Twenty-year survival following orthotopic heart transplantation in the United States

The Impact of Heart Failure Chronic Treatment Prior to Cardiac Transplantation on Early Outcomes

Background and Objectives: Cardiac transplantation represents the option for patients with end-stage heart failure (HF), providing the best survival rate. However, the postoperative complications of transplant patients remain a challenge for clinicians. The objective of our study was to evaluate the effect of preoperative chronic HF treatment on the occurrence of in-hospital complications. Materials and Methods: We retrospectively included a total of 50 patients who underwent cardiac transplantation between January 2011 and December 2023 from the Emergency Institute for Cardiovascular Diseases and Transplantation of Targu Mures. We correlated the preoperative chronic HF treatment with the postoperative complications by Spearmen's correlation coefficient, respectively. With logistic regression, the associations between the treatment and specific complications were determined. Results: Significant negative correlations were found between Carvedilol treatment with 2-month mortality (r = -0.30; 95% CI: -0.53--0.02; p = 0.03), Ramipril with hospital stay (r = -0.38; 95% CI: -0.60--0.12; p < 0.01) and intensive care unit (ICU) stay (r = -0.37; 95% CI: -0.59--0.11; p = 0.01), and Spironolactone usage with hospitalization duration (r = -0.28; 95% CI: -0.52--0.01; p = 0.04). Furthermore, Carvedilol treatment represented a protective factor against early acute kidney injury (AKI) (OR: 0.22; 95% CI: 0.05-0.91; p = 0.03). Spironolactone treatment was a protective factor against AGR (OR: 0.12; 95% CI: 0.02-0.66; p = 0.01) treatment, in contrast to angiotensin-converting enzyme inhibitor (ACEI) therapy (OR: 5.30; 95% CI: 1.03-27.17; p = 0.04). Conclusions: Pre-transplant Carvedilol treatment was negatively correlated with the 2-month mortality rate. Ramipril and Spironolactone therapy were negatively correlated with hospitalization duration, and Ramipril was additionally correlated with ICU stay. Moreover, Carvedilol therapy represented a protective factor against early AKI. Pre-transplant Spironolactone was associated with lower event rates of AGR, in contrast to ACEI treatment. Prospective studies with larger cohorts are needed in order to draw drastic conclusions.

Management of Myocardial Infarction and the Role of Cardiothoracic Surgery

Myocardial infarction (MI) is a leading cause of mortality globally and is predominantly attributed to coronary artery disease (CAD). MI is categorized as ST-elevation MI (STEMI) or non-ST-elevation MI (NSTEMI), each with distinct etiologies and treatment pathways. The goal in treatment for both is restoring blood flow back to the myocardium. STEMI, characterized by complete occlusion of a coronary artery, is managed urgently with reperfusion therapy, typically percutaneous coronary intervention (PCI). In contrast, NSTEMI involves a partial occlusion of a coronary artery and is treated with medical management, PCI, or coronary artery bypass grafting (CABG) depending on risk scores and clinical judgment. The Heart Team approach can assist in deciding which reperfusion technique would provide the greatest benefit to the patient and is especially useful in complicated cases. Despite advances in treatment, complications such as cardiogenic shock (CS) and ischemic heart failure (HF) remain significant. While percutaneous coronary intervention (PCI) is considered the primary treatment for MI, it is important to recognize the significance of cardiac surgery in treatment, especially when there is complex disease or MI-related complications. This comprehensive review analyzes the role of cardiac surgery in MI management, recognizing when it is useful, or not.

Unique 40-year survival after heart transplantation with normal graft function and spontaneous operational tolerance

Unique 40-year survival after heart transplantation with normal graft function and spontaneous operational tolerance.

Heart Transplantation in a Patient With a Heterotopic Percutaneous Tricuspid Valve Prosthesis: A Case Report

The bicaval transcatheter prosthesis (TricValve) allows the treatment of cava reflux in patients with severe tricuspid regurgitation and high surgical risk. It consists of the implantation of 2 self-expanding valves in both vena cava without directly approaching the native tricuspid valve. Heart transplantation in this setting may require some modifications compared with the conventional bicaval technique. We describe the clinical case of a 69-year-old woman with a background of rheumatic mitral valve disease who required a mitral valve replacement a few decades before. Ongoing clinical deterioration with biventricular dysfunction and severe tricuspid regurgitation was treated with a percutaneous bicaval heterotopic self-expanding valve system, with no clinical benefit. The patient underwent an elective heart transplantation. For the surgical approach, venous cannulation was performed percutaneously for both the right internal jugular and right femoral vein. Due to the impossibility of extracting percutaneous caval valves, the biatrial technique was selected for heart implantation. The postoperative course was difficult, but the patient was successfully discharged home 2 months postoperatively. She remains in good clinical condition with normal heart function 1 year after the transplant. To our knowledge, this is the first report describing a heart transplant in a patient with a bicaval transcatheter prosthesis.

International Survey on Perioperative Management of Patients With Infective Endocarditis

OBJECTIVES

To estimate the current practice in the perioperative management of patients undergoing cardiac surgery due to infective endocarditis.

DESIGN

A prospective, open, 24-item, web-based cross-sectional survey.

SETTING

Online survey endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC).

PARTICIPANTS

Members of the EACTAIC.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 156 responses from 44 countries were received, with a completion rate of 99%. The response rate was 16.6%. Most respondents (76%) practiced cardiac anesthesia in European hospitals, and most respondents stated that a multidisciplinary endocarditis team was not established at their center, that cardiac anesthesiologists appeared to be involved infrequently in those teams (36%), and that they were not involved in decision-making on indication and timing of surgery (88%). In contrast, the cardiac anesthesiologist performed intraoperative antibiotic therapy (62%) and intraoperative transesophageal echocardiography (90%). Furthermore, there was a relative heterogeneity concerning perioperative monitoring, as well as for coagulation and transfusion management.

CONCLUSIONS

This international survey evaluated current practice among cardiac anesthesiologists in the perioperative management of patients with infective endocarditis and the anesthesiologist's role in multidisciplinary decision-making. Heterogeneity in treatment approaches was identified, indicating relevant knowledge gaps that should encourage further clinical research to optimize treatment and postoperative outcomes in this specific population.

Short stature is a risk factor for heart transplant morbidity and mortality

BACKGROUND

Short stature is associated with mortality after cardiac surgery and may increase size mismatch risk among transplant recipients. Yet, stature's impact on heart transplant outcomes is not well-characterized.

METHODS

The Scientific Registry of Transplant Recipients was queried for data on all adult heart transplants in the United States from 2000 to 2022. Recipients were stratified into five cohorts by sex-corrected stature. Morbidity was assessed with Kruskal-Wallis and chi-squared tests. Mortality was analyzed using Kaplan-Meier estimation. Risk factors for mortality were assessed with multivariable Cox regression.

RESULTS

Among 43,420 transplant recipients, 5321 (12.2%) had short stature (females >4'11″ & ≤5'1″; males >5'4″ & ≤5'7″) and 765 (1.8%) had very short stature (females ≤4'11″; males ≤5'4″). Very short stature patients had higher waitlist status (1A and 1), more congenital heart disease, and received more oversized donor hearts than other cohorts (all p < 0.05). Very short stature patients had decreased 30-day, 1-, 5-, and 10-year survival (94.6%, 84.3%, 69.3% and 52.5%, respectively, all p < 0.001), but less acute rejection (p = 0.005) and comparable stroke rates (p = 0.107). On multivariable regression adjusting for congenital heart disease and oversized donor hearts, very short and short stature were associated with 10-year mortality (hazard ratios: 1.40 and 1.12, respectively, both p < 0.005).

CONCLUSIONS

Short stature confers increased mortality risk for heart transplant recipients and merits inclusion in prognostic models.

Individual-Level Socioeconomic Position and Long-Term Prognosis in Danish Heart-Transplant Recipients

Socioeconomic deprivation can limit access to healthcare. Important gaps persist in the understanding of how individual indicators of socioeconomic disadvantage may affect clinical outcomes after heart transplantation. We sought to examine the impact of individual-level socioeconomic position (SEP) on prognosis of heart-transplant recipients. A population-based study including all Danish first-time heart-transplant recipients (n = 649) was conducted. Data were linked across complete national health registers. Associations were evaluated between SEP and all-cause mortality and first-time major adverse cardiovascular event (MACE) during follow-up periods. The half-time survival was 15.6 years (20-year period). In total, 330 (51%) of recipients experienced a first-time cardiovascular event and the most frequent was graft failure (42%). Both acute myocardial infarction and cardiac arrest occurred in ≤5 of recipients. Low educational level was associated with increased all-cause mortality 10-20 years post-transplant (adjusted hazard ratio [HR] 1.95, 95% confidence interval [CI] 1.19-3.19). During 1-10 years post-transplant, low educational level (adjusted HR 1.66, 95% CI 1.14-2.43) and low income (adjusted HR 1.81, 95% CI 1.02-3.22) were associated with a first-time MACE. In a country with free access to multidisciplinary team management, low levels of education and income were associated with a poorer prognosis after heart transplantation.

HVAD versus heartmate III bridge to heart transplantation: Waitlist and posttransplant outcomes

BACKGROUND

This study compared outcomes of patients bridged with either the Heartware HVAD or Heartmate 3 (HM3) device to orthotopic heart transplantation (OHT).

METHODS

The United Network of Organ Sharing registry was queried to perform two separate analyses of adult, isolated OHT candidates bridged with HVAD or HM3. First, waitlist outcomes were compared among patients waitlisted 1/1/2015-3/20/2020. Second, posttransplant survival was compared among those transplanted 1/1/2015-3/20/2020.

RESULTS

Two thousand two hundred fifty-five candidates were waitlisted within the study period, 1587 (70.4%) bridged with HVAD and 668 (29.6%) with HM3. At 1 year from waitlisting, cumulative incidence of OHT higher in the HVAD cohort (p < .001). During the same time period, 2643 patients underwent OHT, 2154 (81.5%) with prior HVAD and 489 (18.5%) with HM3. Yearly proportions of patients bridged with HM3 increased across the study period and decreased for HVAD (p < .001). HM3-bridged recipients had shorter waitlist times, longer graft cold ischemic times, and experienced a higher rate of posttransplant dialysis requirement. Unadjusted and risk-adjusted posttransplant mortality rates were similar between both groups.

CONCLUSIONS

Posttransplant survival is equivalent regardless of device type used for bridging. However, HM3 patients had lower likelihood of reaching transplantation, which may be a reflection of the recent heart allocation policy changes.