was higher in group 2 (3 of 103, 3% versus 13 of 74, 18%, p = 0.04), with higher prevalence of prosthetic-related complications (2 of 103, 2% versus 12 of 74, 15%, p = 0.002). Reoperation was more prevalent in group 2 (1 of 103, 1% versus 5 of 74, 8%, p = 0.04), and limited to patients having root replacement using the inclusion technique. Functional status of survivors was comparable in the 2 groups (83 of 103, 80% versus 45 of 74, 61% of patients in New York Heart Association class I, p = 0.1)., Conclusions: Aortic root replacement using the Carboseal composite graft offers excellent long-term results, with negligible prevalence of prosthetic-related complications. Superior performance compared to other available composite grafts in the present series may be influenced by more recent adoption of the Carboseal conduit and concomitant uniform adoption of coronary button technique.

Background: The aim of the present study was to verify the efficacy of preserving the aortic valve in patients with acute type A aortic dissection complicated by significant aortic regurgitation., Methods: From January 1979 to December 1996, 178 patients (125 males; mean age 57 +/- 9 years) underwent emergency surgery for acute type A aortic dissection, with an overall operative mortality rate of 21%. Based on a retrospective analysis of the preoperative angio- or echocardiographic findings, the 141 survivors were divided into 2 groups: Group 1 (G1) included 80 patients (57%) with no or mild aortic regurgitation, and Group 2 (G2) the remaining 61 patients with moderate-to-severe aortic regurgitation. The native aortic valve was preserved by means of a uniform technique consisting of reconstruction of the aortic root and sinotubular junction in 99 patients (70%) [68 in G1 (85%) and 31 in G2 (51%)]. Forty-two patients required aortic valve (8 patients; 6%) or total root replacement (34 patients; 24%)., Results: At a mean follow-up of 4 +/- 3.6 years (range, 6 months to 19 years), 19 of the 99 patients with a preserved aortic valve developed moderate-to-severe aortic insufficiency [19%; 7/68 in G1 (10%) and 12/31 in G2 (39%)]. Multivariate analysis revealed that moderate-to-severe preoperative aortic valve insufficiency was a significant risk factor for development of postoperative aortic valve regurgitation (p = 0.008). Reoperation was necessary in 7 G1 patients (10%) and in 8 G2 patients (26%), with an actuarial freedom from reoperation at 5 and 10 years of 93% +/- 7% and 80% +/- 9% in G1 patients, and 81% +/- 8% and 40% +/- 15% in G2 patients (p = 0.045)., Conclusions: Preservation of the aortic valve and aortic root is recommended in patients with acute type A aortic dissection and absent or mild aortic insufficiency. Patients presenting with moderate-to-severe aortic regurgitation and treated conservatively present an increased risk of recurrent valvular insufficiency.

Background: Aortic root remodeling (ARR) has recently been proposed for patients with aortic aneurysms and valve insufficiency (AI). To define factors associated with a favorable functional outcome, a review of the mid-term results with ARR was undertaken., Methods: Between March 1994 and October 1997, 17 consecutive patients (11 men, 6 women), aged 57 +/- 11 years (range 35-71), had elective ARR for aortic aneurysm with or without annuloaortic ectasia (13), sinus of Valsalva aneurysm (3), or chronic aortic dissection (1). Moderate or severe AI was present in 11 patients (65%). Preoperative aortic root diameter was 58 +/- 5 mm (range 51-70). ARR involved replacement of all three aortic sinuses and coronary button reimplantation, using grafts with a mean diameter of 28 +/- 2 mm (range 24-30)., Results: There was one early death (6%) due to multiple organ failure. Survivors were followed for 16 +/- 12 months (range 1-44). Actuarial 3-year survival was 94% +/- 6%. Discharge echocardiogram showed a decrease in AI in all patients: AI was absent in 11 (69%) and mild in 5 (31%). Recurrence of moderate or severe AI after a mean of 16 +/- 9 months (range 9-28) was noted in 6 patients (37%), 3 of whom had no AI at discharge. Five of 6 patients required aortic valve replacement. Comparison of demographic and operative variables showed that severe preoperative AI (67% vs 20%, p = 0.06), annuloaortic ectasia (100% vs 20%, p = 0.002), and cystic medial necrosis (100% vs 20%, p = 0.002) were significantly more prevalent in patients developing severe AI at follow-up. The 10 patients (63%) with absent AI showed durable competence of the valve and relief from symptoms at follow-up., Conclusions: Despite early restoration of valve competence, AI may recur and progress after ARR at medium-term follow-up in a proportion of patients. The severity of preoperative AI and the nature of aortic root disease may negatively influence the durability of repair. Continued observation of results with ARR appears mandatory to identify the appropriate surgical candidates.

Background: Aortic root replacement (ARR) is a technically demanding procedure that can be performed using a variety of prosthetic devices. Root replacement in the young, but grown-up, patient poses unique problems in terms of the long-term outcome and active lifestyle that must be guaranteed by this operation. To identify the "ideal" substitute for ARR in the young, clinical results in teenagers and young adults (<35 years) operated on in the past two decades were reviewed., Methods: Thirty-eight patients younger than 35 years underwent ARR between January 1980 and December 1996. Eighteen patients, aged 30+/-5 years, had ARR with composite graft (group 1), whereas 20 patients, aged 28+/-6 years, had ARR with aortic homografts or pulmonary autografts (group 2). Primary indication for the operation was aortic insufficiency with anuloaortic ectasia (12 of 18) in group 1 and aortic insufficiency with or without anuloaortic ectasia (16 of 20) in group 2. Urgent ARR was required in 3 (17%) group 1 patients and 1 (5%) group 2 patient (p = 0.01)., Results: Operative deaths were 2 (11%) in group 1, caused by hemorrhage and low output, and none in group 2. There were 4 (25%) late deaths in group 1, caused by embolism (2), hemorrhage, and myocardial infarction, and 1 (5%) in group 2, caused by arrhythmia. Survival was 81% +/- 9%, and 55%+/-18% at 2 and 10 years in group 1 versus 94%+/-5% at 2 years in group 2 (p = 0.04). Freedom from valve-related events was 93%+/-6% and 62%+/-18% at 2 and 10 years in group 1 versus 100% at 2 years in group 2 (p = 0.02). Freedom from reoperation in group 1 was 75% +/- 22% at 10 years, whereas no reoperations were done in group 2. Seven (58%) group 1 patients versus 1 (5%) group 2 patient were on cardiac medications (p = 0.001), and 11 (92%) group 1 patients versus no group 2 patients were on warfarin therapy at follow-up. All survivors were back to school or prior employment., Conclusions: Survival early after ARR does not differ depending on the type of prosthesis. Valve-related events are common, and reoperation may be needed late after ARR with composite grafts. Despite limited follow-up with biologic devices, the prevalence of complications with composite grafts makes homograft or autograft ARR preferable in adolescents and young adults.

Background: Stentless xenografts have been proposed as substitutes for the diseased aortic valve. Cases of valve failure requiring reoperation have thus far been sporadic. To establish the prevalence and outcome of reoperation on stentless aortic xenograft valves, all patients operated on between October 1992 and October 1996 were reviewed., Methods: One hundred ninety-nine patients, 94 men and 105 women aged 70+/-7 years, had stentless aortic valve replacement for aortic stenosis (in 139), insufficiency (19), or both (38). Three prostheses were used, including the Biocor PSB (Belo Horizonte, Brazil) (106), Toronto SPV (St. Jude Medical, Inc., St. Paul, MN) (52), and O'Brien-Angell (Cryolife, Atlanta, GA) (41). While the Biocor PSB and Toronto SPV prostheses are designed to be implanted freehand with inflow and outflow suture lines, the O'Brien-Angell valve requires a single suture line., Results: There were 7 (3.5%) total and 6 (3%) valve-related reoperative procedures during a follow-up extending up to 4 years (mean 26+/-20 months). All but one valve-related reoperation, due to endocarditis 36 months after implant, were early (less than 12 months after initial operation). Prevalence of valve-related reinterventions was 1%, 0%, and 12%, and freedom from reoperation at 3 years was 98%+/-2%, 100%, and 81%+/-8%, in patients receiving the Biocor PSB, Toronto SPV, and O'Brien-Angell valves, respectively (p = 0.0039). Cause of reoperation was technical in 3 (O'Brien-Angell), pannus in-growth in 1 (O'Brien-Angell), valve tear in 1 (O'Brien-Angell), and endocarditis in 1 (Biocor PSB). All patients survived replacement of the xenograft with a stented bioprosthesis (5) or homograft root (1) and were discharged after a mean hospital stay of 6+/-3 days (range, 4 to 12 days). At follow-up 15+/-8 months after reintervention (range, 6 to 34 months), all patients are symptom-free with no evidence of recurrent valve obstruction, regurgitation, or infection., Conclusions: Reoperation for stentless xenograft failure is a rare overall event. Implant of the O'Brien-Angell valve may be associated with a higher prevalence of early reintervention because of nonstructural failure. When needed, reoperation on a stentless xenograft is generally a simple procedure and carries a low surgical risk.

Background: The midterm clinical results after aortic valve replacement with the Biocor PSB stentless xenograft on all patients operated between October 1992 and October 1996 were reviewed., Methods: One hundred six patients, aged 70+/-6 years, had aortic valve replacement for aortic stenosis (67%), regurgitation (11%), or both (22%). Associated procedures were done in 49 patients (46%), including coronary artery bypass in 30 patients, mitral valve repair/replacement in 16, and ascending aorta replacement in 5 patients. Aortic cross-clamp and cardiopulmonary bypass times were 96+/-24 and 129+/-31 minutes, respectively., Results: There were 3 (3%) early deaths due to low output (2 patients) and cerebrovascular accident (1 patient). Follow-up of survivors ranged from 6 to 66 months (mean, 39+/-14 months). Survival was 94%+/-2% and 90%+/-3% at 1 and 5 years. There were 5 late deaths due to cardiac cause (2), cancer (2), and pulmonary embolism (1 patient). No patient had structural valve deterioration, whereas 100% and 95%+/-3% were free from valve-related events at 1 and 5 years. There were two reoperations due to narrowing of the left coronary ostium and endocarditis, with an actuarial freedom from reoperation of 99%+/-1% and 98+/-1% at 1 and 5 years, respectively. Functional results demonstrated a mean peak transprosthetic gradient of 16+/-12 mm Hg, with only 1 patient (1%) with a 55 mm Hg gradient. No cases of valve regurgitation greater than mild were recorded at follow-up. Assessment of New York Heart Association functional class demonstrated a significant improvement (2.9+/-0.6 versus 1.4+/-0.7; p=0.01). All patients were free from anticoagulation., Conclusions: Aortic valve replacement using the Biocor PSB stentless xenograft offers excellent midterm survival, negligible valve deterioration, and a very low rate of valve-related events, which are comparable to estimates reported with other models of stentless xenografts and currently available stented xenografts. Hemodynamic performance is favorable and quality of life satisfactory.

The ability of inhaled nitric oxide to reduce pulmonary vascular resistance is currently used to select borderline patients for reparative surgery and to treat postoperative crises of pulmonary hypertension. A case of an infant with non-restrictive VSD who classified as a nitric oxide responder both in the catheterization laboratory and after surgery, but developed recurrent pulmonary hypertension is described. The limitations of inhaled nitric oxide in predicting the natural history of successfully operated patients are discussed.

Background: Use of intravenous furosemide is generally avoided in critically ill neonates and infants soon after open heart operations to prevent fluctuations in intravascular volume and resulting circulatory instability., Methods: To assess and compare the safety and efficacy of continuous versus intermittent intravenous furosemide, we undertook a prospective, randomized trial in 26 consecutive patients less than 6 months of age. Inclusion criteria were presence of low-output syndrome requiring inotropic support (24/26 patients) or pulmonary hypertension requiring vasodilator therapy (10/26 patients) within 6 hours of discontinuation of cardiopulmonary bypass. Eleven patients received 0.1 mg x kg(-1) x h(-1) continuous intravenous furosemide (group 1) and 15 received 1 mg/kg bolus every 4 hours (group 2) for 24 hours. Mean age (3.7 +/- 3.4 versus 1.8 +/- 2.5 months) and weight (4.6 +/- 2.1 versus 4.3 +/- 1.7 kg) were comparable., Results: Group 2 infants showed slightly greater absolute urinary output (2.5 +/- 1.1 mL/kg per hour versus 3.3 +/- 1.1 mL/kg per hour, p = 0.05). However, urinary output per dose of drug was significantly larger in group 1 infants (1.0 +/- 0.4 versus 0.5 +/- 0.2 mL x kg(-1) x h(-1); p = 0.002) with lesser fluctuations (variance, 1.9 +/- 1.6 versus 3.8 +/- 2.1; p = 0.02) and fluid replacement needs (20.6 +/- 3.8 versus 51.8 +/- 14.4; p = 0.001). Electrolyte replacement requirements were similar. A trend toward greater hemodynamic instability in group 2 patients (heart rate variance 88.4 +/- 79.8 versus 128.3 +/- 82.7; p = 0.09; central venous pressure variance 2.8 +/- 1.90 versus 4.1 +/- 3.7; p = 0.07; mixed venous oxygen saturation variance, 32.3 +/- 27.6 versus 45.7 +/- 20.4; p = 0.06) was noted. All patients who completed the study protocol survived operation and were discharged home., Conclusions: We conclude that (1) commonly used doses of both intermittent and continuous intravenous furosemide infusion can be safely administered to critically ill neonates and infants as early as 6 hours after operation, (2) continuous infusion yields an almost comparable urinary output with a much lower dose of furosemide, and (3) intermittent administration is associated with greater fluctuations in urinary output and greater needs for fluid replacement therapy.

Primary cardiac sarcomas constitute a rare entity that have been uniformly associated with poor long-term survival. A case of left atrial leiomyosarcoma involving the interatrial septum and the right atrial free wall and presenting with syncope and atrial fibrillation, is described. Two extensive surgical excisions followed by adjuvant radiation and chemotherapy improved survival with a good quality of life. This approach of combined surgical, medical and radiation therapy may offer better longterm outcome, since our patient is the longest survivor thus far reported.

Transposition of the great arteries with [S, D, L] segmental anatomy is a rare complex congenital heart lesion. The morphologic features of this unusual disease make surgical repair more challenging than in [S, D, D] transposition. Here reported is the experience with the surgical treatment of this pathologic condition in 2 patients presenting with significant associated anomalies of the right side of the heart and pulmonary outflow tract. Relevance of the specific anatomic features of the transposition [S, D, L] complex is reviewed in terms of feasibility of biventricular repair using the Rastelli operation.

Background: The optimal surgical treatment of complex (multiple level or recurrent) left ventricular outflow tract obstruction (LVOTO) in infancy is controversial. Staged procedures expose the children to the need for reoperation, and currently available techniques of aortoventriculoplasty are associated with the morbidities of biological and mechanical prostheses., Methods: Between July 1992 and January 1996, we have performed 24 aortic root replacements with the pulmonary autograft in pediatric patients (< 18 years). Of this group, 8 were infants and children with complex LVOTO aged 9 days to 22 months (mean, 8.6 +/- 8 months) and weighing 3.3 to 10.2 kg (mean, 6.3 +/- 2.6 kg). The diagnoses were interrupted aortic arch/ventricular septal defect/subaortic stenosis in 3, recurrent aortic stenosis in 2, aortic stenosis and subaortic stenosis in 1, and aortic stenosis/subaortic stenosis/mitral stenosis/regurgitation in 2. All patients had undergone one to three previous operative procedures (mean, 1.5 +/- 0.8 procedures/patient). Preoperative echocardiographic peak LVOT gradient was 71.7 +/- 25 mm Hg (range, 40 to 110 mm Hg) and aortic annulus size was 7.2 +/- 2.3 mm (range, 4 to 10.6 mm). The surgical technique included replacement of the aortic root with the pulmonary autograft combined with incision of the conal septum to relieve subaortic stenosis or accommodate for size discrepancy between the aortic and pulmonary autograft root and a pulmonary homograft placed in the right ventricular outflow tract., Results: There were no perioperative or late deaths at follow-up (range, 2 to 25 months; mean, 13.5 +/- 8 months). Mean hospital stay was 15 +/- 17 days (range, 4 to 53 days). Three children had the following complications: diaphragmatic paresis (1), delayed pericardial effusion (1), and atrioventricular block requiring a pacemaker (1). In follow-up, echocardiographic findings showed absent aortic regurgitation in 3 and trivial aortic regurgitation in 5, and no significant LVOTO (mean peak gradient, 6.2 +/- 7.6 mm Hg; range, 0 to 16 mm Hg). Pulmonary homograft regurgitation was absent in 5, trivial in 2, and moderate in 1. Peak right ventricular outflow tract gradient by echocardiogram was trivial in 7, and a significant gradient of 55 mm Hg has developed in 1 infant. There were no infective or embolic complications during follow-up., Conclusions: Our experience shows that aortic root replacement with the pulmonary autograft can be performed in children with excellent clinical results. The technique of root replacement combined with ventriculoplasty allows definitive and simultaneous relief of complex and multiple-level obstructive lesions. Considering the growth potential of the pulmonary autograft, this should be regarded as the optimal treatment modality in infants with complex LVOTO:

Background: Pulmonary hypertension due to persistent fetal circulation is rarely associated with transposition of the great arteries and intact ventricular septum. Previous attempts at management of affected neonates using prostaglandin E1 and balloon atrial septotomy followed by surgical repair have been largely unsuccessful., Methods: Between September 1992 and April 1995, 45 neonates underwent repair of transposition of the great arteries with the arterial switch operation. Two patients (4%) with transposition of the great arteries and intact ventricular septum presented with profound reversed differential desaturation and right-to-left shunting at the level of the ductus arteriosus after balloon atrial septotomy. A diagnosis of persistent pulmonary hypertension was established and both neonates entered an experimental management protocol using inhaled nitric oxide and rapid arterial switch operation., Results: Preoperative hemodynamic stabilization was achieved in 1 patient using 40 parts per million of inhaled nitric oxide, whereas the other required in addition extracorporeal membrane oxygenation for severe biventricular dysfunction. Both underwent successful surgical repair 4 to 5 days after admission, but received postoperatively 1 week of inhaled nitric oxide therapy for persistent pulmonary hypertension. Follow-up echocardiography at 3 months showed good biventricular function and normal geometry of the ventricular septum, suggesting low pulmonary artery pressure, in both., Conclusions: A management protocol using inhaled nitric oxide and extracorporeal membrane oxygenation followed by the arterial switch operation was successfully used in neonates with transposition of the great arteries, intact ventricular septum, and persistent pulmonary hypertension. Wider use of preoperative and postoperative inhaled nitric oxide may improve the surgical outcome of this difficult subset of patients.

The surgical management of tetralogy of Fallot has undergone important changes in recent years. Earlier repair of tetralogy of Fallot is now favored by many institutions. At Stanford University Medical Center, we have performed definitive repair of tetralogy of Fallot at the time of presentation, regardless of the child's age, with few exceptions. In this report, we describe our results with early repair, and we believe these support the contention that infants who undergo early repair (< 1 year of age) have postoperative results similar to those of children who undergo repair at an older age. Complications related to shunts are prevented by the infant repairs, and, in the future, reduced ventricular ectopy may be demonstrated to be a benefit of such repairs.

Primary pulmonary trunk sarcoma is a rare and highly lethal disease. A case of multicentric pulmonary trunk leiomyosarcoma with right and left main pulmonary artery involvement, mimicking massive pulmonary embolism, is described. The importance of a timely diagnosis and of radical surgical excision is discussed.

A rare case of single, pedunculated, ball-like rhabdomyoma of the pulmonary valve, causing moderate right ventricular outflow obstruction in an infant with tuberous sclerosis, is presented. The diagnostic and surgical implications are discussed.

Acute myocardial ischemia and infarction due to retrograde coronary artery dissection are uncommon complications after ascending aortic dissection. A case of acute aortic dissection with massive right ventricular failure successfully treated by replacement of the ascending aorta and postoperative right ventricular mechanical support is presented. Although mechanical assistance may be hazardous after ascending aortic replacement, because of the need of anticoagulation, it represents a valid therapeutic option when severe right ventricular failure due to acute myocardial infarction ensues.

Between January 1987 and September 1991, 112 operative survivors of heart transplantation were initially immunosuppressed with cyclosporin A and azathioprine without prednisone. Eighty-eight patients (79%) remained on a regimen of double therapy for a mean follow-up of 25 +/- 15 months (range, 1 to 54 months), whereas 24 patients (21%) had oral prednisone, 5 mg/day, added to maintenance therapy for persistent or repeated rejection. There were 5 early deaths (4%) because of acute rejection (4 patients) or infection (1 patient). Only 1 patient died late after heart transplantation of chronic rejection. Actuarial survival was 95% +/- 2% and 94% +/- 3% at 12 and 48 months, respectively. Mean rate of acute rejection was 1.7 +/- 1.0 episodes per patient, with a 5% +/- 2% freedom from rejection at 48 months. Ten patients (9%) required in-hospital treatment for infection; the actuarial freedom from infectious episodes was 85% +/- 4% at 48 months. Actuarial freedom from hypertension was 43% +/- 7% at 48 months. At annual catheterization, mean left ventricular ejection fraction was 0.64 +/- 0.08 and 0.62 +/- 0.05 at 1 year and 4 years, respectively, with evidence of coronary lesions in 9 patients (8%). In conclusion, steroid-free immunosuppression after heart transplantation is associated with a high incidence of acute rejection. However, the excellent medium-term survival and the low incidence of both infection and chronic rejection seem to justify a wider use of such treatment.

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.

Between November 1985 and November 1991, 180 patients underwent heart transplantation at our institution; 55 of these patients (31%) were over 55 years of age. Eighteen patients (10%) received hearts from donors who were over 40 years of age (mean age, 47 years; range, 40 to 55 years); (group 1); 37 hearts (21%) were from donors who were under 40 years of age (mean age, 23 years; range, 8 to 38 years). Mean recipient age was 59 years (range, 55 to 64 years) and 57 years (range, 55 to 68 years) in groups 1 and 2, respectively. The main indication for transplantation was ischemic heart disease in group 1 and dilated cardiomyopathy in group 2. Perioperative mortality and intensive care assistance were similar in the two groups. Survival was 88% versus 84% at 1 year and 81% versus 80% at 4 years in groups 1 and 2, respectively. Although infections were more frequent in group 1 (0.27 versus 0.11 episode/patient), the incidence of acute rejection was comparable in the two groups (1.50 versus 1.65 episode/patient). Angiographic and echocardiographic controls showed normal graft function up to 4 years, with low incidence of chronic rejection in both groups. We conclude that heart transplantation in patients over 55 years of age with donors over 40 years of age offers excellent short-term and mid-term results. The consideration of older donors makes heart transplantation a valid therapeutic option for selected patients in the sixth and seventh decade of life, in spite of chronic donor shortage.