Impact and analysis of a quantitative donor risk scores to predict short and long-term mortality in orthotopic heart transplantation

Introduzione Il trapianto cardiaco rimane la terapia di scelta nei pazienti in scompenso cardiaco avanzato. Purtroppo il numero dei donatori rimane molto limitato e non sufficiente a soddisfare il fabbisogno dei pazienti in lista d’attesa. In Italia, la valutazione del singolo donatore è basata su multipli fattori ma non esiste uno standard assoluto che possa predirne l’impatto sugli outcomes dopo l’intervento. Materiali L’obiettivo dello studio è stato quello di analizzare i pazienti che hanno ricevuto un trapianto di cuore presso il nostro istituto con particolare riferimento ai donatori, in modo da: (1) valutare l’impatto della donazione sugli outcomes intraospedalieri e sulla sopravvivenza a lungo termine, (2) identificare fattori di rischio del donatore predittivi di mortalità intraospedaliera e disfunzione precoce del graft (3), validare gli attuali score di rischio internazionali sul donatore non ancora utilizzati nella pratica clinica. Risultati Dal 2000 sono stato eseguiti 461 trapianti di cuore presso il Policlinico di Sant’Orsola. Una disfunzione precoce d’organo si è verificata in 74 pazienti (16.1%): di questi in 51 casi (11.1%) è stato necessario impiantare un supporto meccanico di assistenza cardiocircolatorio. Tra le variabili donatore dipendente solo il picco di troponina e un supporto inotropo con noradrenalina hanno rappresentato fattori di prognostici negativi per mortalità intraospedaliera. Tra gli score di rischio più comunemente utilizzati in ambito internazionale solo il RADIAL score sembrerebbe predire gli outcomes a breve e lungo termine post-trapianto. Conclusioni Il donatore ha un forte impatto sulla prognosi dopo il trapianto. Seppur i nostri donatori presentavano un normale profilo di rischio gli attuali score internazionali ad eccezione del RADIAL non sembrerebbero essere predittivi sulla prognosi di questi pazienti. Prossimo obiettivo sarà quello di creare un algoritmo decisionale per la gestione delle donazione basato sulle caratteristiche del donatore in modo da ottimizzare al massimo l’allocazione degli organi cardiaci.Introduction Heart transplantation is the therapeutic option still offering the best long-term survival and quality of life to patients with advanced heart failure. Organ availability is the main limitation to the access to care for most patients. Methods Objective of the study was to evaluate our overall experience on heart transplantation with particular regard to donor influence on early and late results. Moreover, new predictive donor risk scores (Donor, Radial and Weiss scoring systems) were applied to our population to understand their possible implications and impact on post-operative outcomes and survival. Results Between January 2000 and December 2017, 461 patients received a heart transplantation. An early graft failure was detected in 16.1% (74/461). Mechanical circulatory support was used in 11.1% (51/461). Of the donor related factors only the peak of troponine (p<0.001) and use of noradrenaline (p=0.02) negatively influenced on early outcomes. Of the actual available scoring systems, the Donor score didn’t influence the outcomes, the RADIAL significantly influenced both early mortality and late survival and the Weiss only on late survival. Conclusions According to our experience heart transplantation offers a definitive and stable treatment over time. The most validated donor scoring systems didn’t homogeneously demonstrate a strong correlation with post-operative outcomes and only the radial score seems an accurate predictor. Next step will be to set up a donor management protocol to maximize heart function protection and improve cardiovascular diagnostics algorithms

Open thoracoabdominal aortic aneurysm repair in the modern era: results from a 20-year single-centre experience

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Extracorporeal Membrane Oxygenation Support as Treatment for Early Graft Failure After Heart Transplantation

Early graft failure (EGF) is a major risk factor for death after heart transplantation (Htx) accounting for >40% of deaths within 30 days postoperatively. According to the last International Society for Heart and Lung Transplantation (ISHLT) consensus statement, the graft dysfunction (GD) is to be classified into primary (PGD), in case of an unknown triggering factor or secondary (SGD) where there is a discernible cause such as acute rejection, pulmonary hypertension, or known surgical complications. The diagnosis of GD is to be made within 24 h after completion of Htx surgery and a severity scale for GD should include mild, moderate, or severe grades based on specified criteria. Mechanical circulatory support (MCS) for GD should be considered when medical management is not sufficient to support the newly transplanted graft. Currently, extra‐corporeal membrane oxygenation (ECMO) is widely accepted as treatment of severe EGF, given its easy and quick setup, the system versatility, the optimal end‐organ perfusion provided, and the possibility of both biventricular and lung assistance by usage of a low‐cost single pump

Aortic Root Replacement With Biological Valved Conduits

none9The execution of Bentall procedures using biological valved conduits is expanding owing to the increased incidence of aortic valve and root diseases in the aging population. To review the available data, a systematic search identified 29 studies with a total of 3,298 patients. Although evidence on short-term results suggested favorable outcomes after biological Bentall operations, data beyond 5 years are limited and highlight the urgent need for further investigations with longer follow-up.openCastrovinci, Sebastiano; Tian, David H; Murana, Giacomo; Cefarelli, Mariano; Berretta, Paolo; Alfonsi, Jacopo; Yan, Tristan D; Di Bartolomeo, Roberto; Di Eusanio, MarcoCastrovinci, Sebastiano; Tian, David H; Murana, Giacomo; Cefarelli, Mariano; Berretta, Paolo; Alfonsi, Jacopo; Yan, Tristan D; Di Bartolomeo, Roberto; Di Eusanio, Marc

Commentary: Carotid is the best alternative for femoral transcatheter aortic valve replacement?

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Open thoracoabdominal aortic aneurysm repair: Is there a "sex problem?"

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Is wall stress like Wall Street when it comes to speculating on bicuspid versus tricuspid aortic valve aneurysm?

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Frozen elephant trunk technique: Ready to get back to the future?

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Con-debate: short circulatory arrest times in arch reconstructive surgery: is simple retrograde cerebral perfusion or hypothermic circulatory arrest as good or better than complex antegrade cerebral perfusion for open distal involvement or hemi-arch?

Aortic arch open surgery continues to represent a formidable challenge for heart surgeons. In fact, the interruption of physiological brain perfusion is a major detrimental effect during the systemic circulatory arrest resulting in a series of neurological complications. In order to protect the brain from these injuries, three techniques have been proposed and widely utilized as a means of protecting the brain: deep hypothermic circulatory arrest (DHCA), retrograde cerebral perfusion (RCP) and antegrade cerebral perfusion (ACP). The basis for all the techniques is the protection afforded by hypothermia with the consequent metabolic suppression