Introduction Emery–Dreifuss muscular dystrophy (EDMD) is a rare inherited neuromuscular disorder frequently associated with progressive cardiac involvement, particularly in patients carrying LMNA mutations. End‐stage heart failure may develop despite optimal medical and device therapy, although heart transplantation remains an uncommon therapeutic option because of concerns regarding the underlying neuromuscular disease. Case Presentation We report the case of a 35‐year‐old woman with LMNA ‐related EDMD who developed advanced biventricular heart failure complicated by recurrent atrial and ventricular arrhythmias, complete atrioventricular block, implantable cardioverter‐defibrillator implantation, and multiple thromboembolic events. Pretransplant neurological and respiratory assessments demonstrated preserved functional status without severe musculoskeletal impairment. Owing to refractory ventricular tachyarrhythmias and progressive heart failure, the patient underwent orthotopic heart transplantation in December 2022. Postoperative recovery was uneventful, with discharge on postoperative day 21. At 43‐month follow‐up, she remained alive with preserved graft function, no episodes of rejection, stable respiratory function, and no evidence of neurological deterioration. Conclusion Heart transplantation may be a feasible treatment option for carefully selected patients with EDMD and end‐stage heart failure. Careful multidisciplinary assessment is essential to identify candidates who can achieve favorable long‐term outcomes.

Introduction: Acute type A aortic dissection (ATAAD) is a rare but potentially catastrophic complication following transcatheter aortic valve implantation (TAVI). Most reported cases occur during or shortly after the procedure and are attributed to procedural aortic injury. Very late presentations occurring years after successful TAVI are exceptionally uncommon, and evidence regarding their optimal management remains limited. Case Presentation: An 86-year-old man presented with acute chest pain four years after transfemoral implantation of a self-expanding Evolut R 29-mm transcatheter heart valve. Transthoracic echocardiography revealed pericardial effusion with signs of impending cardiac tamponade. Computed tomography angiography confirmed Stanford type A acute aortic dissection involving the ascending aorta. Emergency surgical repair was performed through replacement of the ascending aorta and hemiarch using a vascular graft. The previously implanted transcatheter valve was preserved because it remained structurally intact and functionally normal. The postoperative course was uneventful, and the patient was discharged on postoperative day 9 with preserved prosthetic valve function (mean gradient 11 mmHg, peak velocity of 2.1 m/s, EOA 1.8 cm2, EF 50%, TAPSE 18 mm and no evidence of paravalvular or intraprosthetic regurgitation). Discussion: To better contextualize this rare presentation, a focused review of the literature on delayed and late ATAAD after TAVI was performed. Only a limited number of cases were identified, highlighting the exceptional rarity of this complication. Reported management strategies included conservative treatment, endovascular interventions, and open surgical repair, with considerable heterogeneity in outcomes. Compared with previously published reports, the present case is notable for the exceptionally long interval between TAVI and dissection onset and for the successful valve-preserving surgical repair. These findings suggest that emergency surgery with preservation of a functioning transcatheter valve may be a feasible option in carefully selected patients. Conclusions: Very late ATAAD after TAVI is an exceptionally rare but life-threatening condition. This case demonstrates that valve-preserving surgical repair can be successfully performed even in selected octogenarian patients. As the population of long-term TAVI survivors continues to expand, awareness of late aortic complications, prompt diagnosis, and referral to specialized aortic centers remain essential for achieving favorable outcomes.

Background: To address organ shortage and reduce waitlist mortality, the use of extended criteria donors (ECDs) in heart transplantation is increasing. Methods: We retrospectively analysed outcomes in 236 heart transplant recipients: 140 received standard donor (SD) hearts and 96 received ECD hearts. Results: No significant differences were found in early or mid-term survival between the SD and ECD groups with a 30-day mortality rates of 13% vs. 10% (p = 0.662) and estimated 1-year survival of 75% (95% CI: 62.3-78.3%) and 71% (95% CI: 55.3-76.2%) (p = 0.556), respectively. Mechanical ventilation prior to transplant (p < 0.001), ischemic time (p = 0.022), peripheral vascular disease (p = 0.011), and chronic obstructive pulmonary disease (p = 0.022) were the only independent predictors of mortality. Conclusions: In our cohort, heart transplantation using ECD was not associated with increased early or mid-term adverse events. This approach may help expand the donor pool without compromising post-transplant outcomes.

Background: Takotsubo cardiomyopathy (TTC) has been historically considered a contraindication for heart donation due to its transient left ventricular dysfunction. However, emerging evidence supports that hearts from donors with fully recovered Takotsubo Cardiomyopathy can be safely transplanted. Methods: This case series describes seven heart transplantations performed between January 2022 and September 2025 using donors with previously diagnosed Takotsubo cardiomyopathy. Donor characteristics, intraoperative data, echocardiography data and postoperative outcomes were analyzed. Results: The mean donor age was 33.5 years (range 18-58), with a male-to-female ratio of 6:1. All donors exhibited echocardiographic evidence of Takotsubo Cardiomyopathy at the time of brain death, with full or partial recovery before procurement. Coronary angiography excluded obstructive coronary disease. Echocardiographic follow-up demonstrated the mean LVEF increased to 52 ± 6%, reaching 58 ± 4% at 12 months, global longitudinal strain (GLS) improved progressively (from -14.2 ± 2.8% to -18.5 ± 1.9%), confirming normalization of myocardial deformation and the right ventricular function, assessed by TAPSE, rose from 15 ± 3 mm at discharge to 20 ± 2 mm at 12 months. All patients transplanted with donors who had Takotsubo cardiomyopathy are alive at the 12-month follow-up. Conclusions: Hearts from donors with resolved Takotsubo Cardiomyopathy can be safely used for transplantation without compromising early- or mid-term outcomes. Expanding donor eligibility criteria to include selected TTC donors may contribute to mitigating organ shortages in advanced heart failure patients.

Background Bioprosthetic heart valves (BHVs) are widely used in cardiac surgery but are limited by structural valve deterioration (SVD). The Translink study showed that immune responses to xenogeneic glycans contribute to SVD. Hyaluronan (HA), a glycosaminoglycan with size-dependent biological functions, has been implicated in inflammation, xenoreactivity, and valve calcification. This study investigated humoral immune responses to HA oligosaccharides in a subgroup of the Translink cohort.Patients and methods Serum samples from 258 BHV recipients and 78 cardiac surgery controls were analyzed by ELISA, and a representative subset was further profiled using a printed glycan array (PGA). BHV recipients were classified with clinically significant SVD (A), as de novo implantation (B1), or long-term without SVD (B2). Controls included mechanical valve replacement or coronary artery bypass patients, either de novo (B1C) or long-term post-surgery (B2C). ELISA quantified IgG and IgM antibodies against HA fragments of increasing length (HA2, HA24, HA84), while PGA mapped fine specificity across HA2-HA40.Results All subjects exhibited measurable baseline anti-HA IgG and IgM antibodies. ELISA revealed a fragment-length dependence, with the shortest fragment, HA2, showing the highest antibody binding, and progressively lower reactivity with longer oligomers. Following de novo cardiac surgery, both BHV recipients and controls showed a transient increase in anti-HA antibodies, peaking at one month and declining within 6-12 months. In contrast, PGA consistently identified HA34 as the dominant immunogenic fragment across all cohorts and time points.Conclusions Anti-HA antibodies are constitutively present in humans, undergo transient amplification after cardiac surgery, regardless of prosthesis type, and display marked fragment-length specificity. Short HA2 fragments predominate in ELISA responses, whereas intermediate-length oligomers, such as HA34, emerge as conserved, immunodominant targets in PGA. These findings extend the Translink paradigm from xenogeneic to matrix-derived glycan immunity and identify anti-HA antibodies as potential biomarkers of postoperative inflammation and tissue remodeling, which could be relevant to SVD.

Background/Objectives: Heart transplantation (HTx) is a lifesaving procedure for end-stage heart failure patients; however, postoperative infections remain a major challenge due to immunosuppressive therapy and surgical complications. Traditional biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) have limitations in distinguishing infections from systemic inflammatory response syndrome (SIRS). Emerging markers such as Presepsin and interleukin-6 (IL-6) may improve diagnostic accuracy. This study aimed to evaluate the kinetics and reliability of these four inflammatory biomarkers in heart transplant recipients in the immediate postoperative period. Methods: This retrospective observational study included 126 patients who underwent HTx at Policlinic of Bari between January 2022 and November 2024. Patients were categorized into infected (n = 26) and non-infected (n = 100) groups based on clinical and microbiological criteria. Biomarkers (CRP, PCT, Presepsin, and IL-6) were measured preoperatively and on postoperative days (PODs) 1, 2, 3, 4, 5, and 10. Statistical analyses included the Mann-Whitney U test and logistic regression to identify the independent predictors of infection. Results: CRP and PCT levels differed significantly between the groups only on day 10, limiting their use as early infection markers. In contrast, Presepsin levels were significantly elevated in infected patients from day 1 (p < 0.001), whereas IL-6 levels showed significant differences from day 3 onward. Presepsin showed the strongest association with infection in the early postoperative phase. Conclusions: Presepsin and IL-6 outperformed CRP and PCT in detecting early postoperative infections in heart transplant recipients. Their early elevation supports their use as reliable markers for guiding timely clinical intervention and improving patient outcomes. Further research is needed to validate these findings in larger cohorts and with different immunosuppressive regimens.

This case report highlights an innovative surgical approach in orthotopic heart transplantation (OHT) for a patient with the largest recorded giant left atrium, measuring a biplanar volume of 1906 mL. The patient, a 63-year-old man with severe heart failure and a history of mitral and aortic valve replacements, presented with atrial fibrillation, moderate systolic dysfunction, and severe cardiomegaly. Despite optimized medical therapy, his condition warranted heart transplantation. The procedure involved a novel surgical technique utilizing Teflon reinforcement and a bovine pericardial patch to reconstruct the significantly enlarged left atrium. Postoperative outcomes were favorable, with no rejection episodes and resolution of pulmonary symptoms. This report underscores the challenges of atrial size mismatch in OHT and the necessity for tailored surgical strategies to address extreme anatomical variations. The successful outcome exemplifies the potential of customized approaches in complex heart transplant cases.

INTRODUCTION:The Fontan procedure and its modifications have dramatically transformed prognosis in individuals with single ventricle physiology, yet long-term outcomes remain challenging due to the high incidence of short and long-term complications. Common issues include arrhythmias, heart failure, Fontan-associated liver disease and an increasing need for reintervention or transplantation, all of which substantially impact on patients' quality of life and longevity. As this population ages, late cardiac and extracardiac complications are common, which underscores the need for ongoing monitoring and comprehensive multidisciplinary care aimed at early and effective management. AREAS COVERED:This review summarizes current evidence on the long-term outcomes after Fontan-type surgery. It describes the unique pathophysiology of the Fontan circuit, and critically evaluates incidence, severity, and management strategies for common cardiac and extracardiac complications, focusing on established clinical practice and recent advances. The review also highlights the value of continued specialist multidisciplinary care. EXPERT OPINION:Emerging research supports the potential of novel medical therapies and devices to further improve outcomes, yet optimal care remains grounded in multidisciplinary management rather than experimental approaches. Continued research is vital to support clinical guidelines and improve the quality of life and outcomes of individuals living with a Fontan-type circulation.

Introduction and Objective: Tissue turnover in the human heart requires the recruitment of multipotent cardiac progenitor cells (hCPC). Defective hCPC number and pro-angiogenic capacity contribute to diabetes- and obesity-related heart failure in humans. Evidence supports potential cardiovascular benefits of dual GIP/GLP-1 receptor agonists. The aim of this study was to evaluate whether hCPC express functional GLP-1R and GIPR, and to investigate the ability of the GIP/GLP-1 receptor agonist tirzepatide to prevent palmitate-induces apoptosis, autophagy, and senescence in hCPC. Methods: hCPC were obtained from right auricle biopsies of non-obese, non-diabetic subjects undergoing elective cardiac surgery. GLP-1R and GIPR mRNA and protein expression were demonstrated by quantitative real-time PCR and immunoblotting, respectively. hCPC, pretreated or not with 100 nM tirzepatide for 1 h, were exposed to 0.25 mM palmitate for 16 h. CREB phosphorylation was evaluated by immunoblotting. Apoptosis, autophagy and senescence, were evaluated by cleaved caspase-3, LC3-II and p21Cip1/WAF1 immunoblotting, respectively. Results: hCPC express both functional GLP-1R and GIPR. Exposure of hCPC to tirzepatide for 5 min activated CREB (p<0.05). Treatment of hCPC with palmitate induced apoptosis, autophagy and senescence (p<0.05). Pretreatment of hCPC with tirzepatide prevented palmitate-induced apoptosis, autophagy, and senescence (p<0.05). Conversely, the GLP-1R agonist exendin-4 prevented palmitate-induced apoptosis and autophagy, whereas GIP prevented apoptosis, but not autophagy. Conclusion: hCPC express functional GLP-1R and GIPR that mediate partially overlapping bioeffects. Tirzepatide prevents palmitate-induced apoptosis, autophagy, and senescence of hCPC, showing that dual pharmacological targeting through both GLP-1R and GIPR might be required to exert full beneficial effects on hCPC survival and function. C. Colabufo: None. I. Calderoni: None. R. Doria: None. C. Caccioppoli: None. G. Palma: None. G. Santarpino: None. T. Bottio: None. A.D. Milano: None. A. Leonardini: None. A. Natalicchio: Speaker's Bureau; AstraZeneca, Lilly Diabetes, Novo Nordisk, Sanofi. S. Perrini: None. A. Cignarelli: None. F. Giorgino: Advisory Panel; Abbott. Consultant; Amgen Inc. Advisory Panel; AstraZeneca, Bayer Pharmaceuticals, Inc, Biomea Fusion, Boehringer-Ingelheim, Daiichi Sankyo, Eli Lilly and Company. Research Support; Eli Lilly and Company. Board Member; European Association for the Study of Diabetes. Consultant; Medtronic. Advisory Panel; Mundipharma, Novo Nordisk, Roche Diabetes Care. Research Support; Roche Diabetes Care. Advisory Panel; Sanofi. L. Laviola: Speaker's Bureau; A. Menarini Diagnostics, Abbott, AlfaSigma, Ascensia Diabetes Care, AstraZeneca. Advisory Panel; Boehringer-Ingelheim, Eli Lilly and Company. Speaker's Bureau; Boehringer-Ingelheim, Eli Lilly and Company. Research Support; Medtronic. Speaker's Bureau; Medtronic. Advisory Panel; Novo Nordisk. Speaker's Bureau; Novo Nordisk. Advisory Panel; Roche Diabetes Care. Speaker's Bureau; Roche Diabetes Care. Advisory Panel; Sanofi. Speaker's Bureau; Sanofi.

Background/objectives:Heart transplantation remains the definitive treatment for end-stage heart failure. However, donor shortages and the increasing age of candidates present significant challenges. This report aims to highlight the feasibility and successful outcome of heart transplantation in an elderly patient, questioning traditional age-based eligibility criteria. Methods:A 76-year-old male with idiopathic dilated cardiomyopathy and severe heart failure underwent orthotopic heart transplantation. Preoperative assessments included right heart catheterization, echocardiography, and cardiac index evaluation. A suitable 66-year-old female donor was identified, and transplantation was performed using the bicaval technique. Postoperative outcomes were monitored through echocardiography and biopsy analysis. Results:The patient had an uneventful postoperative course, with extubation on day 1 and discharge on postoperative day 30. Follow-up at 14 months showed excellent clinical recovery, with an improved left ventricular ejection fraction (LVEF) of 58% and global longitudinal strain (GLS) of -20.8%. No signs of rejection were observed on biopsy. Conclusions:This case represents the oldest documented successful heart transplant recipient discharged home. The findings suggest that age alone should not be a limiting factor in transplantation eligibility. Expanding criteria to include well-selected elderly patients could help address the growing demand for donor hearts.

Background/Objectives: Heart transplantation is a life-saving procedure for patients with end-stage heart failure, yet it involves significant psychological and emotional challenges throughout its various stages. International guidelines recommend a multi-professional approach to the care of these patients and a psycho-social assessment for listing. The recommendations focus on content aspects, but not on the psychometric measure to be administered to patients as part of the assessment. Therefore, the purpose of this study is to provide the preliminary results of administering the protocol used by our center, measuring coping strategies, cognitive functioning, quality of life, and psychological distress in a sample of patients who are candidates for and undergo cardiac transplantation, and to observe any variations after the procedure. Methods: We conducted a comprehensive psychological-clinical assessment involving 40 patients, focusing on psychosocial functioning, cognitive reserves, mental health, and coping strategies. Tools such as the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT), Beck Depression Inventory-II (BDI-II), Montreal Cognitive Assessment (MoCA), General Anxiety Disorder 7 (GAD-7), and Medical Outcomes Survey Short Form 36 (SF-36) were employed to evaluate readiness for transplantation and post-transplant adaptation. Results: Results showed high levels of clinical anxiety (52.5%) and low perceived physical health (98%) before the transplant, while post-operative evaluations indicated reduced anxiety (13.51%) and depressive symptoms (10.81%), along with improved psychological well-being and reintegration into daily life. Conclusions: These results show improvement in physical and cognitive levels, accompanied by a state of enhanced psychological well-being after transplantation. A longitudinal psychological approach, from pre-transplant screening to post-discharge follow-up, is needed to address distress, improve coping mechanisms, and promote treatment adherence. This integrative strategy is critical to improving the quality of life and long-term outcomes for heart transplant recipients.

The ongoing global shortage of donor hearts dictates the need for innovative solutions to enlarge the donor pool and to reduce mortality of patients on the waiting list. The extended-heart-transplantation-criteria premise is to match patients who fall outside traditional eligibility criteria with donor hearts that have high risk features. In our case, the donor experienced ventricular fibrillation episodes. Given the idiopathic arrhythmogenic substrate of the transplanted heart, we decided to protect the receiver with a subcutaneous implantable cardioverter defibrillator in the short-term post heart transplantation. It represents the first experience worldwide in this specific setting of sudden cardiac death.

Background/Objectives: Retained fragments of cardiovascular implantable electronic device (CIED) leads are frequently observed after orthotopic heart transplantation (OHT), but their clinical relevance remains unclear. Methods: We conducted a single-center, retrospective study of 179 adult patients who underwent OHT between January 2022 and January 2025. Post-transplant imaging was used to identify retained lead fragments. Patients were grouped based on the presence or absence of retained leads. The primary endpoint was all-cause mortality at 30, 90, and 150 days post-transplant. Survival analysis was performed using Kaplan–Meier estimates and Cox proportional hazards modeling. Results: Among 112 patients with pre-transplant CIEDs, 18 (16%) had retained intravascular lead fragments. These patients had significantly lower survival at 30 days (66.7% vs. 94.7%), 90 days (61.1% vs. 90.3%), and 150 days (55.0% vs. 83.5%) compared to those without retained fragments (log-rank p = 0.002). The presence of retained leads was independently associated with increased mortality (HR: 3.71; 95% CI: 1.55–8.84; p = 0.003), even after adjusting for potential confounders. Conclusions: Retained CIED lead fragments are independently associated with higher early post-transplant mortality. These findings support the need for individualized intraoperative strategies to mitigate hardware-related risks in high-risk transplant candidates.

Kawasaki disease (KD), or mucocutaneous lymph node syndrome, is a rare systemic inflammatory condition predominantly affecting children under 5 years of age. Complications such as giant coronary artery aneurysms, although rare due to advancements in treatment, remain life-threatening. Coronary artery bypass grafting (CABG) has been a well-established treatment for severe coronary lesions caused by KD. In rare cases of ischemic cardiomyopathy in pediatric patients, heart transplantation may be the only option. We report a case of a 15-year-old male with a history of KD diagnosed at 9 months of age, complicated by giant coronary aneurysms of the left anterior descending and right coronary arteries, who underwent a successful double CABG using the left internal mammary artery) and a saphenous vein graft.

We report a clinical case of multifactorial shock and primary adrenal insufficiency (PAI), caused by bilateral adrenal hemorrhage in the context of catastrophic antiphospholipid syndrome (CAPS) triggered by a COVID-19 infection. A 54-year-old woman was admitted with cardiogenic shock, presenting with severe cardiac dysfunction, neurological alterations, and systemic embolism. Despite initial treatment for suspected septic shock, her condition deteriorated, with bilateral adrenal hemorrhages, markedly elevated adrenocorticotropic hormone (ACTH) levels, low cortisol, and positive antiphospholipid antibodies, leading to the diagnosis of PAI. A multidisciplinary approach, including endocrinology and cardiology expertise, enabled the prompt initiation of hydrocortisone and anticoagulant therapy, which significantly improved her hemodynamic stability and overall clinical status. At follow-up, partial recovery of left ventricular function was observed, although residual cardiac dysfunction persisted. This case highlights the diagnostic challenges associated with CAPS, a rare autoimmune disorder with life-threatening manifestations, including PAI due to adrenal infarction. The overlapping symptoms of CAPS and septic shock often delay diagnosis, underscoring the importance of early recognition of adrenal involvement in patients with CAPS. Furthermore, the patient clinical history, including anticoagulant withdrawal and previous thrombotic events, suggests a need for heightened vigilance in similar cases. In recent years, strong evidence has emerged on the similarities between CAPS and COVID-19, particularly related to the immungenic power of this viral infection and hypercoagulability, but it is also considered that COVID-19 can trigger CAPS. Our findings emphasize the critical role of a coordinated multidisciplinary approach in managing complex CAPS presentations and underline the importance of timely hormone replacement and anticoagulation to improve outcomes in PAI associated with adrenal hemorrhage.

Heart transplantation (HT) is the treatment of choice for patients with end-stage heart failure. The main benefit of HT is to increase survival, exercise capacity, and quality of life, compared to medical treatment. Considering the shortage of organ availability, an increased number of marginal donors has been considered in the last years, with increased risk of short- and long-term complications. Acute kidney injury (AKI) requiring renal-replacement therapy (RRT) after HT is common and severely affects clinical outcomes. The aim of this study was to evaluate the epidemiology and outcomes of HT-associated AKI requiring RRT. We conducted a single-centre retrospective analysis including adult patients who underwent HT at Cardiac Surgery Unit at the University Hospital Policlinico, Bari, Italy between March 2022 and August 2024. We classified patients in two groups based on the need of RRT after HT (no-RRT group and RRT group). The primary outcome was to assess the incidence of AKI requiring RRT and related 30-day mortality. Differences in baseline HT characteristics between groups were tested with t tests or Mann–Whitney U tests for continuous data, as appropriate, and chi-square test for categorical data. Multivariate logistic regression analyses were performed to assess risk factors for post-transplant RRT and 30-day mortality. 137 HT recipients were included in the study; 60 patients developed AKI requiring RRT (43.7%), while the remaining 77 were classified as no-RRT group (56.3%). Mean recipient age was 58 years with a predominance of male gender (81%), without significant differences between groups. Days on waiting list for HT were higher in the no-RRT group, as most of patients received HT in election. Patients in the RRT group presented a lower pre-HT eGFR (median eGFR 55.7 vs 69.1, P = 0.009), while the proportion of patients requiring ECMO (41.6% vs 14.2%, P < 0.001) and RRT (RRT, 18.3% vs 2.5%, P = 0.001) before HT was higher. All patients were treated with continuous RRT (CRRT), with a median time of CRRT treatment of 19 days (IQR 4.7–36.7). 20 patients (20.4%) died at 30 days, with a higher percentage in the RRT group (40% vs 5.1%, P < 0.001). In a multivariate analysis, the need of ECMO before (OR 3.16, 95% CI 1.13–8.78, P = 0.027) and after HT (OR 10.38, 95% CI 4.24–25.38, P < 0.001) were associated with the need of post-HT RRT. In a multivariate regression analysis, only the need of post-HT CRRT was independently associated with increased risk of mortality (OR 9.205, 95% CI 2.367–35.804, P = 0.001). HT-associated AKI requiring RRT was associated with high mortality rate and worse short-term outcomes compared to HT recipients who did not require RRT. These findings emphasize the importance of optimizing workflows and procedures to prevent potential reversible risk factors for AKI and improve HT outcomes.

Background:Postcardiotomy cardiogenic shock (PCCS) is a critical condition with high mortality. When biventricular dysfunction occurs, veno-arterial ECMO alone may not provide adequate unloading. Paracorporeal BiVAD can offer balanced support as a bridge to heart transplantation. Case:A 61-year-old woman developed PCCS following bioprosthetic aortic valve replacement. Despite VA-ECMO and intra-aortic balloon pump support, biventricular failure persisted. A paracorporeal BiVAD was implanted, achieving rapid hemodynamic and pulmonary improvement. After 7 days of BiVAD support, she underwent successful orthotopic heart transplantation. At 1-year follow-up, the patient remains alive without graft rejection or vasculopathy. Conclusion:Early conversion from VA-ECMO to BiVAD may improve outcomes in refractory PCCS with biventricular failure, serving as an effective bridge to transplantation.