Steroid-free and steroid withdrawal protocols in heart transplantation: the review of literature.

Abstract Corticosteroids (CSs) are still the mainstay of induction, rescue, and maintenance in heart transplantation (HTx). However, their use is associated with significant and well-documented side effects usually related to the dose administered and the duration of therapy. Moreover, CSs interfere with the recipient's quality of life and with the active process of graft tolerance. Physicians have been exploring ways to avoid or reduce CSs in association with other immunosuppressive drugs, minimizing side effects and costs. The regimens are classified as steroid-free or steroid withdrawal protocols. The studies analyzed in this review come to similar conclusions as benefits and adverse consequences: steroid-free protocols should be advisable and mandatory in pediatric patients, insulin-dependent diabetes mellitus (IDDM), presence of infection, familial metabolic disorders/obesity, severe osteoporosis, and in the elderly. On the other hand, steroid withdrawal can be successfully achieved in 50-80%, with late better than early withdrawal, no increase in rejection-related mortality, no adverse impact on survival, and probably a better quality of live. Safety and efficacy can certainly be improved by an individualized approach to the transplant recipient

Therapeutic Drug Monitoring of Micophenolate Mofetil in Cardiac Transplant Patients by Limited Sampling Strategy: An Update

In the last few years, much progress in avoiding acute and chronic rejection in transplanted patients has been made by introducing new and more effective drugs with different formulations and combinations, and fewer side effects. Standardized protocols have been proposed for different organs, but individualized therapy based on immunosuppressive therapy blood monitoring is necessary because of pharmacological interaction, new generic drug introductions, and different absorptions and biodistributions. In specific mycophenolate mofetil dosing through mycophenolic acid (MPA), therapeutic drug monitoring has demonstrated minimal risk of organ transplant rejection. Even if the MPA area under the 12 h concentration–time curve is more accurate than MPA levels, it appears to be resource consuming and clinically impractical because of the need for numerous blood samples. Limited sampling strategy (LLS) has been proposed to overcome this problem. In heart-transplanted patients, MPA LSS is useful in guiding clinical management and dosing. The purpose of this chapter is to describe the state of the art of MPA LSS employment in heart transplantation and to perform an update of the scientific literature

Right minithoracotomy as an alternative approach for endovascular repair of thoracic aortic aneurysm

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Highlights of the 2022 Brano Heart Failure Forum: Part Two

Since 2007, the Branislav “Brano” Radovancevic Heart Failure Forum (BHFF) has been held annually to provide a venue for experts to present and discuss “Innovations and New Treatment Strategies in Heart Failure.” Clinicians and researchers gather yearly in a different Eastern European city to discuss the latest in heart failure diagnostics and therapeutics. The 2022 BHFF forum was held on the 6th thru 8th of September 2022 in Trieste, Italy. It was attended by over 94 faculty from 14 countries. In addition, participation through online streaming was available. Throughout the forum, 17 sessions focused on challenges and solutions related to mechanical circulatory support (MCS) and heart transplantation. The second portion of conference highlights from available presentations is presented herein

Multiple Intracardiac Sewing Needles in a Schizophrenic Woman With Self-Injurious Behavior

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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

ECMO as Bridge to Heart Transplantation

Extracorporeal membrane oxygenation (ECMO) is increasingly employed to support patients affected by refractory cardiogenic shock. When patients cannot be weaned from ECMO because of severe heart dysfunction, heart transplantation (HTx) or implantation of a durable mechanical circulatory support should be considered. Traditionally, the use of ECMO as a direct bridge to HTx was burdened by high mortality. However, during these last years, the widespread employment of ECMO increased centers’ experience in the management of this device, and new allocation policies provided the highest priority level for ECMO HTx candidates. Therefore, these factors could have mitigated the negative outcomes previously reported. The aim of this chapter is to describe the role of ECMO as a direct bridge to HTx, analyzing results of this strategy, and how to determine candidacy and risk stratification among the severely ill population of patients supported by this mechanical circulatory support