Matiullah Masroor

Objective: The impact of underweight or low-BMI donors on heart transplantation (HTx) outcomes remains poorly understood. This study aims to investigate the effect of underweight donors on post-transplant outcomes. Methods: We retrospectively analyzed 574 patients divided into 2 groups based on donor BMI: underweight donors (BMI < 20 kg/m², n = 101, 17.6%) and normal-weight donors (BMI 20–25 kg/m², n = 473, 82.4%). Baseline variables and postoperative outcomes were compared using the Student’s t-test for continuous variables and the chi-squared test for categorical variables. Propensity score matching (PSM) was performed to balance baseline differences and control for confounders. Survival analysis was performed using the Kaplan–Meier method. Results: The matched cohort included 71 patients per group, with balanced baseline characteristics. Compared to the normal-weight group, recipients of underweight donors had significantly higher rates of respiratory complications (64.8% vs. 47.9%, p = 0.042), neurological complications (15.9% vs. 4.2%, p = 0.021), renal complications (17.4% vs. 5.6%, p = 0.029), and longer postoperative hospital stay (37.2 vs. 28.4 days, p < 0.001). No significant difference was observed in hospital mortality (2.8 vs. 4.2%, p = 0.649). The overall follow-up time was 72.2 ± 1.9 months (range 68.5 to 75.8). The 1-, 3-, and 5-year survival rates for the underweight and normal-weight donor BMI groups were 83.1% vs. 85.9% (p = 0.624), 75.6% vs. 80.2% (p = 0.527), and 72.0% vs. 77.3% (p = 0.468), respectively. Conclusions: Patients receiving hearts from underweight donors demonstrate comparable long-term survival to those from normal-weight donors but have a higher risk of postoperative complications. These findings suggest that underweight donors could be cautiously utilized to expand the donor pool, offering lifesaving opportunities to recipients who might otherwise experience adverse outcomes due to donor scarcity, albeit with an increased risk of postoperative complications.

Objective: Obesity is one of the common risk factors for heart failure. Heart transplantation (HTx) is a gold standard treatment option for end-stage heart failure. The relationship between obesity and HTx outcomes is not very clear. This study aims to investigate the impact of recipient BMI on heart transplantation outcomes.Methods: From 2012–2021, 821 patients underwent HTx in our center. Patients with age less than 18 years, multiorgan transplantation, re-transplantation, and missing recipient BMI data were excluded. The remaining 694 patients were divided into four BMI categories based on the recipient's BMI value. BMI < 18.5 kg/m² (n = 70), BMI 18.5–24.99 kg/m² (n = 432), BMI 25–29.99 kg/m² (n = 156), and BMI ≥ 30 kg/m² (n = 36). Analysis of variance and chi-square test with post hoc test according to the types of variables was performed to find differences among the groups. Kaplan–Meier analysis with a Log-rank test was performed for the survival analysis. Cox regression analysis was performed to adjust for confounders and see the effect of variables on mortality.Results: Some preoperative variables, such as recipient gender and diabetes status, were statistically significantly different between the groups. However, there was no significant difference in the postoperative outcomes except for high intra-aortic balloon pump (IABP) use in the BMI ≥ 30 kg/m² group based on unadjusted analysis. The Kaplan–Meier survival analysis showed no short or long-term survival difference between the groups. The 5-year survival was 75%, 70%, 71%, and 83% in underweight, normal weight, overweight, and obese recipient BMI groups, respectively. Recipient BMI was not associated with follow-up mortality on multivariable analysis. Preoperative IABP use, history of chronic kidney disease, and recipient age were the independent risk factors for long-term mortality. The risk of mortality was five times higher in patients with preoperative IABP use and two times higher in patients with a history of CKD. A one-year increase in recipient age was associated with a 3.4% increase in mortality risk.Conclusion: The recipient BMI did not significantly impact post-transplantation survival after multivariable adjustment. However, unadjusted analyses showed comparable non-survival outcomes across BMI groups. Our study suggests that selected underweight and class I obese patients may undergo heart transplantation without increased risk of post-transplantation mortality.

Background: Obesity is a common risk factor for heart failure, and heart transplantation (HTx) is the treatment of choice for end-stage heart failure. Due to the limited availability of the donor’s heart, efforts are made to increase the donor pool on one hand and to find predictors that can impact HTx outcomes on the other hand. These predictors can help improve donor organ allocation and HTx outcomes. This study aims to investigate the impact of the donor-recipient BMI ratio on follow-up mortality and other outcomes after HTx. Methods: From 2012 to 2021, 821 patients underwent HTx in our centre. Patients under 18 years, re-transplantation, multiorgan transplantation, and missing recipient and donor BMI data were excluded. The final sample size of 653 patients was divided into three quartile categories based on the donor-recipient (D-R) BMI ratio. D-R BMI ratio < 0.86 (n = 156), D-R BMI ratio 0.86–1.12 (n = 338), and D-R BMI ratio > 1.12 (n = 159). Analysis of variance and chi-square test with post hoc test according to the types of variables were performed to find differences among the groups. Kaplan-Meier survival analysis was used to evaluate survival, and the difference between the curves was checked with the log-rank test. Cox regression analysis was used to adjust for confounders and find independent predictors of mortality. Results: Some preoperative variables were statistically different between the groups. The D-R BMI ratio did not impact follow-up mortality after adjustment for confounders. The 7-year survival in D-R BMI ratios < 0.86, 0.86–1.12, and > 1.12 was 73%, 68%, and 70% respectively (p = 0.532). There was no significant difference in other postoperative outcomes, including ICU stay, systemic complications, and mechanical circulatory support use, between the groups based on unadjusted analysis. Conclusion: The donor-recipient BMI ratio had no significant impact on post-transplantation mortality. Postoperative outcomes other than survival were also comparable between the groups. These outcomes were observed in a specific D-R BMI ratio range (0.77–1.26), and extreme BMI ratios may have different results. The results of this study support the liberal use of donor and recipient BMI during patient matching, which can decrease the likelihood of potential donor non-use and subsequently increase the donor pool.

Ischemic cardiomyopathy patients with severe left ventricular dysfunction are a specific group of patients with poor surgical outcomes. There are few surgical treatment options in practice for the treatment of these patients such as heart transplantation, coronary artery bypass surgery, surgical ventricular restoration, etc. Despite multiple treatment options, there are no explicit clinical guidelines available to guide surgeons in choosing the most appropriate option and ensuring that the specific patient can benefit from the selected surgical treatment. Heart transplantation is the gold standard treatment for ischemic cardiomyopathy patients with severe left ventricular dysfunction, but it is limited to very few highly equipped centers around the world due to donor shortages, complex perioperative and surgical management, and limited technological and human resources. It is evident from some studies that heart transplant-eligible candidates can benefit from alternative surgical options such as coronary artery bypass surgery alone or combined with surgical ventricular restoration. Therefore, alternative surgical options that are used for most of the population, especially in developing and underdeveloped countries, need to be discussed to improve their outcomes. A challenge in the recent era which has yet to find a solution is to determine which heart transplant candidate can benefit from simple revascularization compared to a complex heart transplantation procedure. Myocardial viability testing was one of the most important determinants in deciding whether a patient should undergo revascularization, but its role in guiding appropriate surgical options has been challenged. This review aims to discuss the available surgical management options and their long-term outcomes for patients with ischemic cardiomyopathy, which will eventually help surgeons when choosing a surgical procedure.

Cardiac blood cyst is a very rare benign tumor of the heart in adults. Though it is very common in the first half year of life, it regresses with time and its occurrence is very rare in children older than six months and in adults. Until now less than 100 valvular blood cyst cases have been reported in adults. We present a case of a 66-year-old male who presented to us with exertional chest tightness, shortness of breath, and right leg weakness for two weeks. He was diagnosed with a cardiac mass two months ago in another hospital. The physical examination was unremarkable. Abdominal ultrasound showed a cyst in the liver and left kidney. Echocardiography showed a mass-occupying lesion of a cystic nature in the mitral valve with moderate mitral regurgitation. Based on echocardiography findings and computed tomography report, the preliminary diagnosis of mitral valve cystic tumor was made. The patient underwent minimally invasive resection of the cyst. The posterior mitral cusp was repaired and a mitral annuloplasty ring was placed. The postoperative recovery was uneventful. The histopathology report confirmed the diagnosis of a cardiac blood cyst. The patient was followed up for six months without any complications. This case is presented to enrich the medical literature on the cardiac blood cyst. Although a cardiac blood cyst is a rare entity in adults, it still should be considered in the differential diagnosis of cardiac tumors. Because the natural history and hemodynamic effects are very diverse, large symptomatic cardiac blood cysts, especially in the left heart should be resected to avoid complications.

Background: There are no guidelines on the surgical management for ischemic cardiomyopathy (ICM) patients with severe left ventricular dysfunction. The present study aims to assess the long‐term survival of these patients treated with two different surgical techniques, coronary artery bypass grafting (CABG) and heart transplantation (HTx).Methods: This retrospective study included 218 ICM patients with left ventricular ejection fraction (LVEF) ≤35% who underwent CABG (n = 106) and HTx (n = 112) from 2011 to 2021 in a single center. After propensity adjustment analysis each group consisted of 51 patients. Clinical characteristics were evaluated for all‐cause follow‐up mortality by the Cox proportional hazards regression model. A risk prediction model was generated from multivariable‐adjusted Cox regression analysis and applied to stratify patients with different clinical risks. The long‐term survival was estimated by Kaplan–Meier analysis for different surgery groups.Results: Long‐term survival was comparable between CABG and HTx groups. After being stratified into different risk subgroups according to risk predictors, the HTx group exhibited superior survival outcomes compared to the CABG group among the high‐risk patients (67.8% vs 44.4%, 64.1% vs 38.9%, and 64.1% vs 33.3%, p = 0.047) at 12, 36, and 60 months respectively, while the survival was comparable between HTx and CABG groups among low‐risk patients (87.0% vs 97.0%, 82.4% vs 97.0%, and 70.2% vs 91.6%, p = 0.11) at 12, 36, and 60 months respectively in the PSM cohort.Conclusion: Long‐term survival in ICM patients with severe left ventricular dysfunction who received CABG or HTx was comparable in general. Nonetheless, a favorable outcome of HTx surgery compared to CABG was observed among high‐risk patients.

Intracardiac leiomyoma is a rare benign right heart tumor that usually extends from the intravenous system. The patient often has a history of uterine leiomyoma. We report a 46-year-old female patient who presented to us with exertional dyspnea, chest tightness, and shortness of breath for two weeks and had a history of uterine leiomyoma resection. Echocardiography showed a pedunculated solid mass in the right heart with the pedicle attached to the inferior vena cava. The surgery was performed under cardiopulmonary bypass established through the femoral artery and vein with a probable diagnosis of leiomyoma. The tumor was removed by ingenious surgical technique: a snare made of silk suture in which the tumor’s pedicle was trapped, and the tumor with its pedicle was carefully removed with the help of a scalpel along the silk suture. The histopathology report confirmed the diagnosis of intravenous leiomyoma. The postoperative course was uneventful and the patient was discharged a week later. Intracardiac leiomyoma is a rare benign smooth muscle tumor. Surgery is the mainstay of treatment with different surgical approaches available. It is possible to completely remove cardiac leiomyomas through sternotomy without the need for an abdominal incision if the leiomyoma is originated in the inferior vena cava not far from the right atrium.

Background: Donor/recipient size matching is paramount in heart transplantation. Body weight, height, body mass index, body surface area, and predicted heart mass (PHM) ratios are generally used in size matching. Precise size matching is important to achieve better clinical outcomes. This study aims to determine the donor/recipient ascending aortic diameter (AAoD) ratio as a metric for donor selection and its effect on postoperative clinical outcomes in heart transplant patients.Methods: We retrospectively reviewed all consecutive patients who underwent heart transplantation from January 2015 to December 2018. A cutoff value of 0.8032 for the donor/recipient AAoD ratio (independent variable for the primary endpoint during unmatched cohort analysis) was determined for predicting in-hospital mortality. The patients were divided into two groups based on the cutoff value. Group A, AAoD < 0.8032 (n = 96), and Group B, AAoD > 0.8032 (n = 265). A propensity score-matched (PSM) study was performed to equalize the two groups comprising 77 patients each in terms of risk. A Cox regression model was developed to identify the independent preoperative variables affecting the primary end-point. The primary endpoint was all-cause in-hospital mortality.Results: A total of 361 patients underwent heart transplantation during the given period. On the multivariate analysis, donor/recipient PHM ratio [HR 16.907, 95% confidence interval (CI) 1.535–186.246, P = 0.021], donor/recipient AAoD ratio < 0.8032 (HR 5.398, 95% CI 1.181–24.681, P = 0.030), and diabetes (HR 3.138, 95% CI 1.017–9.689, P = 0.047) were found to be independent predictors of in-hospital mortality. Group A had higher 3-year mortality than Group B (P = 0.022). The surgery time was longer and postoperative RBC, plasma, and platelets transfusion were higher in Group A (P < 0.05). Although not statistically significant the use of continuous renal replacement therapy (P = 0.054), and extracorporeal membrane oxygenation (P = 0.086), was realatively higher, and ventilation time (P = 0.079) was relatively longer in Group A.Conclusions: The donor/recipient AAoD ratio is a potential metric for patient matching and postoperative outcomes in heart transplantation. A donor/recipient AAoD ratio > 0.8032 could improve post-heart transplantation outcomes and donor heart utilization.

Coronary artery bypass grafting (CABG) is the gold standard procedure for multi vessels and left main coronary artery disease. The prognosis and survival outcomes of CABG surgery are highly dependent on the patency of the bypass graft. Early graft failure which can occur during or soon after CABG remains a significant issue, with reported incidences of 3–10%. Graft failure can lead to refractory angina, myocardial ischemia, arrhythmias, low cardiac output, and fatal cardiac failure, emphasizing the importance of ensuring graft patency during and after surgery to prevent such complications. Technical errors during anastomosis are among the leading causes of early graft failure. To address this issue, various modalities and techniques have been developed to evaluate graft patency during and after CABG surgery. These modalities aim to assess the quality and integrity of the graft, thus enabling surgeons to identify and address any issues before they lead to significant complications. In this review article, we aim to discuss the strengths and limitations of all available techniques and modalities, with the goal to identify the best modality for evaluating graft patency during and after CABG surgery.