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BACKGROUND: Post-acute myocardial infarction papillary muscle rupture (post-AMI PMR) may present variable clinical scenarios and degree of emergency due to result of cardiogenic shock. Veno-arterial extracorporeal life support (V-A ECLS) has been proposed to improve extremely poor pre- or postoperative conditions. Information in this respect is scarce. METHODS: From the CAUTION (meChanical complicAtion of acUte myocardial infarcTion: an InternatiOnal multiceNter cohort study) database (16 different Centers, data from 2001 to 2018), we extracted adult patients who were surgically treated for post-AMI PMR and underwent pre- or/and postoperative V-A ECLS support. The end-points of this study were in-hospital survival and ECLS complications. RESULTS: From a total of 214 post-AMI PMR patients submitted to surgery, V-A ECLS was instituted in 23 (11%) patients. The median age was 61.7 years (range 46-81 years). Preoperatively, ECLS was commenced in 10 patients (43.5%), whereas intra/postoperative in the remaining 13. The most common V-A ECLS indication was post-cardiotomy shock, followed by preoperative cardiogenic shock and cardiac arrest. The median duration of V-A ECLS was 4 days. V-A ECLS complications occurred in more than half of the patients. Overall, in-hospital mortality was 39.2% (9/23), compared to 22% (42/219) for the non-ECLS group. CONCLUSIONS: In post-AMI PMR patients, V-A ECLS was used in almost 10% of the patients either to promote bridge to surgery or as postoperative support. Further investigations are required to better evaluate a potential for increased use and its effects of V-A ECLS in such a context based on the still high perioperative mortality. ispartof: ARTIFICIAL ORGANS ispartof: location:United States status: Published online

OBJECTIVES Papillary muscle rupture (PMR) is a rare but potentially fatal complication of acute myocardial infarction. The aim of this study was to analyse the patient characteristics and early outcomes of the surgical management of post-infarction PMR from an international multicentre registry. METHODS Patients underwent surgery for post-infarction PMR between 2001 through 2019 were retrieved from database of the CAUTION study. The primary end point was in-hospital mortality. RESULTS A total of 214 patients were included with a mean age of 66.9 (standard deviation: 10.5) years. The posteromedial papillary muscle was the most frequent rupture location (71.9%); the rupture was complete in 67.3% of patients. Mitral valve replacement was performed in 82.7% of cases. One hundred twenty-two patients (57%) had concomitant coronary artery bypass grafting. In-hospital mortality was 24.8%. Temporal trends revealed no apparent improvement in in-hospital mortality during the study period. Multivariable analysis showed that preoperative chronic kidney disfunction [odds ratio (OR): 2.62, 95% confidence interval (CI): 1.07–6.45, P = 0.036], cardiac arrest (OR: 3.99, 95% CI: 1.02–15.61, P = 0.046) and cardiopulmonary bypass duration (OR: 1.01, 95% CI: 1.00–1.02, P = 0.04) were independently associated with an increased risk of in-hospital death, whereas concomitant coronary artery bypass grafting was identified as an independent predictor of early survival (OR: 0.38, 95% CI: 0.16–0.92, P = 0.031). CONCLUSIONS Surgical treatment for post-infarction PMR carries a high in-hospital mortality rate, which did not improve during the study period. Because concomitant coronary artery bypass grafting confers a survival benefit, this additional procedure should be performed, whenever possible, in an attempt to improve the outcome. Clinical trial registration clinicaltrials.gov: NCT03848429.

Background: The present study evaluates outcomes of LVAD patients, taking into account the device strategy and the INTERMACS profile. Methods: We included 192 LVAD-patients implanted between January 2012 and May 2021. The primary and secondary end-points were survival and major adverse events between Profiles 1–3 vs. Profile 4, depending on implantation strategies (Bridge-to-transplant-BTT; Bridge-to-candidacy-BTC; Destination-Therapy-DT). Results: The overall survival was 67% (61–75) at 12 months and 61% (54–70) at 24 months. Profile 4 patients showed significantly higher survival (p = 0.018). Incidences of acute right-ventricular-failure (RVF) (p = 0.046), right-ventricular-assist-device (RVAD) implantation (p = 0.015), and continuous-venovenous-hemofiltration (CVVH) (p = 0.006) were higher in Profile 1–3 patients, as well as a longer intensive care unit stays (p = 0.050) and in-hospital-mortality (p = 0.012). Twelve-month and 24-month survival rates were higher in the BTT rather than in BTC (log-rank = 0.410; log-rank = 0.120) and in DT groups (log-rank = 0.046). In the BTT group, Profile 1–3 patients had a higher need for RVAD support (p = 0.042). Conclusions: LVAD implantation in elective patients was associated with better survival and lower complications incidence. LVAD implantation in BTC patients has to be considered before their conditions deteriorate. DT should be addressed to elective patients in order to guarantee acceptable results.

Although Heart Transplant is still the gold standard treatment for end-stage heart failure patients, the limitation of this procedure is the discrepancy between the amount of waiting list patients and donors. Organ Care Systems, preventing the detrimental effects of cold ischemia, potentially increase donor pool. Herein we report three cases where high-risk excisions were required to clarify the nature of suspected lesions in donors. We decided to retrieve the organs and to place them in the devices before performing the excision. Our experience confirm the possibility to utilise this device as a time buffer in these peculiar scenarios.

(1) Objectives: The aim of this study was to investigate the impact of the prolonged use of continuous-flow left ventricular assist devices (LVADs) on heart transplant (HTx) candidates. (2) Methods: Between January 2012 and December 2019, we included all consecutive patients diagnosed with end-stage heart failure considered for HTx at our institution, who were also eligible for LVAD therapy as a bridge to transplant (BTT). Patients were divided into two groups: those who received an LVAD as BTT (LVAD group) and those who were listed without durable support (No-LVAD group). (3) Results: A total of 250 patients were analyzed. Of these, 70 patients (28%) were directly implanted with an LVAD as BTT, 11 (4.4%) received delayed LVAD implantation, and 169 (67%) were never assisted with an implantable device. The mean follow-up time was 36 ± 29 months. In the multivariate analysis of survival before HTx, LVAD implantation showed a protective effect: LVAD vs. No-LVAD HR 0.01 (p < 0.01) and LVAD vs. LVAD delayed HR 0.13 (p = 0.02). Mortality and adverse events after HTx were similar between LVAD and No-LVAD (p = 0.65 and p = 0.39, respectively). The multi-state survival analysis showed a significantly higher probability of death for No-LVAD vs. LVAD patients with (p = 0.03) or without (p = 0.04) HTx. (4) Conclusions: The use of LVAD as a bridge to transplant was associated with an overall survival benefit, compared to patients listed without LVAD support.

Background: In this study, we assessed the mid-term outcomes of patients who received a heart donation from a marginal donor (MD), and compared them with those who received an organ from a standard donor (SD). Methods: All patients who underwent HTx between January 2012 and December 2020 were enrolled at a single institution. The primary endpoints were early and long-term survival of MD recipients. Risk factors for primary graft failure (PGF) and mortality in MD recipients were also analyzed. The secondary endpoint was the comparison of survival of MD versus SD recipients. Results: In total, 238 patients underwent HTx, 64 (26.9%) of whom received an organ from an MD. Hospital mortality in the MD recipient cohort was 23%, with an estimated 1 and 5-year survival of 70% (59.2–82.7) and 68.1% (57.1–81), respectively. A multivariate analysis in MD recipients showed that decreased renal function and increased inotropic support of recipients were associated with higher mortality (p = 0.04 and p = 0.03). Cold ischemic time (p = 0.03) and increased donor inotropic support (p = 0.04) were independent risk factors for PGF. Overall survival was higher in SD than MD (85% vs. 68% at 5 years, log-rank = 0.008). However, risk-adjusted mortality (p = 0.2) and 5-year conditional survival (log-rank = 0.6) were comparable. Conclusions: Selected MDs are a valuable resource for expanding the cardiac donor pool, showing promising results. The use of MDs after prolonged ischemic times, increased inotropic support of the MD or the recipient and decreased renal function are associated with worse outcomes.

Key Points Question What are the early outcomes of surgical treatment of postinfarction ventricular septal rupture? Findings In this cohort study of 475 patients from 26 different centers worldwide, the early mortality rate for surgically treated ventricular septal rupture was 40.4%, mostly due to low cardiac output, and it did not improve in the last 2 decades. Meaning The findings of this study suggest that patient-tailored preoperative and perioperative management of postinfarction ventricular septal rupture should be addressed to improve the current suboptimal survival rates., This cohort study assesses the clinical characteristics and early outcomes for patients who received surgery for postinfarction ventricular septal rupture and identifies factors independently associated with mortality., Importance Ventricular septal rupture (VSR) is a rare but life-threatening mechanical complication of acute myocardial infarction associated with high mortality despite prompt treatment. Surgery represents the standard of care; however, only small single-center series or national registries are usually available in literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic. Objectives To assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction VSR and to identify factors independently associated with mortality. Design, Setting, and Participants The Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort (CAUTION) Study is a retrospective multicenter international cohort study that includes patients who were treated surgically for mechanical complications of acute myocardial infarction. The study was conducted from January 2001 to December 2019 at 26 different centers worldwide among 475 consecutive patients who underwent surgery for postinfarction VSR. Exposures Surgical treatment of postinfarction VSR, independent of the technique, alone or combined with other procedures (eg, coronary artery bypass grafting). Main Outcomes and Measures The primary outcome was early mortality; secondary outcomes were postoperative complications. Results Of the 475 patients included in the study, 290 (61.1%) were men, with a mean (SD) age of 68.5 (10.1) years. Cardiogenic shock was present in 213 patients (44.8%). Emergent or salvage surgery was performed in 212 cases (44.6%). The early mortality rate was 40.4% (192 patients), and it did not improve during the nearly 20 years considered for the study (median [IQR] yearly mortality, 41.7% [32.6%-50.0%]). Low cardiac output syndrome and multiorgan failure were the most common causes of death (low cardiac output syndrome, 70 [36.5%]; multiorgan failure, 53 [27.6%]). Recurrent VSR occurred in 59 participants (12.4%) but was not associated with mortality. Cardiogenic shock (survived: 95 [33.6%]; died, 118 [61.5%]; P

Background and Aims: Right ventricle failure (RVF) can be a fatal complication following left ventricle assist device (LVAD) implant. Careful intra and postoperative management is becoming increasingly important. Unfortunately, the attempts are limited to the prediction and not to the treatment. There are no data on Ketogenic parenteral nutrition (KPN) for the targeted treatment of RVF. The aim of our retrospective observational case-control study is to determine whether KPN may play a role as additional treatment to conventional therapy after LVAD implantation.Material and Methods: This is a retrospective single center analysis of a case series on prospectively collected data. From February 2012 to April 2021, 192 patients have been implanted with an LVAD. All the patients were managed with optimal medical and surgical therapy. One-hundred-seven patients were treated with additional KPN as adjuvant therapy against and in prevention of acute RVF (KPN-Group), defined according to International Society Heart and Lung Transplantation (ISHLT) guidelines. The remaining 85 patients, managed without KPN, constituted our control group (No-KPN-Group).Results: In KPN-Group acute-RVF occurred in 31 patients (29%), while causing death in 14 patients (13%). In the No-KPN-Group acute-RVF was observed in 32 patients (37.6%), while causing death in 20 patients (23.5%). According to echocardiographic and hemodynamic results, the majority of KPN-Group patients responded with RV function improvement (range 4–60% of TAPSE increase, p Conclusion: KPN was well tolerated. A complete recovery of the RV function was achieved in the majority of the patients and results lasted beyond the duration of KPN. Future research to understand the underlying mechanism, and identification of suitable patients and treatment duration is necessary.

We describe an unexpected complication in a 46-years-old man affected by ischemic cardiomyopathy who received a prolonged mechanical cardiac support by means of right transaxillary Impella 5.0. The postoperative course was complicated by recurrent septicemia from multi-durg resistant Acinetobacter baumanii. He underwent implantation of venoarterial extracorporeal membrane oxygenation because of refractory cardiac arrest, followed by Impella removal that has been complicated by embolic stroke. The likely source of the embolus was a large thrombus inside the innominate artery. After a long-standing right transaxillary device implantation, particularly in patients with intercurrent septic episodes, a CT angiographic scan should be planned to exclude arterial thrombosis before removal of the transarterial device.

Background Propensity score matching is a statistical method that is often used to make inferences on the treatment effects in observational studies. In recent years, there has been widespread use of the technique in the cardiothoracic surgery literature to evaluate to potential benefits of new surgical therapies or procedures. However, the small sample size and the strong dependence of the treatment assignment on the baseline covariates that often characterize these studies make such an evaluation challenging from a statistical point of view. In such settings, the use of propensity score matching in combination with oversampling and replacement may provide a solution to these issues by increasing the initial sample size of the study and thus improving the statistical power that is needed to detect the effect of interest. In this study, we review the use of propensity score matching in combination with oversampling and replacement in small sample size settings. Methods We performed a series of Monte Carlo simulations to evaluate how the sample size, the proportion of treated, and the assignment mechanism affect the performances of the proposed approaches. We assessed the performances with overall balance, relative bias, root mean squared error and nominal coverage. Moreover, we illustrate the methods using a real case study from the cardiac surgery literature. Results Matching without replacement produced estimates with lower bias and better nominal coverage than matching with replacement when 1:1 matching was considered. In contrast to that, matching with replacement showed better balance, relative bias, and root mean squared error than matching without replacement for increasing levels of oversampling. The best nominal coverage was obtained by using the estimator that accounts for uncertainty in the matching procedure on sets of units obtained after matching with replacement. Conclusions The use of replacement provides the most reliable treatment effect estimates and that no more than 1 or 2 units from the control group should be matched to each treated observation. Moreover, the variance estimator that accounts for the uncertainty in the matching procedure should be used to estimate the treatment effect.

Objectives 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. Background The worldwide severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic has created unprecedented challenges for public health, demanding exceptional efforts for the successful management and treatment of affected patients. Heart transplant patients represent a unique cohort of chronically immunosuppressed subjects in which SARS-CoV-2 may stimulate an unpredictable clinical course of infection. Methods Since February 2020, we enrolled all 47 cases (79% male) in a first cohort of patients, with a mean age of 61.8 ± 14.5 years, who tested positive for SARS-CoV-2, out of 2,676 heart transplant recipients alive before the onset of the COVID-19 pandemic at 7 heart transplant centers in Northern Italy. Results To date, 38 patients required hospitalization while 9 remained self-home quarantined and 14 died. Compared to the general population, prevalence (18 vs. 7 cases per 1,000) and related case fatality rate (29.7% vs. 15.4%) in heart transplant recipients were doubled. Univariable analysis showed older age (p = 0.002), diabetes mellitus (p = 0.040), extracardiac arteriopathy (p = 0.040), previous PCI (p = 0.040), CAV score (p = 0.039), lower GFR (p = 0.004), and higher NYHA functional classes (p = 0.023) were all significantly associated with in-hospital mortality. During the follow-up two patients died and a third patient has prolonged viral-shedding alternating positive and negative swabs. Since July 1st, 2020, we had 6 new patients who tested positive for SARS-CoV-2, 5 patients asymptomatic were self-quarantined, while 1 is still hospitalized for pneumonia. A standard therapy was maintained for all, except for the hospitalized patient. Conclusions The prevalence and mortality of SARS-CoV-2 should spur clinicians to immediately refer heart transplant recipients suspected as having SARS-CoV2 infection to centers specializing in the care of this vulnerable population.

Right ventricular primary graft dysfunction after heart transplant is a serious life-threatening condition. The severe form, refractory to maximal medical therapy, has traditionally required temporary mechanical support through veno-arterial extracorporeal membrane oxygenation or central right ventricular support. The Protek Duo is a dual lumen cannula recently introduced in the market, which allows for the institution of a percutaneous right ventricular support. We present the first promising case series of the use of this novel support in patients with right ventricular primary graft dysfunction after heart transplant.

In this work we aimed to evaluate the evolution of our surgical experience with the implantation of a continuous flow left ventricular assist device (LVAD), from the original full sternotomy approach to less invasive surgical strategies including mini-sternotomy and/or mini-thoracotomies. We reviewed all consecutive patients implanted with a continuous flow LVAD at our Institute. To exclude the possible bias related to the device used, out of 91 collected LVADs implants, we selected only those patients (n = 42) who received, between 2012 and 2015, the HeartWare HVAD. The analysis focused on the surgical approach used for the LVAD implant. Most of the patients (95%) were affected by dilated or ischemic cardiomyopathy, with an INTERMACS class I-II in the majority of cases (77%). The LVAD implant was performed through a full sternotomy in 10 patients (24%); the remaining 32 cases (76%) were managed with minimally invasive procedures. These were left mini-thoracotomy with upper mini-sternotomy (20 patients, 62%), right and left mini-thoracotomy (7 patients, 22%), and a recently developed left mini-thoracotomy with outflow graft anastomosis to the left axillary artery (5 patients, 16%). The most common adverse event on device was right heart failure (26%). Eighteen patients (43%) were transplanted. Overall estimated 24 months survival (on device or after transplant) was 68 ± 7%. The causal analysis, adjusted by propensity score weighting baseline data and sample size, showed that left mini-thoracotomy with outflow anastomosis to the left axillary artery resulted in a significantly reduced rate of post implant right heart failure (P < 0.01), and mechanical ventilation time (P = 0.049). To conclude, in our series, by applying mini-invasive implant techniques in the majority of cases, mid-term survival of continuous flow LVADs in severely compromised patients was satisfactory. In the adjusted analysis, the left anterior mini-thoracotomy with outflow anastomosis to the left axillary artery showed the most favorable results.

Congenital mitral valve (MV) dysplasia is a relatively rare and highly complex cardiac disease. We sought to provide a comprehensive analysis of the current surgical techniques for treating mitral valve insufficiency and the results of mitral valve repair at our institution. Between 1972 and 2017, 104 consecutive patients underwent surgical repair of congenital MV dysplasia-insufficiency at our institution. Among these, 59 patients presented with MV insufficiency (or prevalent MV insufficiency) and were part of the study. There was 1 early (1.7%) and 1 late death (1.7%). Survival at 5, 10 and 20 years was 98%, 98% and 94%, respectively. Eight patients (14%) required MV replacement for residual significant MV insufficiency. Freedom from re-intervention for MV dysfunction at 5, 10 and 20 years were 89%, 84% and 79%, respectively. Surgical techniques for treating mitral valve insufficiency must be tailored for each patient with the main goal of achieving a proper valve function, rather than a "normal" anatomy. The mechanism underlying valve dysfunction in congenital mitral valve insufficiency is multifactorial and requires the application of a variety of surgical techniques in each case.

Left ventricular assist devices (LVADs) are an established option for the treatment of end-stage heart failure. Last-generation devices are characterized by a miniaturized pump size, allowing for intra-pericardial placement. This feature enabled the introduction of less-invasive implantation techniques, which have been linked to many favorable effects. The HeartMate 3 LVAD is a continuous-flow centrifugal pump, recently introduced for clinical use. Here, we describe the minimally invasive implantation of the HeartMate 3 through a bilateral mini-thoracotomy.

The post-auricular (PA) driveline positioning for percutaneous power delivery is a specific feature of the Jarvik 2000 FlowMaker LVAD. We applied several technical refinements to optimise the PA implant. Here, we present and discuss these modifications. We retrospectively reviewed all patients implanted with Jarvik 2000 at our Institution. Different PA implant techniques were described. A machine learning analysis was performed to evaluate the determinants of driveline infection. From December 2008 to December 2017, 62 patients were implanted with Jarvik 2000, at our Institution. The PA connection was managed through the “question mark-shaped” incision in 24 patients (39%) and with the “C-shaped” in 18 (29%), whereas 10 (16%) cases received the “vertical incision” and 10 (16%) the “orthogonal incision”. The implant technique resulted highly predictive of driveline infection. The rate of driveline infections was numerically lower among cases managed with the last two techniques. After evolving through different implant techniques, we propose and suggest the “orthogonal incision” to maximise the advantages of the Jarvik 2000 post-auricular driveline.

Background: Propensity score matching represents one of the most popular techniques to deal with treatment allocation bias in observational studies. However, when the number of enrolled patients is very low, the creation of matched set of subjects may highly depend on the model used to estimate individual propensity scores, undermining the stability of consequential clinical findings. In this study, we investigate the potential issues related to the stability of the matched sets created by different propensity score models and we propose some diagnostic tools to evaluate them. Methods: Matched groups of patients were created using five different methods: Logistic Regression, Classification and Regression Trees, Bagging, Random Forest and Generalized Boosted Model. Differences between subjects in the matched sets were evaluated by comparing both pre-treatment covariates and propensity score distributions. We applied our proposal to a cardio-surgical observational study that aims to compare two different procedures of cardiac valve replacement. Results: Both baseline characteristics and propensity score distributions were systematically different across matched samples of patients created with different models used to estimate propensity score. The most relevant differences were observed for the matched set created by estimating individual propensity scores with Classification and Regression Trees algorithm. Conclusion: Clinical stability of matched samples created with different statistical methods should always be evaluated to ensure reliability of final estimates. This work opens the door for future investigations that fully assess the implications of this finding.

Purpose The aim of the study was to evaluate the trend of all the three type of rejection, cellular, humoral and mixed, during 6 years of follow-up , from 2012 to 2017 at the our transplant center, to evaluate pre-transplant clinical predictive factors for acute rejections and mortality. Methods We evaluated 149 patients heart transplanted adult patients transplanted from January 2012 and December 2017 at the university of Padua . Post transplant monitoring EMBs from 2012 to December 2018 were reevaluated . All the pre-transplant clinical were collected in a data base. The statistical analysis was subdivided in two parts. In the first part we analyzed the trend of the three different type of rejections, calculated the rate expressed as a average number of rejections for patients per year, with a Poisson distribution. In the second part we applied Machine learning method (ML), and algorithm Random Forest (RF) to analyzed the pre-transplant factors for the onset of acute rejections and for mortality. Results Of the 149 pts , 108(72,5%) were male and 41 (27,5%) female, mean age at transplantation 53,7±11,9 years for male and 46,2±15,4 for female. Two thousand and thirty three EMBs were performed during follow up with a mean number of 13,5±4,27 EMBs per patient. Of these , 1163 (57,2%) were negative for rejection, 31 (1,5%) positive for humoral rejection (pAMR+), 796 (39,2%) positive for ACR , 43 (2,1%) positive for mixed rejection. For all type of rejection there were a decreasing trend during the 6 years of follow up. The reduction in the mean number of rejection was 53,4% for acute rejection. Pre transplant predictive factors of cellular rejection were the pathology leading to heart transplant with a predictive value of 0,9%, age at transplant with a value of 0,8%. For humoral rejection the predictive factors were preforming antibodies anti HLA class II with a predictive value of 1,9%, previous pregnancies and miscarriage with a predictive value of 1,8% . The risk of mortality was influenced by age of donor with a risk value of 7,8%, the age at transplant with a risk value of 6,6%. Conclusion We have demonstrated that there is a decreasing trend of the three types of rejection during the last 6 years of follow up, in particular of cellular rejection. This is not in relation with changing in immunosuppressive drugs , but probably is due to pre and postoperative better management of heart transplant patients.

Background and aim of the study Congenital mitral valve (MV) dysplasia is a relatively rare and highly complex cardiac disease. We present our results and illustrate the techniques used to repair these valves. Methods Between 1972 and 2014, 100 consecutive patients underwent surgical repair of congenital MV dysplasia at our institution. Predominant MV regurgitation was present in 53 patients (53%) whereas mitral stenosis was prevalent in 47 (47%). Results There were five early (5%) and eight late deaths (9%). Actuarial survival was 95%, 94%, and 93% at 5, 10, and 20 years, respectively. Sixteen patients (18%) required reintervention due to subsequent MV dysfunction. Actuarial freedom from reintervention for MV dysfunction was 95%, 92%, and 89% at 5, 10, and 20 years, respectively. Conclusions The mechanism underlying the valve dysfunction in congenital mitral valve dysplasia is multifactorial and requires the application of a variety of surgical techniques for repair. doi: 10.1111/jocs.12743 (J Card Surg 2016;31:352-356).

Purpose The aim of the study was to evaluate the trend of all the three type of rejection, cellular, humoral and mixed, during 6 years of follow-up, from 2012 to 2017 at the our transplant center, to evaluate pre-transplant clinical predictive factors for acute rejections and mortality. Methods We evaluated 149 patients heart transplanted adult patients transplanted from January 2012 and December 2017 at the university of Padua. Post transplant monitoring EMBs from 2012 to December 2018 were reevaluated . All the pre-transplant clinical were collected in a data base. The statistical analysis was subdivided in two parts. In the first part we analyzed the trend of the three different type of rejections, calculated the rate expressed as a average number of rejections for patients per year, with a Poisson distribution. In the second part we applied Machine learning method (ML), and algorithm Random Forest (RF) to analyzed the pre-transplant factors for the onset of acute rejections and for mortality. Results 1163 (57,2%) were negative for rejection, 31 (1,5%) positive for humoral rejection (pAMR+), 796 (39,2%) positive for ACR, 43 (2,1%) positive for mixed rejection. For all type of rejection there were a decreasing trend during the 6 years of follow up. The reduction in the mean number of rejection was 53,4% for acute rejection. Acute cellular rejection decreased significantly in relation to humoral rejection, in particular for the severe grade. Pre transplant predictive factors of cellular rejection were the pathology leading to heart transplant with a predictive value of 0,9%, age at transplant with a value of 0,8%. For humoral rejection the predictive factors were preforming antibodies anti HLA class II with a predictive value of 1,9%, previous pregnancies and miscarriage with a predictive value of 1,8% . The risk of mortality was influenced by age of donor with a risk value of 7,8%, the age at transplant with a risk value of 6,6%. Conclusion We have demonstrated that there is a decreasing trend of the three types of rejection during the last 6 years of follow up, in particular of cellular rejection. This is not in relation with changing in immunosuppressive drugs, but probably is due to pre and postoperative better management of heart transplant patients.

AIMS We analysed the outcomes with the use of a new-generation continuous-flow left ventricular assist device (CF-LVAD) as a bridge-to-transplant (BTT). MATERIALS AND METHODS We included all patients implanted with an intrapericardial CF-LVAD as BTT, between January 2012 and December 2016. Primary outcomes were overall survival, survival on waiting list and postheart transplant (HTx) survival. The outcomes after HTx were compared with those of a contemporary cohort of patients transplanted without previous CF-LVAD (No-LVAD group, n = 73). RESULTS We included 53 patients with a median age of 52 years (interquartile range: 43-59 years). Seventy-two percent were in INTERMACS profile 1-2 before implant; all entered the HTx waiting list after receiving the CF-LVAD. HTx was performed in 42 (79%) cases (LVAD group). Overall estimated survival (considering both pre-HTx and post-HTx) was 89% [95% confidence interval (CI) 81-98%] at 1 year and 80% (CI 70-92%) at 2 years. The estimated survival on waiting list was 91% (CI 80-100%) at 6 months, whereas the 1-year estimated post-HTx survival was 88% (CI 79-98%). The Kaplan-Meier curves of survival after HTx of LVAD versus No-LVAD group were comparable (log-rank P = 0.54), as well as the rates of post-HTx adverse events. A multivariable model of survival after HTx, accounting for the most relevant patient characteristics, identified LVAD use as a significant protective factor [LVAD versus No-LVAD hazard ratio 0.22 (CI 0.06-0.91)]. CONCLUSION The use of new-generation intrapericardial CF-LVADs as a BTT resulted, in our series, in satisfactory pre-HTx and post-HTx outcomes.

Background The role of extracorporeal life support (ECLS) in primary cardiogenic shock (PCS) is well established. In this study, we evaluated the impact of etiology on outcomes. Methods Between January 2009 and March 2013, we implanted a total of 249 patients with ECLS; we focused on 64 patients for whom peripheral ECLS was the treatment for PCS. Of these, 37 cases (58%) were “acute” (mostly acute myocardial infarction: 39%); 27 (42%) had an exacerbation of “chronic” heart failure (dilated cardiomyopathy: 30%; post-ischemic cardiomyopathy: 9%; and congenital: 3%). Results In the group with chronic etiology, 23 patients were bridged to a left ventricular assist device (52%) or heart transplantation (33%). In the group with acute etiology, ECLS was used as a bridge-to-transplantation in 3 patients (8%), a bridge-to-bridge in 9 (24%), and a bridge-to-recovery in 18 (49%). One patient in each group was bridged to conventional surgery. Recovery of cardiac function was achieved in only the group with acute primary cardiogenic shock (18 vs 0 patients, P = .0001). A mean flow during support of ≤60% of the theoretic flow (body surface area × 2.4) was a predictor of successful weaning (P = .02). Median duration of ECLS support was 7 days (range: 2-11.5 days). Nine patients (14%) died during support; 30-day overall survival was 80% (51 of 64 patients); and 59% of patients were discharged, in whom survival at 48 months was 90%. Thirty-day survival was correlated with duration of ECLS support. Conclusions In “chronic” heart failure, ECLS represents a bridge to a ventricular assist device or heart transplantation, whereas in “acute” settings, it offers a considerable chance of recovery, and is often the only required therapy.

OBJECTIVES Surgical management of acute DeBakey Type I aortic dissection without intimal tear in the aortic arch is controversial. This study compared short- and long-term outcomes of total arch replacement (TAR) versus limited ascending aorta/hemiarch replacement (no-TAR) in a consecutive series of patients. METHODS Between January 1998 and December 2015, 220 consecutive patients were operated for DeBakey Type I acute aortic dissection; 135 cases did not exhibit an intimal entry tear in the aortic arch and were subsequently selected to comprise the primary study cohort. A secondary subgroup analysis was made within these 135 cases, which comprised patients who received antegrade cerebral perfusion as the neuroprotective strategy of choice (n = 45). RESULTS Mean follow-up period was 5 ± 4 years. Among the patients selected, 21 (16%) underwent TAR. Thirty-day mortality was higher in the TAR group (38% vs 21%, P = 0.04). Postoperative complication rates were similar between the groups (61% vs 73%, P = 0.31). Long-term mortality and late aortic reintervention rates were also similar (7% vs 30%, P = 0.36 and 27% vs 14%, P = 0.32, respectively). From the subgroup of patients with antegrade cerebral perfusion, 14 (31%) underwent TAR and 31 (69%) had no-TAR. Mean follow-up-time was 3 ± 2 years. Thirty-day mortality was higher in the TAR group (50% vs 16%, P

Objectives The “one-and-a-half ventricle repair” (1.5 VR) is applied to several congenital heart diseases with hypoplastic right ventricle (RV), with good functional and clinical results in infants and children, but feasibility in adult population is being explored. Materials and Methods This is a retrospective analysis of medical records of all adult patients undergoing 1 + 1/5 VR between 2000 and 2012. Results Five patients (M/F = 4/1, mean age of 42.3 years, range 29–66.8) underwent 1 + 1/5 VR. Underlying diagnoses were Ebstein's anomaly (EA) in three, hypoplastic RV and tricuspid valve (TV) in two. Mean TV annulus Z-score was −3.0; mean pulmonary vascular resistance was 1.6 WU/m2. Eleven associated procedures were performed simultaneously to 1.5 VR. There were no operative deaths. All patients were discharged home alive and in good clinical condition on anticoagulation regimen. At a mean follow-up of 8.6 ± 5.2 years, there was one cerebral stroke-related death; two patients experienced major complications. Two patients are in NYHA Class I, one is in NYHA Class II, and the last in NYHA Class III on a transplant list. Conclusions The one-and-a-half ventricle repair in adult patients is feasible with low mortality. However, advanced age-associated co-morbidities and prolonged chronic RV preoperative dysfunction may jeopardize long-term results when compared to children. doi: 10.1111/jocs.12350 (J Card Surg 2014;29:542–545)

The benefits of total arterial (TAR) versus conventional (CR) revascularization are controversial in the higher-risk cohort of elderly patients. Taking for granted its benefit on long-term survival, we evaluated the effect of TAR on safety (death, myocardial infarction, and stroke) of patients undergoing CABG. Between 2000 and 2009, 487 patients >75 years underwent isolated CABG at our institution (150 TAR and 337 CR). Patients with arterial free-grafts were excluded. After propensity matching, the outcomes of 131 TAR and 127 CR patients were compared. TAR patients had lower incidence of post-operative myocardial infarction (p = 0.025) and stroke (p = 0.005). They also experienced shorter intensive care unit (p = 0.046) and ward stay (p = 0.028), lower output of TnI (p = 0.035), and less wound complications (leg included) (p = 0.0001), while mortality was comparable (p = 0.57). In our cohort of elderly patients with multivessel disease, TAR was associated with lower rates of myocardial infarction, stroke, and shorter hospital stay.

Despite substantial progress in surgical techniques and perioperative management, the treatment and long-term follow-up of type A acute aortic dissection (AAD) still remain a major challenge. The objective of this retrospective, multicentre study was to assess in a large series of patients the early and long-term results after surgery for type A AAD.We analysed the preoperative, intraoperative and postoperative conditions of 1.148 consecutive patients surgically treated in seven large referral centres from 1981 to 2013. We applied to each patient three different multi-parameter risk profiles (preadmission risk, admission risk and post-surgery risk) in order to compare risk factors and outcome. Long-term Kaplan-Meier survival was evaluated.The median age was 64 years and the male population was predominant (66%). Identified diagnosis of collagen disease was present in 9%, and Marfan syndrome in 5%. Bicuspid aortic valve was present in 69 patients (6%). Previous cardiac surgery was identified in 10% of the patients. During surgery, the native aortic valve was preserved in 72% of the cases, including leaflet resuspension in 23% and David operation in 1.2%. Considering aortic valve replacement (AVR: 28%), bioprosthesis implantation was performed in 14.7% of the subjects. Neurological impairment at discharge was shown in 23% of the cases among which 21% of patients had new neurological impairment versus preoperative conditions. The overall 30-day mortality rate was 25.7%. All risk profiles remained independently associated with in-hospital mortality. During the available follow-up of hospital survivors (median: 70 months, interquartile range: 34-113, maximum: 396), cardiac-related death occurred in 7.9% of the subjects. The cumulative survival rate for cardiac death was 95.3% at 5 years, 92.8% at 10 years and 52.8% at 20 years. Severe aortic regurgitation (AR) (grade 3-4) at the time of surgery showed to be a significant risk factor for reintervention during the follow-up (P

We sought to examine the efficacy in preventing surgical site infection (SSI) in cardiac surgery, using two different incise drapes (not iodine-impregnated and iodine-impregnated). A cost analysis was also considered. Between January 2008 and March 2015, 5100 consecutive cardiac surgery patients, who underwent surgery in our Institute, were prospectively collected. A total of 3320 patients received a standard not iodine-impregnated steri-drape (group A), and 1780 patients received Ioban(®) 2 drape (group B). We investigated, by a propensity matched analysis, whether the use of standard incise drape or iodine-impregnated drape would impact upon SSI rate. Totally, 808 patients for each group were matched for the available risk factors. Overall incidence of SSI was significantly higher in group A (6.5 versus 1.9 %) (p = 0.001). Superficial SSI incidence was significantly higher in group A (5.1 vs 1.6 %) (p = 0.002). Deep SSI resulted higher in group A (1.4 %) than in group B (0.4 %), although not significantly (p = 0.11). Consequently, the need for vacuum-assisted closure (VAC) therapy use resulted 4.3 % in group A versus 1.2 % in group B (p = 0.001). Overall costs for groups A and B were 12.494.912 € and 11.721.417 €, respectively. The Ioban(®) 2 offered totally 773.495 € cost savings compared to standard steri-drape. Ioban 2 drape assured a significantly lower incidence of SSI. Additionally, Ioban(®) 2 drape proved to be cost-effective in cardiac surgery.

To evaluate predictors of early and long-term outcomes of surgical repair of acute Type A aortic dissection. Retrospective single-centre study evaluating patients surgically treated between 1998 and 2013. Clinical follow-up was performed. Complications were classified according to the International Aortic Arch Surgery Study Group recommendations. Statistical analysis included univariate and multivariate analysis of preoperative and operative data. One hundred eighty-five patients were evaluated. The follow-up was complete for 180 patients (97 %). Mean age was 63 years, 82 % had a DeBakey type I aortic dissection, 18 % a type II. Eleven patients (6 %) died intraoperatively, 119 of the remaining (68 %) had postoperative complications. Thirty-day mortality was 21 % (38 patients). Average ICU and hospital stay were 6 and 14 days, respectively. During a mean follow-up time of 6 ± 4 years we observed 44 deaths (31 %). Twenty patients (14 %) needed late thoracic aorta reoperation. Results from the multivariate analysis are as follows. Thirty-day mortality was associated with abdominal pain at presentation (p

OBJECTIVES: Sternal wound dehiscence (SWD) after cardiac surgery is a rare but serious condition associated with considerable costs and morbidity. We sought to evaluate the results of the introduction of vacuum-assisted closure (VAC) therapy in the management of sternal wound dehiscence, compared with those of previous conventional treatments. METHODS: We retrospectively collected 7148 patients who underwent cardiac surgery at our institution between January 2002 and June 2012. A total of 152 (2.1%) patients had a sternal wound dehiscence: 107 were treated with conventional treatments (Group A) and 45 were managed with VAC therapy (Group B). Patients were stratified according to preoperative risk factors and type of sternal wound dehiscence (superficial or deep; infected or not) and compared by means of a propensity-matched analysis. A cost analysis was also performed. RESULTS: Forty-five patients of each group matched for all preoperative risk factors and type of sternal wound dehiscence. SWD-related mortality rate was significantly lower in Group B (11 vs 0%; P= 0.05). Incidence of mediastinitis (P< 0.0001), sepsis (P= 0.04), delayed SWD infection (P= 0.05), other complication (P= 0.05), surgical sternal revision (P= 0.04) and surgical superficial revision (P< 0.0001) were all significantly lower in Group B. Mean patient cost was 31 106€ in Group A and 24 383€ in Group B, thus achieving a mean saving of 6723€ per patient. CONCLUSIONS: In our experience, the use of VAC therapy for the management of SWD was considerably effective in decreasing mortality (SWD related), incidence of complications and need for surgical procedures; thus, leading to a significant reduction of costs.

Purpose Antithrombotic therapy is essential in LVAD recipients and must be carefully titrated in each patient. Different devices might influence the coagulation system differently. An awareness of this may allow early planning of the most appropriate antithrombotic approach according to LVAD type. We studied the impact of two different continuous flow LVADs on the coagulation system: Jarvik 2000, an axial flow pump, versus HeartWare HVAD, a magnetically levitating centrifugal pump. Methods and Materials Results of platelet count, thromboelastometric and aggregometric tests were compared between 13 patients with Jarvik and 8 patients with HeartWare, all implanted in our center between 2008 and 2012. Results At 7, 14, 21 and 28 days HeartWare patients showed significantly higher levels of platelets, Intem-Extem MCF, TRAP and COL tests. After 2 months we observed a remarkable reduction of the markers of coagulation activation in HeartWare patients. Conclusions The two pumps have markedly different effects on hemostasis. The HeartWare causes hyperactivation of the coagulation system compared to the Jarvik. Accordingly, HeartWare patients usually need both anticoagulant and antiplatelet drugs, while Jarvik patients are usually managed only with anticoagulation. TEST POSTOP. DAY HVAD JARVIK P PLATELETS 7 241,4±113,9 114,4±53,5 0,01 14 457,7±109,1 119,2±70,14 21 385,2±75,8 140,7±83,9 0,0002 28 326,5±7,8 168,9±81,3 0,03 60 353±102,6 166,1±77,9 0,002 135 292±99 180,1±90 0,17 INTEM MCF 7 68,1±5,2 61,2±2 0,007 14 73,8±7,3 64,4±3,2 0,0104 21 77,5±3,2 58,2±6,4 0,0004 28 76,1± 5,2 53,4±8,7 EXTEM MCF 7 67,8±4,9 60±3,2 0,004 14 71,9±5,5 63,4±6 0,02 21 78±4 60,4±2,4 28 75,5±6,9 54,2±4,2 0,0001 FIBTEM MCF 7 32,5±4,5 28±2,4 0,03 14 36,9±8,1 28±4,1 0,02 21 41,5±13,1 30,6±6,8 0,09 28 35,4±26,2 19,8±10,4 0,25 TRAP 7 68,2±16,7 30,3±17,2 0,005 14 86±20,7 53,2±28,6 0,05 21 99,9±37,7 53±1,2 0,04 28 108,1 ± 21,4 51,2±1,5 0,01 COL 7 37±9,6 16,6±9,6 0,004 14 35,8±18 29,3±20,8 0,64 21 34,8±3,9 17±8,5 0,01 28 40,2±12,3 15±0,8 0,02