Milestone Operations in Heart Valve and Aortic Replacement: Anniversaries Worth Remembering

Seventy years ago, in 1952, Charles A. Hufnagel implanted a caged-ball prosthesis into the descending thoracic aorta, to treat a patient with aortic valve insufficiency. In 1962, 60 years ago, the first aortic homograft was implanted in a subcoronary position by Donald N. Ross and Brian G. Barratt-Boyes. Forty years ago, in 1982, the first anticalcification treatment was introduced in commercially manufactured porcine bioprostheses. All such important or even milestone events should be remembered, since they witness efforts made by those who have significantly influenced the clinical history of aortic and valvular diseases.

Metabolic Syndrome and Heart Transplantation: An Underestimated Risk Factor?

Metabolic Syndrome (MetS), a multifactorial condition that increases the risk of cardio-vascular events, is frequent in Heart-transplant (HTx) candidates and worsens with immunosuppressive therapy. The aim of the study was to analyze the impact of MetS on long-term outcome of HTx patients. Since 2007, 349 HTx patients were enrolled. MetS was diagnosed if patients met revised NCEP-ATP III criteria before HTx, at 1, 5 and 10 years of follow-up. MetS was present in 35% of patients pre-HTx and 47% at 1 year follow-up. Five-year survival in patients with both pre-HTx (65% vs. 78%, p < 0.01) and 1 year follow-up MetS (78% vs 89%, p < 0.01) was worst. At the univariate analysis, risk factors for mortality were pre-HTx MetS (HR 1.86, p < 0.01), hypertension (HR 2.46, p < 0.01), hypertriglyceridemia (HR 1.50, p=0.03), chronic renal failure (HR 2.95, p < 0.01), MetS and diabetes at 1 year follow-up (HR 2.00, p < 0.01; HR 2.02, p < 0.01, respectively). MetS at 1 year follow-up determined a higher risk to develop Coronary allograft vasculopathy at 5 and 10 year follow-up (25% vs 14% and 44% vs 25%, p < 0.01). MetS is an important risk factor for both mortality and morbidity post-HTx, suggesting the need for a strict monitoring of metabolic disorders with a careful nutritional follow-up in HTx patients.

Influence of a regional network combined with a systematic multidisciplinary approach on the outcomes of patients with acute type A aortic dissection

BACKGROUND

Whether in patients with acute type A aortic dissection reduction of intervals between onset of symptoms and diagnosis influences patient outcomes is still not completely defined.

METHODS

In 199 patients with acute type A aortic dissection, the efficacy of a systematic multidisciplinary approach and institution of a regional network were evaluated; 90 patients operated before 2016 (Group1) were compared with 109 repaired after 2016 (Group2) for early and late outcomes.

RESULTS

Mortality was reduced from 13% in Group1 to 4% in Group2 (p = 0.013). In Group2 a more patients (46%) had arch replacement compared to Group1 (29%)(p = 0.06). In Group2 axillary artery cannulation was almost routinely used (91% vs 67%, p < 0.001) with shorter circulatory arrest time (37 vs 44 min, p < 0.001). The interval from diagnosis to surgery dropped from 210 min in Group1 to 160 min in Group2 (p < 0.001); this reduction was evident both in patients admitted to the emergency department of a spoke and/or a hub center. Patients presenting with or developing shock were reduced from Group1 to Group2 and in particular those reaching the hub center from spoke centers. Survival at 1 and 5 years was 82 ± 4% and 70 ± 5% in Group1 vs 92 ± 3% and 87 ± 8% in Group2 (p = 0.007).

CONCLUSIONS

Outcomes of patients with acute type A aortic dissection improved using a systematic multidisciplinary approach while a network between spoke and hub centers reduced intervals between diagnosis, transportation to hub center and repair, limiting the incidence of tamponade and shock.

Heart Transplantation in High-Risk Recipients Employing Donor Marginal Grafts Preserved With Ex-Vivo Perfusion

Extending selection criteria to face donor organ shortage in heart transplantation (HTx) may increase the risk of mortality. Ex-vivo normothermic perfusion (EVP) limits ischemic time allowing assessment of graft function. We investigated the outcome of HTx in 80 high-risk recipients transplanted with marginal donor and EVP-preserved grafts, from 2016 to 2021. The recipients median age was 57 years (range, 13-75), with chronic renal failure in 61%, impaired liver function in 11% and previous cardiac surgery in 90%; 80% were mechanically supported. Median RADIAL score was 3. Mean graft ischemic time was 118 ± 25 min, "out-of-body" time 420 ± 66 min and median cardiopulmonary bypass (CPB) time 228 min (126-416). In-hospital mortality was 11% and ≥moderate primary graft dysfunction 16%. At univariable analysis, CPB time and high central venous pressure were risk factors for mortality. Actuarial survival at 1 and 3 years was 83% ± 4%, and 72% ± 7%, with a median follow-up of 16 months (range 2-43). Recipient and donor ages, pre-HTx extracorporeal life support and intra-aortic balloon pump were risk factors for late mortality. In conclusion, the use of EVP allows extension of the graft pool by recruitment of marginal donors to successfully perform HTx even in high-risk recipients.

Closed Mitral Valvotomy: Celebrating 100 Years of Surgical History

The year 2023 marks the 100th anniversary of the first successful valvotomy for mitral valve stenosis by Elliott C. Cutler in 1923. Closed-chest mitral valve commissurotomy developed further before being replaced by an open procedure after the advent of the heart-lung machine. Currently, because of the almost complete disappearance of rheumatic disease in the Western World, mitral commissurotomies are infrequently performed in those countries, although the procedure-either closed or open-is still performed in developing countries and select patients. This review retraces the 100-year journey from a historic operation to the current era-a milestone in the treatment of patients with mitral stenosis.

Replacement of a Calcified Aortic Valve in a Porcine Aortic Root with the Perceval Sutureless Bioprosthesis

We report a 79-year-old patient who had aortic valve replacement (AVR) using a porcine aortic root. Due to degeneration of the porcine aortic valve, he required reoperation during which a heavily calcified porcine root and aortic annulus prevented insertion of any traditional bioprosthesis. AVR was achieved using a sutureless bioprosthesis, combined with mitral valve replacement. The present case confirms the feasibility and advantages of using sutureless valve implantation in complex and high-risk redo procedures.

Artificial chordae for mitral valve repair

BACKGROUND

Mitral valve repair using expanded polytetrafluoroethylene sutures to replace mitral chordae tendineae is a well-established procedure. However, the incidence of neo-chordae failure causing recurrent mitral regurgitation is not well defined.

METHODS

We have reviewed the reported cases of complications after mitral valve repair related to the use of neo-chordae. This study was mainly carried out through PubMed, Medline, and Google Chrome websites.

RESULTS

We have identified a total of 26 patients presenting with rupture of polytetrafluoroethylene neo-chordae, mostly being described as isolated cases. Few other cases of recurrent mitral regurgitation with hemolysis were found, where reoperation was not caused by neo-chordal failure but most likely by technical errors. At pathological investigation the findings were substantially similar in all reported cases. The neo-chordae retained their length and pliability, became covered with host tissue and rupture was mainly related to suture size. Mild calcification was observed not interfering with chordal function; chordal infection did never occur.

CONCLUSIONS

The use of artificial neo-chordae provides excellent late results with durable mitral valve repair stability. Chordal rupture may occur late postoperatively leading to reoperation because of recurrent mitral regurgitation. Despite its rarity, this potential complication should not be overlooked during follow-up of patients after mitral valve repair using artificial neo-chordae.

P41 ORAL ANTICOAGULATION AFTER REPAIR OF ACUTE TYPE A AORTIC DISSECTION: A REAL RISK ON LONG–TERM?

Objective

To analyse the effects of chronic oral anticoagulation on long–term outcomes after repair of type A acute aortic dissection and its influence on false lumen fate.

Methods

We studied 188 patients (median age 62 years; 74% males) who had repair of type A aortic dissection; patients receiving postoperative chronic oral anticoagulation (n = 59) were compared to those on antiplatelet therapy alone (n = 129).

Results

Median age was similar: 60 (18–79 years) vs 64 years (22–86) (p = 0.11); patients on anticoagulants were more frequently males (88% vs 67%, p = 0.003). After a median follow–up of 8.4 years (2 months to 30 years) 58 patients died, 18 for aortic–related causes, and 37 underwent aortic reintervention. After multivariable adjustment, anticoagulation showed no significant effect on long–term survival (HR 0.85, 95% CI 0.41–1.76; p = 0.66) neither on risk of reintervention (HR 0.55, 95% CI 0.27–1.15; p = 0.11). Analysis of 127 postoperative computed tomography scans showed a patent false lumen in 53% of anticoagulated vs 38% of not anticoagulated patients (p = 0.09); partially thrombosed in 8% vs 28% (p = 0.01) and thrombosed in 39% vs 34% (p = 0.63). In patients with a control computed tomography there were 6 late aortic–related deaths, 1 among patients anticoagulated and 5 in those who were not.

Conclusions

Chronic anticoagulation after repair of type A acute aortic dissection favours persistent late false lumen patency which is not a risk factor for late mortality or reoperation. Chronic anticoagulation can be administered safely to patients with repaired type A acute aortic dissection regardless of its specific indication.

Early awaking of patients following FET allows early recognition of paraplegia with prospects for complete recovery using prompt spinal drainage

We report a patient who presented with paraplegia after ascending aorta and arch replacement using the frozen elephant trunk technique. Immediate postoperatively cerebrospinal fluid drainage allowed successful reversal of spinal cord injury. Early awakening of patients following a frozen elephant trunk technique is mandatory because it allows recognition and treatment of this complication by prompt cerebrospinal liquor drainage.

The Caged-Ball Prosthesis 60 Years Later: A Historical Review of a Cardiac Surgery Milestone

Sixty years ago, 2 cardiac operations dramatically influenced the survival of patients with valvular heart disease. The replacement of an aortic valve by Dwight Harken and of a mitral valve by Albert Starr with mechanical caged-ball valves, both in 1960, was a true milestone in the history of cardiac surgery and the beginning of a long journey toward prosthetic valve replacement full of expectations, hopes, and dreams fulfilled. Caged-ball prostheses underwent numerous modifications in design and materials to improve reliability and prevent specific mechanical and thrombogenic complications. Clinical and pathologic experience gained during the past 6 decades has enabled the development of safe, durable, and minimally thrombogenic mechanical prostheses.

Hemiarch Versus Arch Replacement in Acute Type A Aortic Dissection: Is the Occam's Razor Principle Applicable?

BACKGROUND AND AIM OF THE STUDY

In patients with acute Type A aortic dissection (A-AAD) whether repair should be limited to ascending aorta/hemiarch replacement or extended to include the aortic arch is still debated. We have analyzed our experience to compare outcomes of patients with A-AAD treated with these 2 different surgical strategies.

METHODS

From 2006 to 2020, a total of 213 patients have undergone repair of A-AAD at our Center; in 163 of them ascending aorta/hemiarch replacement (Group 1) and in 75 ascending aorta and arch replacement (Group 2) were performed. The primary endpoint was early survival and secondary endpoints late survival, freedom from late complications and reoperations. Patients were compared according to era of operation: 2006 to 2013 (Era 1) and 2014 to 2020 (Era 2).

RESULTS

Overall hospital mortality was 12% and 5% in Group 1 and 2; mortality remained stable in Era 1 and 2 for Group 1 (15%), while it decreased from 8% to 1% in Group 2 patients (p = 0.24). Actuarial survival at 5 and 10 years is 72 ± 4% and 49 ± 5% in Group 1 and 77 ± 6% and 66 ± 9% in Group 2 (p = 0.073). Actuarial freedom from reoperation in the entire series is 94 ± 2% and 92 ± 3% at 5 and 10 years. Freedom from reoperation at 5 and 10 years is 92 ± 2% and 89 ± 3% in Group 1 and 98 ± 1% at all intervals in Group 2 (p = 0.068).

CONCLUSIONS

An aggressive approach to A-AAD provides superior long-term results without increasing mortality. Furthermore, arch replacement during A-AAD repair represents a more stable solution with lower incidence of late aortic-related complications. Immediate aortic arch replacement should be considered in the treatment of A-AAD especially in experienced centers.

An Integrated Approach for Treatment of Acute Type A Aortic Dissection

Background and objective: We reviewed a single-institution experience to verify the impact of surgery during different time intervals on early and late results in the treatment of patients with type A acute aortic dissection (A-AAD). Materials and Methods: From 2004 to 2021, a total of 258 patients underwent repair of A-AAD; patients were equally distributed among three periods: 2004-2010 (Era 1, n = 90), 2011-2016 (Era 2, n = 87), and 2017-2021 (Era 3, n = 81). The primary end-point was to assess whether through the years changes in indications, surgical strategies and techniques and increasing experience have influenced early and late outcomes of A-AAD repair. Results: Axillary artery cannulation was almost routinely used in Eras 2 (86%) and 3 (91%) while one femoral artery was mainly cannulated in Era 1 (91%) (p < 0.01). Retrograde cerebral perfusion was predominantly used in Era 1 (60%) while antegrade cerebral perfusion was preferred in Eras 2 (94%,) and 3 (100%); (p < 0.01). There was a significant increase of arch replacement procedures from Era 1 (11%) to Eras 2 (33%) and 3 (48%) (p < 0.01). A frozen elephant trunk was mainly performed in Era 3. Hospital mortality was 13% in Era 1, 11% in Era 2, and 4% in Era 3 (p = 0.07). Actuarial survival at 3 years is 74%, in Era 1, 78% in Era 2, and 89% in Era 3 (p = 0.05). Conclusions: With increasing experience and a more aggressive approach, including total arch replacement, repair of A-AAD can be performed with low operative mortality in many patients. Patient care and treatment by a specific team organization allows a faster diagnosis and referral for surgery allowing to further improve early and late outcomes.

Combined Replacement of Aortic Valve and Ascending Aorta-A 70-Year Evolution of Surgical Techniques

Simultaneous replacement of the ascending aorta and aortic valve has always been a challenging procedure. Introduction of composite conduits, through various ingenious procedures and their modifications, has changed the outlook of patients with aortic valve disease and ascending aorta pathology. In the past 70 years, progress of surgical techniques and prosthetic materials has allowed such patients to undergo radical procedures providing excellent early and long-term results in both young and elderly patients. This article aims to review the most important technical advances in the treatment of aortic valve disease and ascending aorta aneurysms recognizing the important contributions in this field.

Blood cysts of the cardiac valves in adults: Review and analysis of published cases

BACKGROUND AND AIM

Blood cysts of cardiac valves are generally seen in newborns and infants and very rarely in adults. Although in most cases they are incidental findings they may be associated to severe cardiac or systemic complications. This study analyzes incidence, presentation, and treatment of valvular blood cysts in adults.

METHODS

A review of the pertinent literature through a search mainly on PubMed and Medline was performed.

RESULTS

In patients ≥18 years of age, our search disclosed 54 patients with mitral blood cysts (mean age, 48 ± 18 years), 9 with a tricuspid valve cyst (mean age, 67 ± 15 years), 3 with a blood cyst on the pulmonary valve (age 31, 43, and 44 years), and 1 aortic valve cyst in a 22-year-old man. Most patients were asymptomatic while stroke, syncope, or myocardial infarction occurred in six patients with a mitral valve cyst. Blood cysts were removed surgically in 70% of patients with a mitral cyst, in 55% with a tricuspid cyst, and in all those with a pulmonary or aortic cyst. At histology, the cyst wall was composed mainly by fibrous tissue and with the inner surface lined with typical endothelium.

CONCLUSIONS

Blood cysts of cardiac valves are rare in adults but may cause life-threatening complications, particularly when located on the mitral valve. For such reason, surgical removal appears advisable, with low-risk procedures. Widespread use of multimodality imaging techniques will most likely increase the number of valvular blood cysts diagnosed also in adults.

Heart transplant outcomes in patients with mechanical circulatory support: cold storage versus normothermic perfusion organ preservation

OBJECTIVES

Patients with mechanical circulatory support bridged to a heart transplant (HTx) are at higher risk of postoperative graft dysfunction. In this subset, a mode of graft preservation that shortens graft ischaemia should be beneficial.

METHODS

The outcomes of 38 patients on mechanical circulatory support (extracorporeal life support, left ventricular assist device and biventricular assist device) who received a HTx between 2015 and 2020 were analysed according to the method of graft preservation: cold storage (CS) group, 24 (63%) or ex vivo perfusion (EVP) group, 14 (37%).

RESULTS

The median age was 57 (range 30-73) vs 64 (35-75) years (P = 0.10); 88% were men (P = 0.28); extracorporeal life support was more frequent in the CS group (54% vs 36%; P = 0.27) versus left ventricular and biventricular assist devices in the EVP group (46% vs 64%; P = 0.27). Clamping time was shorter in the EVP group (P < 0.001) and ischaemic time >4 h was higher in the CS group (P = 0.01). Thirty-day mortality was 13% (0-27%) in the CS group and 0% (P = 0.28) in the EVP group. A significantly lower primary graft failure [7% (0-23%) vs 42% (20-63%); P = 0.03] was observed in the EVP group. Survival at 1 year was 79 ± 8% (63-95%) in the CS group and 84 ± 10% (64-104%) in the EVP group (P = 0.95).

CONCLUSIONS

Our results support the use of ex vivo graft perfusion in patients on mechanical circulatory support as a bridge to a HTx. This technique, by shortening graft ischaemic time, seems to improve post-HTx outcomes.

Type A acute aortic dissection with ≥40-mm aortic root: results of conservative and replacement strategies at long-term follow-up

OBJECTIVES

We evaluated the long-term results of aortic root (AR) preservation and replacement in patients operated on for acute type A aortic dissection.

METHODS

Out of 302 patients discharged after repair of acute aortic dissection (1977-2019), 124 patients had an AR ≥40 mm, which was preserved in 84 (68%, group A) patients and replaced in 40 (32%, group B) patients. Group B patients were younger (mean age 57 ± 12 vs 62 ± 11 years, P = 0.07), with a mean AR of 47 vs 43 mm and ≥moderate aortic insufficiency in 65% vs 30%. Survival, causes of death and reoperations were analysed at mean follow-up of 9 ± 8 years (6 months to 40 years).

RESULTS

Actuarial survival of discharged patients at 5, 10 and 15 years was 97% (0.89-0.99), 78% (0.67-0.90) and 75% (0.64-0.88) in group A, and 85% (0.71-0.95), 62% (0.44-0.78) and 57% (0.39-0.76) in group B (log-rank test P = 0.2). Nine patients in group A (7 patients for aortic insufficiency and dilatation of the root and 2 patients for pseudoaneurysm) and 1 patient of group B (pseudoaneurysm of the right coronary button) required proximal reoperation without deaths. At 5, 10 and 15 years, the cumulative incidence of proximal aortic reoperations was 5%, 9% and 25% in group A, and 0%, 3% and 3% in group B (P = 0.02). At multivariable analysis AR >45 mm [hazard ratio (HR) 6.8, P = 0.026] and age (HR 0.9, P = 0.016) were independently associated with proximal reoperation.

CONCLUSIONS

AR preservation in acute type A dissection showed acceptable long-term outcomes. Nevertheless, a more aggressive approach appears a valid option, especially in patients with AR diameter >45 mm.

Bentall procedure with the CarboSeal™ and CarboSeal Valsalva™ composite conduits: long-term outcomes

 

OBJECTIVES

Data on the long-term results with the standard CarboSeal™ mechanical conduit used for the modified Bentall procedure are lacking as well as information on performance of the Valsalva CarboSeal™ conduit.

METHODS

We have analysed 208 recipients of a standard (n = 110) or a Valsalva (n = 98) CarboSeal™ conduit. The median age was 60 years and 90% were males; 35 (17%) had type A aortic dissection and 65 (30%) a bicuspid aortic valve. Data were retrospectively analysed and results were compared between the 2 conduit models.

RESULTS

Early mortality was 1.9%; the mean follow-up was 175 ± 95 for standard and 94 ± 51 months for Valsalva conduits (P < 0.01). Actuarial survival was 86 ± 4%, 75 ± 6%, 59 ± 7% and 51 ± 9% at 5, 10, 15 and 20 years, respectively. There were 13 thromboembolic episodes with 3 deaths with an actuarial freedom of 98 ± 1%, 94 ± 2%, 90 ± 3% and 89 ± 4% at 5, 10, 15 and 20 years, respectively. Reoperation on the aortic root was performed in 9 patients for endocarditis (n = 8) and pseudoaneurysm at the right coronary button (n = 1) with an actuarial freedom of 97 ± 1%, 95 ± 2%, 92 ± 3% and 87 ± 4% at 5, 10, 15 and 20 years, respectively. There were no differences between the 2 conduit models in survival and major postoperative complications.

CONCLUSIONS

The CarboSeal™ conduit has shown gratifying overall performance up to 20 years and appears a valid option for a modified Bentall operation, when a mechanical prosthesis is indicated. Both CarboSeal™ conduit models provided not statistically different overall long-term results.

Left Atrial Appendage Thrombosis and Persistent Atrial Fibrillation: combined Treatment with a Totally Thoracoscopic Approach

Minimally invasive surgical ablation is generally contraindicated in patients with atrial fibrillation and thrombosis of the left atrial appendage.

We have treated three of these patients using an innovative technique based on a bilateral video-thoracoscopic approach, performing a continuous encircling lesion at the pulmonary veins outflow with radio-frequency ablation, simultaneously excluding the left atrial appendage. The postoperative course was uneventful, without neurologic events and all patients maintained a stable sinus rhythm at 1-year follow-up.

This procedure represents a new mini-invasive method to treat persistent atrial fibrillation when partial thrombosis of the left atrial appendage contraindicates other ablation techniques.

Vincenzo Gallucci: Memories of a Surgeon, Scientist, and Teacher

Thirty years ago, Vincenzo Gallucci, MD, head of the Cardiovascular Surgery Institute of the University of Padua Medical School in Italy, died in a car accident at the age of 55 years. Vincenzo Gallucci was one of the most authoritative Italian cardiac surgeons, a fine, gentle, and extremely talented surgeon. He is credited with the first implant of a glutaraldehyde-fixed, stented porcine Hancock bioprosthesis in 1970 and with the first orthotopic heart transplantation performed in Italy in 1985. After 30 years, the memory of a great surgeon, scientist, and teacher is still alive, particularly in those who received his important heritage.

Late complications of the Djumbodis system in patients with type A acute aortic dissection

The Djumbodis system is a metallic stent designed to prevent false lumen dilatation after repair of acute aortic dissection. Although the exact number of Djumbodis stents inserted worldwide could not be ascertained from a review of the literature, available data indicate 9 specific device-related complications from 4 patient series and 3 case reports: stent deformity or fracture (4), progressive enlargement of the distal false lumen (3) and distal pseudoaneurysm (1); a further patient with pseudoaneurysm of the distal suture line is added from personal observation. The present review confirms the inability of the Djumbodis stent to provide reduction and/or elimination of the false lumen after repair of type A dissection, highlighting peculiar device-related complications. Current survivors with a Djumbodis stent should undergo close follow-up to prevent possible catastrophic events due to device failure.

Modern concepts from old ideas in manufacture of cardiac valve prostheses

In reviewing the history of mechanical prosthetic valves, it appears evident how many improvements and technical advances have been obtained in this field. Looking to the past, it must also be underlined how some old concepts, which can be considered quite revolutionary for those years, clearly indicate the great skill and ingenuity of those who conceived them. Old ideas have been revitalized by modern concepts, and this is exemplified when considering the developments of bileaflet and sutureless prostheses.

Bridge to heart transplantation in patients with cardiogenic shock: a 20-year experience with two different surgical strategies

AIMS

We aimed to describe how treatment of patients in cardiogenic shock bridged to heart transplantation with mechanical circulatory support, using either biventricular assist devices (BVADs) or extracorporeal life support (ECLS), has evolved in the last 20 years in our centre.

METHODS

Since 1998, 72 patients with refractory heart failure and indication for heart transplantation have received mechanical circulatory support: 40 had an ECLS system and 32 a BVAD.

RESULTS

Early mortality was similar (17.5 vs. 9.4%, P = 0.25) regardless of the type of support. After a median support time of 8 (1-27) vs. 34 (0-385) days (P < 0.01), 70 vs. 65.6% (P = 0.69) of patients underwent transplantation in the two groups. Prior to transplantation, BVAD patients were more stable with lower need for mechanical ventilation (9 vs. 57%, P < 0.01) and dialysis (0 vs. 38%, P < 0.01). Thirty-day mortality after transplantation was similar (18 vs. 14%, P = 0.53). Patients with extracorporeal support had higher rates of renal (P = 0.02) and respiratory failure (P = 0.03), infections (P = 0.02), atrial fibrillation (P = 0.03) and longer ICU stay (P = 0.01). Late survival was similar, while 5-year freedom from coronary vasculopathy was higher in those with BVAD (P = 0.03).

CONCLUSION

Although ECLS provides faster and simpler assistance compared with BVADs, no differences in early and medium-term outcomes in the last 20 years were observed in patients with cardiogenic shock. However, BVADs provided longer duration of support, better multiorgan recovery allowing more adequate graft selection, resulting in a lower rate of posttransplant complications.

Donor-recipient age interaction and the impact on clinical results after heart transplantation

To evaluate the impact of donor-recipient age matching on clinical outcomes after heart transplantation, a total of 509 patients (January 1990-December 2018, mean follow-up 111 ± 80 months) were stratified into 4 groups (young-R/young-D, young-R/old-D, old-R/young-D, old-R/old-D) according to the recipient (young-R < 60, old-R ≥ 60 years) and the donor (young-D < 50, old-D ≥ 50 years) age. No difference was found among 30-day mortality (P = .11) and postoperative complications between groups. Both unadjusted and adjusted survival was significantly higher for group young-R/young-D than that of other groups, in which survival was similar [adjusted HR for mortality of 2.0(1.2-3.4), 2.1(1.4-3.8) and 2.5(1.6-4.1) for groups old-R/young-D, young-R/old-D, old-R/old-D, respectively]. Compared to other groups, the incidence of grade ≥ 2 CAV was significantly lower in old-R/young-D group [adjusted HR 0.4(0.2-0.7)]. Among young recipients, the rate of acute grade ≥ 2 rejection episodes was higher in those receiving an old donor graft (P = .04). Old recipient groups were more affected by neoplasms and severe renal failure than young recipient groups (P < .01). Employment of hearts from donors ≥50 years of age adversely affects survival in recipients <60 years of age but does not influence outcomes in older recipients. Also, donor and recipient ages seem to have opposite effects on incidence of rejections and CAV of high grade.