Over the past decade, given safety, reduced heart failure-related hospitalizations, and, above all, 5-year mortality rates nearly identical to those of heart transplants, left ventricular assist devices (LVADs) have increasingly become a treatment option for patients with advanced heart failure. However, improvements in functional capacity after LVAD implantation are minimal or modest, depending on pre-implantation right ventricular function, the patient's hemodynamic status, the optimization of guideline-directed medical therapy, and noncardiac factors (physical deconditioning, skeletal muscle alterations, anemia, and alterations in alveolar gas exchange). Therefore, cardiac rehabilitation (CR) is a fundamental element from the early stages after LVAD implantation, as it is not only safe but also highly effective, leading to improved functional capacity and fewer episodes of worsening heart failure, and may be associated with reduced mortality. To perform safe and effective CR in patients with LVADs, it is crucial to account for the unique issues in this group. This includes the difficulty of detecting an arterial pulse with standard tools during CPR and the importance of closely monitoring the transmission line and LVAD controller to prevent unintended damage. Overall, the clinical trial indicates that exercise-based CR has the potential to improve functional capacity. Furthermore, some data suggest that CR is associated with fewer HF-related hospitalizations and may be linked to lower mortality; however, there is no consensus on this matter, partly because most studies supporting this assertion are observational.

Background:In the last few years, mechanical circulatory support in patients with advanced/terminal heart failure (HF) is increasing. New devices have been developed from the known intra-aortic balloon pump to the total artificial heart. However, vascular complications may occur in up to 30% based on the device implanted. Evaluation of the Doppler flow in all vascular territories (cranial, extracranial, abdominal, and peripheral) in patients with these devices might be of great importance but remains still unexplored. This is a proof of concept study in which we provide a practical analysis of the Doppler waveform of different territories in patient with different mechanical circulatory support devices.Methods:Three patients with different mechanical circulatory support system (MCSS) were included in this analysis. Doppler evaluation of several vascular territories has been performed and compared with flow from normal heart. Patients with advanced HF supported by a mechanical circulatory system were included in this analysis.Results:A standard Doppler ultrasound has been performed to evaluate blood flow in the following vascular territories: middle cerebral artery, ophthalmic artery, common carotid artery, intraparenchymal renal artery, common femoral artery, and posterior tibial artery.Conclusions:This is the first report comparing Doppler waveforms between different MCSS. It may represent a practical guide for physicians evaluating the vascular pattern in these patients.

Left ventricular assist device (LVAD) implantation is an important surgical option for patients with advanced heart failure (HF) who are not eligible for heart transplantation (destination therapy) or who are not expected to survive to transplant without durable mechanical circulatory support (bridge-to-transplant). Despite the hemodynamic support provided by LVAD, both atrial and ventricular arrhythmias (AAs and VAs, respectively) are prevalent and contribute to morbidity and mortality, primarily due to right ventricular failure and arrhythmic storm. Management strategies are extrapolated from recommendations for patients with HF with reduced ejection fraction, since available data are limited. Controlling heart rate is a crucial therapeutic approach for AAs since restoration of sinus rhythm often has a minimum effect on hemodynamics. Management of VAs is further complicated by factors unique to LVAD patients, such as suction events. Antiarrhythmic drugs may not work for both AAs and VAs, necessitating escalation therapy or catheter ablation. Given the technical challenges of catheter ablation, a strict cooperation between HF specialists and electrophysiologists is warranted. This review aims to summarize the current scientific evidence and provide clinical guidance for managing arrhythmias in this complex patient group, characterized by significant knowledge gaps.

Scientists, physicians, and engineers have long endeavored to develop a device capable of replacing the function of the heart. The objective is to create a machine or pump for patients suffering from advanced biventricular heart failure, where survival until transplantation is feasible. These total artificial hearts are designed to sustain the patient until a donor heart becomes available. This review aims to present an overview and historical context of the development of the total artificial heart, analyze the currently utilized devices, and briefly discuss future technological innovations in total artificial heart systems.

Despite ongoing advancements in the field of heart failure, heart transplantation remains the definitive treatment for patients with advanced heart failure. Decades of research, surgical innovation, and progress in transplant immunology have enabled the overcoming of persistent challenges associated with this complex procedure. Since the initial preclinical experiments involving heart transplants in canines and primates, the process has been profoundly transformed through the development of the bioptome for endomyocardial biopsies and the introduction of immunosuppressive therapies. More recently, improvements in the preservation and transportation of donor hearts, as well as the utilization of cell-free DNA for evaluating graft rejection, are laying the groundwork for further advancements in non-invasive rejection diagnosis and the expansion of the donor pool.

Takotsubo syndrome (TTS) is a rare cause of myocardial infarction in heart transplant patients. The heterogeneity of reported cases makes it impossible to identify specific characteristics of patients at risk. The occurrence of biventricular TTS is even less frequent its impact on long-term prognosis is unpredictable. We in here describe a rare case of biventricular TTS occurred in a woman 13 years after heart transplant.

Although there are different data supporting benefits of HLA matching in kidney transplantation, its role in heart transplantation is still unclear. HLA mismatch (MM) between donor and recipient can lead to the development of donor-specific antibodies (DSA) which produces negative events on the outcome of heart transplantation. Moreover, DSAs are involved in the development of antibody-mediated rejection (AMR) and are associated with an increase in cardiac allograft vasculopathy (CAV). In this study it is analyzed retrospectively the influence of HLA matching and anti-HLA antibodies on overall survival, AMR and CAV in heart transplantation. For this retrospective study are recruited heart transplanted patients at the Cardiac Transplantation Centre of Naples between 2000 and 2019. Among the 155 heart transplant patients, the mean number of HLA-A, B, -DR MM (0 to 6) between donor and recipient was 4.5 ± 1.1. The results show a negative association between MM HLA-DR and survival (p = 0.01). Comparison of patients with 0-1 MM at each locus to all others with 2 MM, for both HLA class I and class II, has not showed significant differences in the development of CAV. Our analysis detected DSA in 38.1% of patients. The production of de novo DSA reveals that there is not an influence on survival (p = 0.72) and/or AMR (p = 0.39). Instead, there is an association between the production of DSA class II and the probability of CAV development (p = 0.03). Mean fluorescence intensity (MFI) values were significantly higher in CAV-positive patients that CAV-negative patients (p = 0.02). Prospective studies are needed to evaluate HLA class II matching as an additional parameter for heart allocation, especially considering the increment of waiting list time.

Background: Pulmonary arterial elastance (Ea) is a helpful parameter to predict the risk of acute postoperative right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation. A new method for calculating Ea, obtained by the ratio between transpulmonary gradient and stroke volume (EaB), has been proposed as a more accurate measure than the Ea obtained as the ratio between pulmonary artery systolic pressure and stroke volume (EaC). However, the role of EaB in predicting acute RVF post-LVAD implantation remains unclear. Methods and Results: A total of 35 patients who underwent LVAD implantation from 2018 to 2021 were reviewed in this retrospective analysis. Acute RVF after LVAD implantation occurred in 12 patients (34%): 5 patients with moderate RVF (14% of total) and 7 patients with severe RVF. The EaB was not significantly different between the “severe RVF” vs. “not-severe RVF” groups (0.27 ± 0.04 vs 0.23 ± 0.1, p < 0.403). However, the combination of arterial elastance and central venous pressure was significantly different between the “not-severe RVF” group (central venous pressure < 14 mmHg and EaC < 0.88 mmHg/mL or EaB < 0.24 mmHg/mL; p < 0.005) and the “severe RVF” group (central venous pressure > 14 mmHg and EaC > 0.88 mmHg/mL or EaB > 0.24 mmHg/mL; p < 0.005). Conclusions: Ea is a reliable parameter of right ventricular afterload and helps discriminate the risk of acute RVF after LVAD implantation. The combined analysis of Ea and central venous pressure can also risk stratify patients undergoing LVAD implantation for the development of RVF.

Human leukocyte antigen (HLA) matching exerts a protective effect in organ transplantation, ensuring better graft function, fewer episodes of rejection, longer graft survival, and the possibility of lower immunosuppression.1–3 However, the precise influence of HLA incompatibility in heart transplants remains to be determined, and prospective HLA matching is seldom achieved. We previously demonstrated that the odds of in-hospital mortality after heart transplantation is greater in the case of HLA-DR mismatch.

The prognostic role of human leukocyte antigen (HLA) matching in heart transplantation (HTx) is still unclear. We previously demonstrated an association of DR-mismatch with early mortality after HTx. Aim of the study was to evaluate the impact of HLA mismatch on 1 year acute cellular rejection (ACR

Infection with HIV may lead to the development of cardiomyopathy as improved antiretroviral regimens continue to prolong patient life. However, advanced therapeutic options, such as heart transplant, have until recently been precluded to HIV-positive persons. A favorable long-term outcome has been obtained after kidney or liver transplant in HIV-positive recipients fulfilling strict virological and clinical criteria. We recently reported the first heart transplant in a HIV-infected patient carried out in our center. In this article, we detail the major challenges we faced with the management of antiretroviral and immunosuppressive treatments over the first 3 years post-transplant. The patient had developed dilated cardiomyopathy while on antiretroviral treatment with zidovudine, lamivudine and efavirenz. He was in WHO Stage 1 of HIV infection and had normal CD4+ count and persistently undetectable HIV-RNA. In spite of cardiac resynchronization therapy and maximal drug therapy, the patient progressed to end stage heart failure, requiring heart transplant. He was placed on a standard immune suppressive protocol including cyclosporine A and everolimus. Despite its potential pharmacokinetic interaction with efavirenz, everolimus was chosen to reduce the long-term risk of opportunistic neoplasia. Plasma levels of both drugs were monitored and remained within the target range, although high doses of everolimus were needed. There were no infectious, neoplastic or metabolic complications during a 3-year follow-up. In summary, our experience supports previous data showing that cardiac transplantation should not be denied to carefully selected HIV patients. Careful management of drug interactions and adverse events is mandatory.

Early graft failure (EGF) is a dreaded complication after heart transplantation (HT). Despite several improvements, no effective therapy has been developed and the prognosis is poor. We evaluated the risk factors and clinical impact of EGF. In a consecutive series of 317 HTs performed at a single institution between January 1999 and December 2008, variables associated significantly with EGF were sought in bivariate and multivariable discriminant analyses. The deriving propensity score was used to stratify the study sample in to three groups (low, intermediate and high risk for EGF). Comparisons were performed between the higher-risk group and the remaining population in terms of preoperative features and outcomes. EGF occurred in 10.1% of the overall population (2.9, 3.8 and 23.6%, respectively, in the three groups). Overall, EGF-related mortality was 56.3% (100, 75 and 48%, respectively, in the three groups). Determinants of EGF in the highest-risk group were: redo procedure, valvular cardiomyopathy, status one at transplant, recipient male sex, donor-recipient (D/R) weight mismatch, high inotropic donor support, ischaemic time and first day troponin I release. In conclusion, several donor and recipient features predicted EGF. Since such characteristics are not readily modifiable but synergistically determine the occurrence of EGF, optimization of D/R matching is crucial to prevent it.