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Heart transplantation (Htx) remains the gold standard as treatment of patients with advanced heart failure. Donor and recipient characteristics have changed dramatically in recent years, leading to more complex decision-making regarding organ acceptance and postoperative management. Primary aim of the study was to identify donor risk factors variables impacting on in-hospital mortality, early graft failure and follow-up mortality; secondary objective was to validate the available international donor risk scores. Between January 2000 and December 2017, 461 adult patients underwent Htx. UNOS, RADIAL and Eurotransplant scores have been calculated. Clinical features and donor risk scores have been tested in order to identify pre-, intra- and post-operative risk variables and eventually validate the scores on our population. Post-Htx extracorporeal life support (ECLS) was used in 11.1% (51/461). Of the donor related factors, peak of troponine (p<0.001) and use of noradrenaline (p=0.02) negatively influenced on early outcomes, while a ischaemic time >240 minutes (p=0.037) influenced EGF occurrence. The Eurotransplant donor score didn't impact on outcomes, the RADIAL significantly influenced both on early (p=0.02) and late mortality (p=0.004) while the UNOS on late mortality only (p=0.03). On the multivariate model, after adjustment per cohort of scores, noradrenaline infusion resulted to be an independent predictor of in-hospital mortality in the Eurotransplant score >17 population, recipient pre-Htx ECLS and BMI >30 were independent predictors of EGF in the UNOS score >6 population, and recipient age >60 was predictor of late mortality in the RADIAL score >5 (figure 1). Actual heart donor scoring systems do not fully behave as reliable predictors of transplant outcomes. Therefore, every transplant institution should consider developing a local donor scoring systemto provide their own standard graft selection thus preserving the outcomes. [ABSTRACT FROM AUTHOR]

The prognostic impact of pulmonary hypertension (PH) is debated as well as the trend of pulmonary hemodynamic variables after heart transplantation (HTx). We investigated the impact of preoperative PH on postoperative survival and on the evolution of right heart hemodynamics (RHH) after HTx. We reviewed the records of 431 consecutive HTx recipients, divided in a non-PH group (270 pts) and a PH group (161 pts).PH was defined as pulmonary vascular resistance ≥2.5 Wood units (WU) at right heat catheterization: mild (97 pts; PVR: 2.5-3.4WU), moderate (41 pts; PVR: 3.5-4.9WU) and severe PH (23 pts; PVR ≥5.0WU). RHH [systolic/mean/diastolic pulmonary artery-systolic-pressure (PAP), pulmonary-capillary-wedge-pressure (PCWP), transpulmonary gradient (TPG), cardiac output (CO), pulmonary vascular resistance (PVR), pulmonary-arterial-pulsatility-index (PAPi) and right-ventricle-stroke-work-index (RVSWI)] were measured before HTX and 3, 6, 12 months, 3, 5 years after HTX. Survival analysis was conducted using Kaplan-Meier curves. Preoperatively, patients with severe PH had significantly (P<0.001) higher mean PAP (64.5/42.2/28.8 vs. 48.6/32.6/21.8mmHg), TPG (16.8 vs. 9.9mmHg), PVR (6.1 vs. 3.2WU) and RVSWI (568.4 vs. 428.9) than patients with mild/moderate PH. After HTx, the PH-group had a higher incidence of graft dysfunction (20.5 vs. 14.8%;P=0.01), right ventricular failure (9.3 vs. 4.8%;P=0.03), ECMO (10 vs. 5.1%;P=0.01), ICU stay (8.4 vs. 6.8 day;P=0.02) than non-PH patients. In hospital mortality was 10.6% in PH-patients (15.8% vs. 9.9% in severe vs. mild/moderate PH;P=0.04) vs. 6.3% in non-PH group (P=0.01). Ten-years survival rates were 70% in PH-patients (71% in severe PH) vs. 72% in non-PH patients. RHH improved early after HTx, without significant differences between severe PH and mild/moderate PH [PAP (30.1/19.4/10.9 vs. 26.8/17.3/9.8mmHg), TPG (10.9 vs. 8.5mmHg), PVR (1.8 vs. 1.5WU) and RVSWI (506.1 vs. 470.9) but slightly worsened after 3-5 years. Pre-transplant PH is an independent predictor of early mortality after HTx, not affecting long-term survival even when severe. After an early significant improvement of RHH, mean PAP, TPG and PVR increase while CO, PAPi and RVSWI decrease during follow-up. A rigorous monitoring of RHH must be scheduled during FU. [ABSTRACT FROM AUTHOR]

In 2004 the ADONHERS Protocol was created to increase the number of suitable heart donations. It's applied in extended criteria donors and in cases of impossibility to perform coronary angiography. We present the detailed protocol and clinical results of patients transplanted with. The ADHONERS Protocol (AP) included: administration of defined doses of dipyridamole or dobutamine; basal and after test evaluation of regional motion, on a scale from 1 (normal) to 4 (dyskinetic) in each of the 17 segments; sharing of echo images with a second opinion. We included 275 cardiac transplantations performed from 2004 to 2014. Of them, 23 (8.4%) were performed applying the AP. Recently, we used the echo stress in three procurements where coronary angiogram couldn't be performed, with excellent results and no coronary stenosis on the post-transplant angio. Those cases are not included in this cohort. In AP group, recipients were older (55,8 years vs 51,5 p = 0,079) as well as donors (54,5 years vs 37,8 in the NAP (non ADONHERS Protocol) group, p=0.001), while mean ischemic time was shorter (181,9 min vs 197,2 min, p=0.008) and the use of Adrenaline or Dobutamine in donors was inferior (22.7% in AP vs 56.2% in NAP p=0.033). Early and late outcomes were analogous in the two groups. Severe EGF occurred in 8,7% patients AP vs 8,3% in NAP (p=0,95). In hospital mortality of NAP group was 7,9% vs 8.7% (p=0,749). No coronary disease (CAD) was found in the early postop but in the long term CAD occurred in two cases of the AP group (9.5%) vs 12 cases in NAP (5.2%) (p=0.33). Mean follow up time was 74,7 months in AP vs 110,1 (p=0,001) and follow up survival at 1 and 5 years in the AP group was 91.3% and 73% vs 89.7% and 80.9% (p=0.019), but population in the AP group was older. In hospital mortality risk factors were: recipients' age [OR 1.07 (1.01;1.13), p=0.016] and donors' age [OR 1.05 (1.01 ; 1.09), p=0.009], while in the follow-up were recipients' age [1.04 (1.02;1.06), p=0.001], vasculopathy [OR 4.75 (1.28;17.68), p=0.018], donors' age [OR 1.03 (1.01;1.05), p=0.006], donor female gender [OR 2.51 (1.51;4.17) , p=0.00] and gender mismatch [OR 2.28 (1.32 ; 3.96) , p=0.003] Applying the ADONHERS protocol nearly 10% of otherwise discarded hearts can be successfully used for transplantation to unmask inducible ischemia and estimate contractile reserve. [ABSTRACT FROM AUTHOR]

To evaluate the impact of recipients pre-operative right ventricular dysfunction on heart transplantation (Htx) outcomes. We retrospectively analyzed 517 consecutive adult patients who underwent Htx between January 2000 and December 2020, focusing on right heart catheter hemodynamic data, mostly. In-hospital mortality was 8%. Severe Early Graft Failure (EGF) occurred in 6.6% of patients. Right ventricular function and pulmonary circulation hemodynamic variables were weighted in terms of influence on in-hospital mortality: Central Venous Pressure (CVP) [OR 1.09 (1.03;1.15), p=0.004], Pulmonary Artery Systolic Pressure (PASP) [OR 1.02 (1.00;1.04), p=0.05], CVP/ Pulmonary Capillary Wedge Pressure (PCWP) ratio [OR 2.78 (1.14;6.80), p=0.025], Pulmonary Vascular Resistance (PVR) [OR 1.15 (1.01;1.32), p=0.042], Trans-Pulmonary Gradient (TPG) [OR 1.11 (1.03;1.18), p=0.003] and Diastolic Trans-Pulmonary Gradient (DPG) [OR 1.10 (1.02;1.20), p=0.015]. Thereafter, PASP [OR 1.03 (1.00;1.05), p=0.016] and TPG [OR 1.08 (1.01;1.17), p=0.03] did impact negatively on the occurrence of EGF. Preoperative right ventricular dysfunction did not result to influence on follow-up (FU) mortality. On the multivariable analysis, CVP and TPG resulted to be independent predictors of in-hospital mortality while TPG of EGF. By spitting patients population into 4 hemodynamic profiles in terms of pulsatile load, focusing on Pulmonary Artery Compliance (PACi), and right ventricle hemodynamic response to load, focusing on CVP:PCWP ratio, we resulted to have a high PACi/high PVC:PCWP profile with a higher risk of in-hospital mortality [OR 2.40 (1.04;5.54), p=0.05] and EGF [OR 3.40 (1.32;7.28), p= 0.01]. Overall survival at 1, 5 and 10 years was 89.4%, 80.8% and 66.4%, respectively. By analyzing the four hemodynamic profiles, patients with low PACi/high PVC:PCWP showed the worst survival (Log-rank=0.045). In our patients population, CVP and TPG resulted to be independent risk factors of in-hospital mortality while TPG of EGF. Thus, the detection of pre-operative right ventricular dysfunction in potential heart transplant recipients should be managed early and treated properly in terms of preoperative clinical optimization to improve the postoperative outcomes. [ABSTRACT FROM AUTHOR]

Analyze the characteristic of donors and recipients in our center and the results of heart transplantations for the two different levels of priority according to Italian previous allocation system, urgent patients and elective ones. From 2006 to August 2020, 306 heart transplantations were performed at our institution. Of them 54 (17.6%) in urgency. Reasons for urgency were: 24 patients on ECMO support, 8 on IABP and 13 on intravenous inotropes, 4 arrhythmic storms and 5 complicated LVAD. In the urgent population, recipients were predominantly male (68.5 % vs 77.4 % in the elective p=0.17) and significantly younger (46.4 vs 52.2 years, p=0.001). More patients were on ECMO support (42.6% vs 1.7% p=0.000), IABP (42.6 vs 6.7% p=0.000) and mechanically ventilated (46.2% vs 6% p=0.000) pre transplant. The donors of urgent patients were younger than donors of the elective ones (38.9 vs 42.4 years (p=0.06). Donor's gender (68% males) and cause of brain death (brain trauma 44,4%, and cerebral hemorrhage 35,2%) were comparable in the two groups. Mean ischemic time was longer in urgent cases (211 vs 191 minutes, p=0.01) as donations came from across the whole country. Severe Early Graft Failure (EGF) requiring ECMO occurred in 9.4% of patients in the urgent population vs 3.6% in the elective with no significant difference (p=0.076), as well as in hospital mortality that was 11.5% in urgent vs 8.3% (p=0.429). Recipients' risk factors for in-hospital mortality were age [OR 1.05 (1.01;1.09), p=0.028] and Glomerular Filtration Rate (GFR) < 40 ml/min [2.68 (1.04;6.92), p=0.047]. No donors' variable resulted to be a risk factor for in-hospital mortality. Episodes and grade of rejection did not diverge between groups, and so did follow up mortality (16.7% in urgent vs 22.4% in electives p=0.444) Mean follow up time for urgent population was shorter (53.6 vs 75.6 months (p=0.007). Overall 5 and 10 years' mortality was 79.7% and 62% vs 88.1% and 72.8% for urgent and elective patients respectively (p=0.721). This retrospective analysis of our transplantation activity with the different priority regimen shows little differences in terms of mortality and complications. Despite the worse clinical characteristics of the urgent recipients and the longer ischemic time, results do not significantly differ from the elective population, underlying the importance of donation quality. [ABSTRACT FROM AUTHOR]