Outcomes and Complications after Left Ventricular Assist Device Implantation.

BACKGROUND: Heart transplantation is the treatment of choice for selected patients with end-stage heart failure. Persistent donor organ shortage causes a growing demand for mechanical circulatory support not only as a bridge to transplantation but mainly as a destination therapy (DT). METHODS: The aim of the study was to analyze the indications, comorbidities, and complications during the follow-up of all patients undergoing left ventricular assist device (LVAD) implantation with at least 12 months of follow-up time in one of the most experienced clinics in Poland between 2015 and 2023. RESULTS: There were 125 individuals with LVAD implantation, from which 90 had full 12 months of follow-up (85 males - 94%, 5 females - 6%), with a median age of 58 (50.25-63.75) years. The median body mass index was 27.12 (25.27-29.68). The etiology of heart failure was ischemic (n = 44, 49%), dilated cardiomyopathy (n = 44, 49%), and others. Preoperative echocardiography revealed a mean LV ejection fraction of 13.8% and a median LV dimension of 7.55 (6.92-8.2) cm. In 61 patients (68%), imaging confirmed pulmonary hypertension. Thirty-four patients (38%) had diabetes and 16 (18%) were active smokers. Median follow-up was 30 (17.25-42) months, with the longest period being about 82 months. 40 (44%) patients had kidney failure before LVAD implantation, and in 43 cases (48%), we observed relevant, transient deterioration of kidney function. Almost all patients (n = 82, 91%) suffered from anemia (Hb <13 g/dL in males and <12 g/dL in females) in different periods after LVAD implantation due to perioperative bleeding, gastrointestinal bleeding or unknown causes. The lowest Hb level was observed in the first week after LVAD implantation in 53 cases (58%). Median red cell concentrate transfusion demand before the discharge after surgery was 6 (2-8, 5) units. CONCLUSIONS: Appropriate selection of candidates and timing of LVAD implantation are critical for improved outcomes of DT. Anemia and kidney failure are the most frequent follow-up complications. Improved results and increased applicability and durability of LVADs have established this treatment option as an excellent alternative for patients with end-stage heart failure.

Driveline Infection in Patients With Left Ventricular Assist Devices Implanted as Destination Therapy.

BACKGROUND: Donor organ shortages cause increasing demand for mechanical circulatory support in patients with end-stage heart failure not only as a bridge to heart transplantation but mainly as a destination therapy. Improved results and increased applicability and durability of left ventricular assist devices (LVADs) have established this treatment option as an alternative to heart transplantation in selected patients. One of the most common complications after LVAD implantation is driveline infections (DLIs). METHODS: This study aimed to expand the understanding of DLI epidemiology and potential changes in implantation techniques regarding optimizing DLI prevention and treatment among all patients undergoing LVAD (Medtronic's Heartware HVAD and HeartMate 3 Abbott LVAD system) implantation with at least 12 months of follow-up time between 2015 and 2022. RESULTS: There were 120 individuals with LVAD implantation, of whom 90 had 12 months of follow-up (85 men [94%], 5 women [6%]) with a median age of 58 years (50.25-63.75). The median body mass index was 27.12 kg/m2 (25.27-29.68). Of the 90 patients, 43 had ischemic heart failure (48%), 43 had dilated cardiomyopathy (48%), and the remaining 3 had other etiologies (3%), such as postinflammatory, and the remaining 1 had congenital heart defect (1%). Preoperative echocardiography revealed a mean left ventricle ejection fraction of 13.8% and a median left ventricle dimension of 7.55 cm (6.92-8.2). Imaging confirmed pulmonary hypertension in 61 patients (68%). Thirty-four of the 90 patients had diabetes (38%), and 16 were active smokers (18%). Median follow-up was 30 months (17.25-42), with the longest period being 82 months. More than half of the patients (n = 52; 57%) experienced a DLI. The median time to the first episode of DLI was 13 months (6-25). The most common pathogen revealed in wound swab culture was methicillin-sensitive Staphylococcus aureus (n = 23; 44%), Pseudomonas aeruginosa (n = 9; 17%), Proteus mirabilis (n = 4; 7%), and others. We observed that deeper driveline implantation below the left rectus muscle and just above the posterior rectus sheath resulted in fewer DLIs and longer free-from-DLI follow-up time. There was no statistically significant difference in DLI frequency between patients with or without diabetes mellitus. CONCLUSIONS: Appropriate selection of candidates and timing of LVAD implantation are critical for improved outcomes of destination therapy. DLI is the most common complication after LVAD implantation. Optimal surgical techniques and early implementation of targeted antibiotics are crucial. Significant challenges remain in optimizing DLI prevention and treatment.

Preoperative and mid-term right ventricular systolic function assessment, at rest and during exercise, with speckle-tracking echocardiography after left ventricular assist device implantation.

OBJECTIVES: The study aimed to compare pre- and postoperative resting as well as postprocedural resting and exertional right ventricular speckle-tracking echocardiographic parameters at a mid-term follow-up after left ventricular assist device (LVAD) implantation. METHODS: Patients with implanted third-generation LVADs with hydrodynamic bearings were prospectively enrolled (NCT05063006). Myocardial deformation was evaluated before pump implantation and at least three months after the procedure, both at rest and during exercise. RESULTS: We included 22 patients, 7.3 months (IQR, 4.7-10.2) after the surgery. The mean age was 58.4 ± 7 years, 95.5% were men, and 45.5% had dilated cardiomyopathy. The RV strain analysis was feasible in all subjects both at rest and during exercise. The RV free wall strain (RVFWS) worsened from -13% (IQR, -17.3 to -10.9) to -11.3% (IQR, -12.9 to -6; p = 0.033) after LVAD implantation with a particular decline in the apical RV segment [-11.3% (IQR, -16.4 to -6.2) vs -7.8% (IQR, -11.7 to -3.9; p = 0.012)]. The RV four-chamber longitudinal strain (RV4CSL) remained unchanged [-8.5% (IQR, -10.8 to -6.9) vs -7.3% (IQR, -9.8 to -4.7; p = 0.184)]. Neither RVFWS (-11.3% (IQR, -12.9 to -6) vs -9.9% (IQR, -13.5 to -7.5; p = 0.077) nor RV4CSL [-7.3% (IQR, -9.8 to -4.7) vs -7.9% (IQR, -9.8 to -6.3; p = 0.548)] changed during the exercise test. CONCLUSIONS: In patients who are pump-supported, the right ventricular free wall strain tends to worsen after LVAD implantation and remains unchanged during a cycle ergometer stress test.

Nutritional Risk Assessment and Adverse Events in Patients Undergoing Left Ventricular Assist Device Implantation-A Retrospective Cohort Study Using Hospital Information System.

Clinical or subclinical malnutrition occurs in 30% to 70% of patients with advanced heart failure and increases the risk of postoperative adverse events. The main objective of this study was to assess the nutritional status of patients prior to left ventricular assist device (LVAD) implantation using different methods of malnutrition assessment and to evaluate the relationship between nutritional status and postoperative adverse events. A retrospective cohort study included 120 patients aged 26-74 years referred for LVAD surgery. Preoperative nutritional status (NRS-2002-Nutritional Risk Score 2002, NRI-Nutritional Risk Index, PNI-Prognostic Nutritional Index; TLC-total lymphocyte count) and postoperative adverse events were assessed. Moderate to severe malnutrition was found in 55.8%, 43.3%, 40.0%, and 20% of all patients, respectively, according to the PNI, NRI, TLC, and NRS-2002 scores. Patients with a TLC < 1200 cells/m3 had a higher risk of postoperative acute renal failure [hazard ratio (HR): 2.5; 95% confidence interval (95% CI): 1.01-6.3] and death during the observation period [HR = 2.1; 95% CI: 1.2-3.5]. Moderate to severe malnutrition was also associated with a significantly increased risk of in-hospital death [for the NRI score, HR = 4.9 (95% CI: 1.1-22.0); for the PNI score, HR = 5.0 (95% CI: 1.1-22.3)]. In conclusion, moderate to severe malnutrition prior to LVAD implantation has been identified as a risk factor for postoperative acute renal failure and mortality. Assessment of nutritional risk may improve patient selection and early initiation of nutritional support.

How to Improve the Outcomes of LVAD Implantation?

BACKGROUND: Heart transplantation is the treatment of choice for selected patients with end-stage heart failure. Persistent donor organ shortage has resulted in a growing interest in mechanical circulatory support not only as a bridge to transplantation but also as a destination therapy. METHODS: The aim of the study was to analyze the indications, comorbidities, operative technique, complications, and follow-up of all patients undergoing left ventricular assist device implantation in one of the most experienced clinics in Poland between 2015 and 2020 and state the best timing of the procedure. RESULTS: This study included 78 individuals (72 males, 92%; 6 females, 8%) with a median age of 57 years (range, 50-62 years). The median body mass index was 27.12 (range, 25.2-29.5). The etiology of cardiomyopathy was ischemic (n = 31, 39%), dilated cardiomyopathy (n = 47, 60%), and others. Sixty-four patients presented with New York Heart Association class IV (82%). Leading heart rhythm was sinus (n = 31, 40%) and pacemaker rhythm (n = 47, 60%). Sixty-four patients had implantable cardioverter defibrillator implantation (82%). Preoperative echocardiography revealed a median left ventricle ejection fraction of 14.5% (range, 10%-15%) and LV dimension 7.55 cm (range, 6.9-8.275 cm). In 51 patients (65%), imaging confirmed pulmonary hypertension. The intensive care unit stay was 6 days (range, 4.25-11.75 days). Median time to extubation was 25 hours (range, 23.75-70 hours). The median time to discharge was 31.5 days (range, 25-31.85 days). In-hospital mortality was 12 patients (15%). Median follow-up time was 19.5 months (range, 11.25-31 months) months, with the longest follow-up of about 53 months. CONCLUSIONS: Appropriate selection of candidates and timing of left ventricular assist device implantation are critical for improved outcomes of destination therapy.

Echo-guided left ventricular assist device speed optimisation for exercise maximisation.

OBJECTIVE: Current generation left ventricular assist devices (LVADs) operate with a fixed rotation speed and no automated speed adjustment function. This study evaluates the concept of physiological pump speed optimisation based on aortic valve opening (AVO) imaging during a cardiopulmonary exercise test (CPET). METHODS: This prospective crossover study (NCT05063006) enrolled patients with implanted third-generation LVADs with hydrodynamic bearing. After resting speed optimisation, patients were randomised to a fixed-modified speed or modified-fixed speed CPET sequence. Fixed speed CPET maintained baseline pump settings. During the modified speed CPET, the LVAD speed was continuously altered to preserve periodic AVO. RESULTS: We included 22 patients, the mean age was 58.4±7 years, 4.5% were women and 54.5% had ischaemic cardiomyopathy. Exertional AVO assessment was feasible in all subjects. Maintaining periodic AVO allowed to safely raise the pump speed from 2900 (IQR 2640-3000) to 3440 revolutions per minute (RPM) (IQR 3100-3700; p<0.001). As a result, peak oxygen consumption increased from 11.1±2.4 to 12.8±2.8 mL/kg/min (p<0.001) and maximum workload from 1.1 (IQR 0.9-1.5) to 1.2 W/kg (IQR 0.9-1.7; p=0.028). The Borg scale exertion level decreased from 15.2±1.5 to 13.5±1.2 (p=0.005). CONCLUSIONS: Transthoracic AVO imaging is possible during CPETs in patients with LVAD. Dynamic echo-guided pump speed adjustment based on the AVO improves exercise tolerance and augments peak oxygen consumption and maximum workload.

Postoperative Serum Lactate Levels for In-Hospital Mortality Prediction Among Heart Transplant Recipients.

BACKGROUND Hyperlactatemia is a common phenomenon following cardiac surgeries and is associated with prolonged ICU stay and higher morbidity and mortality rates, but such analyses have never focused on patients undergoing heart transplantation (HTX), in whom hyperlactatemia defined with the traditional threshold is observed in nearly every individual. The present study aimed to assess the prognostic value and clinical usefulness of postoperative serum lactate level measurements for in-hospital mortality prediction following HTX. MATERIAL AND METHODS Forty-six consecutive patients who underwent HTX in the Department of Cardiovascular Surgery and Transplantology between 2010 and 2015 were enrolled into a retrospective analysis. Serum lactate level measurements within the first 48 h after HTX were obtained from arterial blood gas analyses, that were routinely conducted every 6 h. Lactate clearance was determined for each patient individually throughout 3 different time frames: the first 24-h (Lac clear 0-24) and second 24-h period (Lac clear 24-48), and the first 48 h after surgery (Lac clear 0-48). RESULTS The ICU admission serum lactate levels differed between the deceased and survivors (7.6 vs. 4.3 mmol/L; p=0.000). Among all tested postoperative lactate level measurements, only the measurement taken upon ICU admission predicted in-hospital mortality (OR 1.94 95% CI [1.09-3.43]; p=0.024). The receiving operating characteristic (ROC) curve for in-hospital mortality was constructed for ICU admission measurement, with the optimal cut-off point estimated at 7.0 mmol/L. CONCLUSIONS Serum lactate level measurement upon ICU admission can be used as a predictive parameter for in-hospital mortality among heart transplant recipients. Values greater than 7.0 mmol/L can predict in-hospital mortality with 90% accuracy.

Postoperative hyperlactatemia and serum lactate level trends among heart transplant recipients.

BACKGROUND: Advanced heart failure (HF), that affects 10% of the HF population, is associated with high mortality rate, meeting 50% at 1-year from diagnosis. For these individuals, heart transplantation (HTX) remains the ultimate and the gold-standard treatment option. Serum lactate level measurements has been proven useful for determining the outcome following other cardiac surgeries and among critically ill patients. Increased serum lactate levels are expected following HTX; however, no detailed analysis has been yet performed in this population. The research aims to estimate the prevalence of hyperlactatemia and describe early postoperative serum lactate level trends among heart transplant recipients. MATERIALS AND METHODS: Forty-six consecutive patients, who underwent HTX between 2010 and 2015, were enrolled into the retrospective analysis. Serum lactate level measurements within first 48 hours post-HTX were obtained every 6 hours from routinely conducted arterial blood gas analyses. The threshold for hyperlactatemia was considered at >1.6 mmol/L, according to upper limit of normal, based on internal laboratory standardization. The highest observed measurement within the observation, regardless of the time point of observation was determined for each patient individually and was appointed as Peak Value. RESULTS: Consecutively measured serum lactate levels differed in time (p = 0.000), with the initial increase and subsequent decrease of the values (4.3 vs. 1.9 mmol/l; p = 0.000). The increase from the baseline level to the Peak Value was statistically significant (4.3 vs. 7.0 mmol/l; p = 0.000). Various serum lactate level trends were identified, with one or more hyperlactatemia episodes. Eventually, 50% of the individuals had normal serum lactate levels at the end of the study, and hyperlactatemia was observed in the other half. CONCLUSIONS: Throughout the observation, all of the patients experienced at least one episode of hyperlactatemia, with the median Peak Value of 7.0 (4.5-8.4) mmol/L. Various serum lactate level trends can be identified in post-HTX patients. Further research is required to determine the clinical usefulness of newly reported serum lactate level trends among heart transplant recipients.

A comparison of the ultrasound measurement of the inferior vena cava obtained with cardiac and convex transducers.

BACKGROUND: Ultrasound measurement of the inferior vena cava diameter and its respiratory variability are amongst the predictors of fluid volume status. The primary purpose of the present study was to compare the consistency of inferior vena cava diameter measurements and the collapsibility index, obtained with convex and cardiac transducers. A secondary aim was to assess the agreement of the patient's allocation to one of the two groups: "fluid responder" or "fluid non-responder", based on inferior vena cava collapsibility index calculation made with two different probes. METHODS: 20 experienced clinicians blinded to the purpose of the study analysed forty anonymized digital clips of images obtained during ultrasound examination of 20 patients. For each patient, one digital loop was recorded with a cardiac and the second with a convex probe. The participants were asked to determine the maximal and minimal diameters of the inferior vena cava in all presented films. An independent researcher performed a comparative analysis of the measurements conducted with both probes by all participants. The calculation of the collapsibility index and allocation to "fluid responder" or "fluid non-responder" group was performed at this stage of the study. RESULTS: The comparison of measurements obtained with cardiac and convex probes showed no statistically significant differences in the measurements of the maximal and minimal dimensions and in the collapsibility index. We also noticed that the decision of allocation to the "fluid responder" or "non-responder" group was not probe-dependent. CONCLUSION: Both transducers can be used interchangeably for the estimation of the studied dimensions.

Impact of Postoperative Bleeding on Short-Term Outcome in Patients After Orthotopic Heart Transplantation: A Retrospective Cohort Study.

BACKGROUND Orthotopic heart transplantation (HTX) remains the ultimate treatment option in patients with end-stage heart failure, endorsed by the European Society of Cardiology guidelines. The aim of the study is a complex evaluation of the postoperative bleeding after HTX and its influence on short-term outcome. MATERIAL AND METHODS A retrospective cohort study consisted of 53 patients (4 females and 49 males, median age 52.5 years, IQR 17 years) who underwent HTX in the Department of Cardiovascular Surgery and Transplantology of John Paul II Hospital in Krakow between 2007 and 2014. RESULTS The median chest tube output within first 24 hours after the surgery was 695 (550-870) mL. Bleeding decreased throughout the observation (p=0.000). The first postoperative hemoglobin level was a significant predictor of excessive blood loss (p=0.017). The volume of chest tube output increased the duration of mechanical ventilation (p=0.046) and the incidence of re-exploration after first 24 hours of observation (p=0.049). In patients with higher chest tube output, more packed red blood cells (PRBC), fresh frozen plasma (FFP), and platelet (PLT) transfusions were required (p=0.000, p=0.019, and p=0.000, respectively). Early rethoracotomy (within the first 24 hours post-surgery) increased the in-hospital mortality (p=0.021; OR 7.43 [1.36-40.64]). CONCLUSIONS The study demonstrates the importance of postoperative bleeding and bleeding complications for short-term outcome in our post-HTX cohort. Throughout the analysis, the first postoperative hemoglobin level was detected to be a significant predictor of postoperative blood loss.

Reliability of focused cardiac ultrasound by novice sonographer in preoperative anaesthetic assessment: an observational study.

BACKGROUND: Use of preoperative echocardiography may help to identify patients with increased cardiac risk, who may benefit from modification of perioperative plan. The objective of our study was to evaluate the reliability of preoperative focused cardiac ultrasound (FoCUS) performed by an anaesthetist with basic ultrasound training and its impact on patient's management. METHODS: The prospective observational study was conducted in 159 adult patients, scheduled for elective operations. Cardiac ultrasound was performed by one anaesthetist with a limited experience of FoCUS. A simple, mnemonic scheme was used for the final reporting of each study. The same scheme was used by a cardiologist who produced an independent report based on digital video loops stored in the machine memory. Anaesthetists in-charge made final perioperative plan. Comparative analysis of anaesthetist and cardiologist performed ultrasound report was made. The incidence of modification of initial perioperative plan resulting from FoCUS report was analyzed. RESULTS: The average time required to complete the examination was 182 s 95% CI [173-190]. Images of quality adequate to answer all questions from the scheme were obtained in 97.5% (155/159) of patients. There was strong agreement between the anaesthetist and the cardiologist in 97.8% (2274/2325) of the examined categories. In two categories (global and regional left ventricle contractility impairment) statistically significant discrepancies between both diagnosticians were confirmed (p McNemar <0.04). When compared with the cardiologist's assessment the agreement of the anesthetist's diagnosis had sensitivity of 0.84, specificity 0.99, positive predictive value 0.78 and negative predictive value 0.99. Kappa statistics showed good agreement between both examining doctors (κ = 0.797). Based on ultrasound findings, the preliminary anaesthetic plan was changed in relation to 20.8% (33/159) of patients. CONCLUSIONS: An anaesthetist with limited training in FoCUS can perform a reliable preoperative examination which alters the perioperative management.

Fibrin clot properties are altered in patients with chronic obstructive pulmonary disease. Beneficial effects of simvastatin treatment.

Increased risk of thrombotic events occurs in chronic obstructive pulmonary disease (COPD). Elevated fibrinogen and C-reactive protein (CRP), being common in COPD, are associated with formation of dense fibrin clots resistant to lysis. Statins have been found to display anti-inflammatory and antithrombotic effects. We investigated fibrin clot properties in COPD patients prior to and following statin therapy. Ex vivo plasma fibrin clot permeability, compaction, and fibrinolysis were assessed in 56 patients with stable COPD, aged 64.9 +/- 9.2 years (mean FEV(1), 54.7 +/- 15.9% predicted), versus 56 controls matched for age, sex and cardiovascular risk factors. Patients were then randomly assigned to receive simvastatin 40 mg/day (n = 28) or to remain without statins for three months (n = 28). Patients with COPD had lower clot permeability (6.1+/- 1.07 versus 9.2 +/- 0.9 10(-9) cm(2), p < 0.0001), decreased compaction (44.9 +/- 4.5 versus 63.9 +/- 6.1%, p < 0.0001), higher maximum D-dimer levels released from clots (4.23 +/- 0.55 versus 3.53 +/- 0.31 mg/l, p < 0.0001) with a decreased rate of this release (75.0 +/- 8.3 versus 80.9 +/- 8.0 microg/l/min, p = 0.03) and prolonged lysis time (9.84 +/- 1.33 versus 8.02 +/- 0.84 min, p < 0.0001) compared with controls. Scanning electron microscopy confirmed denser clot structure in COPD. Multiple linear regression analysis after adjustment for age and fibrinogen showed that in the COPD patients, CRP was the only independent predictor of permeability (R(2) = 0.47, p < 0.001) and lysis time (R(2) = 0.43, p < 0.001). Simvastatin improved clot properties (p < 0.05) despite unaltered CRP and irrespective of cholesterol reduction. Our study shows that fibrin clots in COPD patients are composed of much denser networks that are more resistant to lysis, and these properties can be improved by statin administration.

Cardiac metastasis due to pulmonary metastasis from a transitional cell carcinoma.

We report a rare case of symptomatic cardiac metastasis from a transitional cell carcinoma of the renal pelvis diagnosed by echocardiography. A 75-year-old patient with a long history of neoplasm since 1999 and coronary artery disease with CABG in 2003, was admitted to our department. He underwent cardiac surgery using cardiopulmonary bypass with tumor excision. Histologically it was the same type of transitional cell neoplasm which was operated seven years before. We present all medical history, detailed 2D and 3D echocardiography, intraoperative pictures and discuss possible chain of changes from renal pelvis cancer to clinical manifestation of cardiac mass. There is proved a rapid progression of cardiac tumor with clinical manifestation few months after control TEE examination without any evidence of cardiac mass. It is important that this is a very rare case of left heart metastasis from right side of circulatory system through pulmonary stage of cancer progression.

[Low ejection fraction as risk factor after aortic valve replacement]. / Niska frakcja wyrzutowa jako czynnik ryzyka w operacji wszczepiania sztucznej zastawki aortalnej.

UNLABELLED: The aim of the study is to estimate the operative risk of aortic valve replacement for severe aortic valve stenosis in patients with distinctly impaired left ventricular function (ejection fraction below 40%). From the population of 2512 pts, who underwent aortic valve replacement in the years 1990 to 1999 because of acquired malformation, a group of 108 pts (4.3%), fulfilling the above mentioned conditions was selected. Between them prevailed men, 92 (85.2%), and the average age was 53.4 +/- 14.5. All pts remained in the NYHA functional class III/IV. The average ejection fraction was estimated 28.2 +/- 14.3%. The pts demonstrated concentric left ventricular hypertrophy, severe aortic valve calcifications, the average valvular area was 0.91 cm2, and the pressure gradient over the valve was 71 +/- 44 mmHg. The pts were operated on by different surgeons but after the same protocol of extracorporeal circulation and cardioplegia administration. Low output syndrome occurred in ca 40% of pts, and cardiac failure was the main cause of death. The hospital mortality was 8.6%, and it was over two times higher then the whole population of pts, who underwent aortic valve replacement. All survivors (91.4%) demonstrated clinical improvement already during the early observation. CONCLUSIONS: Low ejection fraction is an important risk factor of surgery for aortic valve stenosis. However, the elevated operative mortality, comparable to other institutions, may be accepted taking for consideration, that surgery is the only way of treatment and improvement may be expected in about 90% of pts, including anatomical and hemodynamic parameters, as well as life longevity and comfort. In the extreme cases the HTX should be considered.

[Clinical relevance of tricuspid regurgitation after orthotopic heart transplantation]. / Znaczenie kliniczne niedomykalnosci zastawki trójdzielnej u pacjentów po ortotopowym przeszczepie serca.

UNLABELLED: Tricuspid regurgitation (TR) is common after heart transplantation (OHT). Some possible factors include: disturbed geometry of right atria anastomosis with subsequent impairment of the functional integrity of the valvular apparatus, asynchronous contraction of the donor and recipient atria compartment and damage of the sub-valvular apparatus during endomyocardial biopsy. THE PURPOSE OF THE STUDY: To determine the incidence of subclinical and severe TR, to evaluate its clinical significance, and to assess the risk factors for TR in the heart transplantation population. METHODS: OHT was performed in 436 patients between 1988 and 2002. 112 pts who died during the first 30 days after the operation were excluded from the analysis. TR was assessed using transthoracic color Doppler echocardiography. TR was graded from 1 to 4. Occurrence of TR in the postoperative period was assessed as early (during the first year after OHT) or late. The following clinical variables were assessed: preoperative transpulmonary gradient and pulmonary vascular resistance, number and grade of rejection episodes, postoperative echocardiographic parameters of right ventricular function, number of heart biopsies. Stepwise multivariate logistic regression was used to correlate the clinical factors with the occurrence of TR. Clinical status of the patients with TR was also evaluated. RESULTS: TR of any grade was observed in all the patients after OHT. TR > or = 2 grade was determined in 285 pts (87.96%). Early occurrence of TR was observed in 80 pts (28.07%). The development of early TR was correlated with preoperative raised transpulmonary gradients, raised vascular resistance and early rejection greater or equal to grade 2 (according to ISHLT). Risk factors for late TR: number of rejection episode greater or equal to grade 2 (p<0.005) and the total number of heart biopsies (p<0.05). Recipients with moderate and severe TR revealed advanced NYHA status compared to those with trivial or mild TR. CONCLUSIONS: 1. Moderate to severe TR commonly occurs following heart transplantation. 2. Various factors contribute to TR after OHT, the prevalence of which may be lowered by early treatment of rejection and reduction of the number of biopsies performed.