Diyar Saeed

Purpose Biventricular assist devices (BiVADs) and total artificial heart (TAH) are the principal bridge-to-transplantation strategies for patients with advanced biventricular heart failure awaiting heart transplantation, but their comparative effectiveness and safety remain uncertain. This systematic review and meta-analysis compared pretransplant outcomes between the two approaches. Methods A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, Web of Science, and Cochrane Library were searched from inception through January 2026 for studies comparing BiVADs and TAH as bridge-to-transplantation strategies. Study quality was assessed using the Newcastle–Ottawa Scale, and certainty of evidence was evaluated using the GRADE framework. Random-effects models were used to compare survival to transplantation, mortality during support, support-related complications, and duration of support. Results Ten retrospective studies involving 2,242 patients met the inclusion criteria. The overall analysis showed no significant difference in survival to transplantation between patients supported with BiVADs and TAH (RR = 0.97, 95% CI (0.84, 1.13), P = 0.74). However, after excluding potentially overlapping cohorts, sensitivity analysis showed a higher rate of survival to transplantation in those supported with TAH (RR = 0.88, 95% CI (0.80, 0.97), P = 0.01). No significant difference was observed in mortality during support in the overall analysis (RR = 1.19, 95% CI (0.88, 1.61), P = 0.26) or after excluding potentially overlapping cohorts (RR = 0.98, 95% CI (0.79, 1.21), P = 0.84). BiVADs were associated with higher rates of bleeding and stroke (RR = 2.79, 95% CI (1.70, 4.59), P < 0.0001 and RR = 2.31, 95% CI (1.53, 3.50), P < 0.0001, respectively), whereas infection did not differ significantly between the two groups (RR = 1.18, 95% CI (0.50, 2.78), P = 0.70). Sensitivity analysis for stroke after excluding potentially overlapping cohorts showed a similarly higher rate in patients supported with BiVADs (RR = 2.39, 95% CI (1.46, 3.93), P = 0.0006). Duration of support did not differ significantly between both groups in the overall analysis (MD = 2.25 days, 95% CI (− 16.46, 20.96), P = 0.81) or after excluding potentially overlapping cohorts (MD = − 0.90 days, 95% CI (− 24.26, 22.46), P = 0.94). Conclusion TAH may be associated with higher rates of survival to transplantation after excluding potentially overlapping cohorts, while BiVAD support may be associated with higher rates of bleeding and stroke. However, all included studies were retrospective, and the certainty of evidence was low for most outcomes. These findings should therefore be interpreted with caution and require confirmation in prospective multicenter studies.

Objectives: This study aimed to assess the prognostic value of six-minute walk distance (6MWD) in stable HeartMate 3 (HM3) recipients. Methods: Data from patients with available 6MWD at 6 months post-implant were obtained from the prospective, multicentre ELEVATE registry. Overall survival and adverse event rates were analysed using Cox regression models adjusted for age and sex, with 6MWD as a continuous predictor, and stratified by median distance (350 m). Results: Six-minute walk distance at 6 months was available in 194 HM3 recipients. Patients walking < median were older (57 vs 52 years, P = .002), had more comorbidities, and reported lower quality of life. Six-minute walk distance correlated positively with haemoglobin (r = 0.20, P = .006) and EuroQoL-5 Dimensions visual analogue scale (EQ-5D VAS) (r = 0.23, P = .004), and inversely with New York Heart Association (NYHA) class (r = –0.47, P < .0001). Kaplan-Meier analyses of patients walking < or ≥ 350 m showed no significant differences in survival (log-rank P = .379), right heart failure (HF) (P = .334), or rehospitalization (P = .243), while survival free from haemocompatibility-related adverse events differed significantly, although marginally (P = .049). Cox models confirmed that 6MWD had no independent prognostic value for mortality (HR 0.98, 95% CI, 0.96-1.01, P = .26) or secondary outcomes. However, patients with < median 6MWD experienced higher rates of major bleeding (Incidence rate ratio (IRR) 2.88, P < .001), major infection (IRR 2.14, P < .0001), and renal dysfunction (IRR 4.78, P = .033). Conclusions: Shorter 6MWD 6 months after HM3 implantation was associated with a higher risk of some adverse events (AEs) but was not prognostic for mortality, HF recurrence, or rehospitalization risk. The prognostic value of 6MWD in HF patients without circulatory support cannot be extrapolated to patients treated with current left ventricular assist devices (LVADs). Clinical trial registration number: ClinicalTrials.gov Identifier: NCT02497950.

Background and Objectives: Left atrial appendage (LAA) closure is a Class I recommendation in patients with atrial fibrillation to reduce the risk of cardioembolic stroke. Achieving reliable and complete LAA exclusion during minimally invasive mitral valve surgery via right minithoracotomy remains technically challenging. We report here to our knowledge the largest series of a novel technique for LAA exclusion using an epicardial clip device applied via right minithoracotomy during minimally invasive mitral valve surgery. Materials and Methods: Between June 2023 and May 2026, 40 patients with atrial fibrillation underwent minimally invasive mitral valve surgery via right minithoracotomy with concomitant LAA exclusion. Cardiopulmonary bypass was established via percutaneous femoral cannulation. Following completion of the intracardiac procedure and prior to aortic cross-clamp removal, a suture was placed around the LAA base via the transverse sinus and used to guide clip deployment under direct vision. Successful closure was confirmed by intraoperative transesophageal echocardiography. Results: Mean patient age was 66.6 ± 8.0 years; 21 patients (53%) were female. Mitral valve repair was performed in 36 patients (90%) and replacement in 4 (10%). Concomitant cryoablation for AF was performed in 31 patients (78%). Successful LAA clip deployment was achieved in all 40 patients (100%). The 35 mm clip was used in 36 patients (90%), the 40 mm clip in 3 patients (8%), and the 45 mm clip in 1 patient (2%). Mean total operative time was 183 ± 58 min; mean CPB time was 134 ± 42 min; mean aortic cross-clamp time was 70 ± 27 min. In-hospital mortality was 0%. One patient (3%) required re-thoracotomy for bleeding, one developed a postoperative stroke, and two required ECMO support. Median hospital stay was 9 days. At discharge, 18 patients (45%) were in sinus rhythm; among the 31 who underwent concomitant cryoablation, 16 (52%) were discharged in sinus rhythm. Conclusions: Minimally invasive LAA exclusion is feasible and safe when performed via right minithoracotomy during minimally invasive mitral valve surgery. The technique achieves high rates of successful deployment and avoids the need for additional incisions or access sites. This approach represents a valuable addition to the armamentarium of concomitant stroke prevention strategies in patients with AF undergoing minimally invasive valvular surgery.

Background and Objectives: Endoscopic beating-heart tricuspid valve (TV) surgery is increasingly adopted in cardiac surgery due to its association with improved postoperative recovery. Conventional approaches require jugular vein cannulation to establish adequate bicaval venous drainage, and caval snaring is considered mandatory during beating-heart TV procedures to prevent intraoperative air lock. We report our single-center experience with a novel percutaneously placed venous cannula (Smart Cannula) that enables minimally invasive TV surgery without jugular cannulation or caval snaring. Materials and Methods: Between February 2025 and May 2026, 31 consecutive patients underwent endoscopic beating-heart TV surgery using the Smart Cannula system for venous drainage. The device is a stent-like cannula with distributed wall perforations allowing sufficient venous return while preventing air lock. Preoperative atrial fibrillation was present in 21 patients (68%). Six patients (19%) underwent isolated TV procedures; the remainder had concomitant procedures. Mean age was 68.2 ± 10.8 years; 16 patients (52%) were female. Two different cannula lengths were used: 680 mm (n = 15) and 730 mm (n = 16). Six patients (19%) had history of prior cardiac surgery. Results: All procedures were completed without intraoperative air lock. Two patients (6%) required intraoperative conversion to sternotomy. Mean cardiopulmonary bypass time was 163 ± 52 min. Seven patients (23%) underwent beating-heart procedures with no aortic cross-clamping; in 24 patients (77%), aortic cross-clamping was required for concomitant procedures (mean cross-clamp time 79 ± 28 min), with tricuspid repair completed on the reperfused beating heart. Re-exploration for bleeding occurred in two patients (6%). Median ICU stay was 5 days and median hospital stay was 10 days. New permanent pacemaker implantation was required in three patients (10%). Thirty-day mortality was 0%. Postoperative echocardiography at discharge demonstrated TR Grade 0 in 61%, mild TR in 32%, and moderate TR in 3% of patients. Conclusions: In this first and largest published series on endoscopic beating-heart TV surgery without caval snaring or jugular vein cannulation, we have shown that the process is feasible and safe, eliminating the need for jugular vein cannulation and caval snaring while maintaining no occurrence of intraoperative air lock. The device enables a simplified venous drainage strategy without compromising operative safety or early clinical outcomes.

Objectives: Microaxial flow pumps (mAFP) effectively bridge patients with cardiogenic shock to durable left ventricular assist device (dLVAD) implantation. The partial-support mAFPs provide only up to 3.5 L/min, which might be insufficient for an effective circulatory support and preconditioning for a dLVAD implantation. Alternatively, patients with refractory shock on partial support may benefit from an escalation to a full-support mAFP. Methods: A retrospective analysis of 130 patients was performed across 17 European cardiac centres who underwent dLVAD implantation following mAFP with or without venoarterial extracorporeal life support (VA-ECLS) between February 2015 and August 2022. Ninety-two patients (70.8%) were bridged on partial-support mAFP, while 38 patients (29.2%) underwent an escalation to full-support mAFP. Results: Median support duration was significantly longer in the escalation group (7 days [4, 11] vs 12 days [9, 21], P < .001). Patients in the escalation group were more likely to be weaned from VA-ECLS before dLVAD implantation, 10 (71.4%) vs 6 (11.3%), P < .001. Thirty-day survival was similar between the escalation and no-escalation groups, 89.5% vs 84.8% (IPTW-weighted OR, 1.00 [95% CI, 0.46-2.22], P = .992). Estimated 1-year survival was higher in the escalation group: 84.0% [95% CI, 73.0-96.6] vs 63.7% [95% CI, 54.3-74.6], HR 0.41 [95% CI, 0.17-0.99], P = .048. Patients with a combination of partial-support mAFP and VA-ECLS had a higher mortality risk than all other patients, HR 2.06 [95% CI, 1.16-3.36], P = .013. Conclusions: In patients with partial-support mAFP and concomitant VA-ECLS, an escalation to a full-support mAFP may translate to improved survival and should be considered to facilitate VA-ECLS weaning.

Objectives: To assess whether tricuspid valve surgery (TVS) during HeartMate 3 (HM3) left ventricular assist device (LVAD) implantation affects long-term survival and outcomes. Methods: The ELEVATE registry enrolled 540 HM3 patients across 26 centres; 463 undergoing primary LVAD implantation and at least mild tricuspid regurgitation (TR) formed this analysis. Concomitant TVS was performed in 70 (15.1%) patients. Five-year outcomes (survival, functional capacity, end-organ function, adverse events) were compared with those with similar severity of TR not receiving TVS in both overall population (with TVS n = 70 vs without TVS n = 264) and matched groups (each group n = 67, primary analysis cohort). Results: In the matched cohort, baseline demographics of patients with or without TVS showed no differences in age (57.9 ± 10.8 vs 57.3 ± 10.0; P = .728), sex (male, 92.5% vs 94.0%; P = 1.000), preoperative short-term mechanical circulatory support rate (6.0% vs 9.0% P = .744), New York Heart Association (NYHA) class and quality of life (QoL) score, and end-organ function. Preoperatively, patients with TVS had shorter 6-minute walk distances (6MWD; 58.0 ± 109.0 m vs 105.3 ± 154.0 m; P = .081). At 5 years, patients with TVS showed no differences in survival (69.0% vs 59.3%, P = .67), 6MWD (311.1 ± 129.5 m vs 295.6 ± 137.7 m, P = .758), QoL score, or end-organ function while presented a lower risk of right heart failure (EPPY 0.038 vs 0.092, P = .03). Conclusions: In the ELEVATE registry, concomitant TVS during HM3 implantation was not associated with differences in 5-year survival; however, it may have a positive effect on functional capacity and right heart function. Clinical registration number: NCT02497950

Heart transplantation has made remarkable strides since its inception in the 1960s. While the transplant volume in the USA has steadily increased over the last decade, significant disparities exist in Europe, fuelled by cultural and legislative differences. Recent advancements such as donation after circulatory death and use of hepatitis C positive donors are embraced to differing degrees among countries. This review serves to summarize the current state and ongoing challenges of heart transplantation in the USA and Europe.

Background: This study aimed to evaluate the diagnostic value of pre-existing computed tomography (CT) examinations for the detection of dental pathologies compared with clinical dental examination in patients with end-stage heart failure. Methods: For this purpose, 59 patients with end-stage heart failure and pre-existing non-dental CT images of the craniofacial region were included. Virtual orthopantomograms (vOPG) were reconstructed. Dental pathologies were analyzed in vOPG and source-CT images. Imaging and clinical findings less than 6 months apart were compared (n = 24). Results: The subjective image quality of vOPG was more often rated as insufficient than CT (66%; 20%; p < 0.01). Depending on examination (CT, vOPG or clinic), between 33% and 92% of the patients could require dental intervention such as treatment of caries and periodontitis or tooth extraction. vOPG led to a higher (80%) prevalence of teeth requiring treatment than CT (39%; p < 0.01). The prevalence of teeth requiring treatment was similar in CT (29%) and clinic (29%; p = 1.00) but higher in vOPG (63%; p < 0.01). CT (stage 3 or 4: 42%) and vOPG (38%) underestimated the stage of periodontitis (clinic: 75%; p < 0.01). Conclusions: In conclusion, available CT images including the craniofacial region from patients with end-stage heart failure may contain valuable information regarding oral health status. The assessability of vOPGs might be insufficient and must be interpreted with caution.

OBJECTIVES: Bridging from a temporary microaxial left ventricular assist device (tLVAD) to a durable left ventricular assist device (dLVAD) is playing an increasing role in the treatment of terminally ill patients with heart failure. Scant data exist about the best implant strategy. The goal of this study was to analyse differences in the dLVAD implant technique and effects on patient outcomes.METHODS: Data from 341 patients (19 European centres) who underwent a bridge-to-bridge implant from tLVAD to dLVAD between January 2017 and October 2022 were retrospectively analysed. The outcomes of the different implant techniques with the patient on cardiopulmonary bypass, extracorporeal life support or tLVAD were compared.RESULTS: A durable LVAD implant was performed employing cardiopulmonary bypass in 70% of cases (n = 238, group 1), extracorporeal life support in 11% (n = 38, group 2) and tLVAD in 19% (n = 65, group 3). Baseline characteristics showed no significant differences in age (P = 0.140), body mass index (P = 0.388), creatinine level (P = 0.659), the Model for End-Stage Liver Disease (MELD) score (P = 0.190) and rate of dialysis (P = 0.110). Group 3 had significantly fewer patients with preoperatively invasive ventilation and cardiopulmonary resuscitation before the tLVAD was implanted (P = 0.009 and P < 0.001 respectively). Concomitant procedures were performed more often in groups 1 and 2 compared to group 3 (24%, 37% and 5%, respectively, P < 0.001). The 30-day mortality data showed significantly better survival after an inverse probability of treatment weighting in group 3, but the 1-year mortality showed no significant differences among the groups (P = 0.012 and 0.581, respectively). Postoperative complications like the rate of right ventricular assist device (RVAD) implants or re-thoracotomy due to bleeding, postoperative respiratory failure and renal replacement therapy showed no significant differences among the groups. Freedom from the first adverse event like stroke, driveline infection or pump thrombosis during follow-up was not significantly different among the groups. Postoperative blood transfusions within 24 h were significantly higher in groups 1 and 2 compared to surgery on tLVAD support (P < 0.001 and P = 0.003, respectively).CONCLUSIONS: In our analysis, the transition from tLVAD to dLVAD without further circulatory support did not show a difference in postoperative long-term survival, but a better 30-day survival was reported. The implant using only tLVAD showed a reduction in postoperative transfusion rates, without increasing the risk of postoperative stroke or pump thrombosis. In this small cohort study, our data support the hypothesis that a dLVAD implant on a tLVAD is a safe and feasible technique in selected patients.