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Background: Severe vascular disease is a relative contraindication to heart transplantation (HTx). We addressed the effect of vascular disease on HTx outcomes.Methods:This is a nonconcurrent cohort study of 402 patients who received HTx at our institution between 1985 and 2004. Pretransplant vascular evaluation included carotid, lower extremity, and renal artery duplex studies, and CTangiogram when indicated. Patients with severe and nontreatable vascular disease were excluded. Patients were divided into Group 1: those with pre-transplant vasculopathy, and Group 2: those without pre-transplant vasculopathy. Group 1 had 24 patients with 25 vascular lesions: 1 aortic dissection, 2 abdominal aortic aneurysm (AAA)’s, 5 carotid artery stenoses, 1 renal artery stenosis, and 16 peripheral vascular lesions. Interventions were performed to 15 lesions prior to HTx and to 2 lesions after HTx.Results:Median follow-up was 5.5 years. Group 1 had higher incidence of ischemic cardiomyopathy (p < 0.001), hypertension (p = 0.028), chronic obstructive pulmonary disease (COPD) (p = 0.004), and smoking history (p < 0.001). There were no differences in sex, hyperlipidemia, diabetes, stroke, or renal dysfunction. Multivariate analysis revealed odds of post-transplant death in Group 1 was 1.4 (95% CI: 0.48—4.1, p = 0.54) times greater than that in Group 2. Cox proportional hazards model for survival showed a 50% increase in the hazard of death in patients with pre-transplant vasculopathy, but without statistical significance. Group 1 had higher incidence of post-transplant stroke (p = 0.001) but no difference in allograft coronary atherosclerosis. Conclusions: Pre-transplant vascular disease seems to have negative effect on outcomes after HTx. Larger scale study is needed for further evaluation. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

A 25-year-old male presented with severe anterior mitral leaflet prolapse secondary to a torn cord. The mitral annulus measured 45 mm. A 33-mm St. Jude’s bileaflet mechanical prosthesis was placed with preservation of the native anterior and posterior leaflets; however, a large intravalvular regurgitant jet was subsequently noted on TEE, associated with loitering of the medial aspect of the native anterior leaflet within the valvular apparatus. The jet resolved following resection of the putative valvular tissue (Figs. 1 and 2). European Journal of Cardio-thoracic Surgery 24 (2003) 298 www.elsevier.com/locate/ejcts

The effects of the pericardium on the amount and distribution of left ventricular myocardial blood flow were studied. In 10 normal dogs, transfusion of blood from a donor dog resulted in modest increases in coronary flow and ventricular diameter that were greater with an open than a closed pericardium. The ratio of subendocardial to subepicardial flow remained normal with or without the pericardium, at low and high diastolic ventricular pressure, and before and after pharmacological vasodilation with chromonar. In 18 dogs, cardiac failure was induced by constant infusion of the metabolic inhibitor, phenformin. Modest ventricular dilatation occurred if the pericardium was open. A progressive rise in myocardial blood flow developed in those with the pericardium open (1.06 rising to 3.02 ml . g-1 . min-1). A lesser increase (0.62 to 1.75 ml . g-1 . min-1) was seen in dogs with the pericardium closed; they selectively increased subendocardial flow, producing an average subendocardial to subepicardial flow ratio of 2.25. Pharmacological vasodilatation then resulted in uniform transmural flow. The pericardium can influence myocardial flow indirectly by influencing myocardial metabolic demand, when the heart is stressed. It may have a beneficial role in preventing the increased oxygen and coronary flow requirements produced by ventricular dilatation.