In the third report of the European Registry for Patients with Mechanical Circulatory Support of the European Association for Cardio-Thoracic Surgery, outcomes of patients receiving mechanical circulatory support are reviewed in relation to implant era. Procedures in adult patients (January 2011–June 2020) were included. Patients from centres with <60% follow-ups completed were excluded. Outcomes were stratified into 3 eras (2011–2013, 2014–2017 and 2018–2020). Adverse event rates (AERs) were calculated and stratified into early phase (3 months). Risk factors for death were explored using univariable Cox regression with a stepwise time-varying hazard ratio (3 months). In total, 4834 procedures in 4486 individual patients (72 hospitals) were included, with a median follow-up of 1.1 (interquartile range: 0.3–2.6) years. The annual number of implants (range: 346–600) did not significantly change (P = 0.41). Both Interagency Registry for Mechanically Assisted Circulatory Support class (classes 4–7: 23, 25 and 33%; P < 0.001) and in-hospital deaths (18.5, 17.2 and 11.2; P < 0.001) decreased significantly between eras. Overall, mortality, transplants and the probability of weaning were 55, 25 and 2% at 5 years after the implant, respectively. Major infections were mainly noted early after the implant occurred (AER_{<3 months}: 1.44 vs AER_{>3 months}: 0.45). Bilirubin and creatinine levels were significant risk factors in the early phase but not in the late phase after the implant. In its 10 years of existence, EUROMACS has become a point of reference enabling benchmarking and outcome monitoring. Patient characteristics and outcomes changed between implant eras. In addition, both occurrence of outcomes and risk factor weights are time dependent.

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.

(1) Background and aim: This study aimed to investigate the impact of prehabilitation on the postoperative outcomes of heart transplantation and its cost-effectiveness. (2) Methods: This single-center, ambispective cohort study included forty-six candidates for elective heart transplantation from 2017 to 2021 attending a multimodal prehabilitation program consisting of supervised exercise training, physical activity promotion, nutritional optimization, and psychological support. The postoperative course was compared to a control cohort consisting of patients transplanted from 2014 to 2017 and those contemporaneously not involved in prehabilitation. (3) Results: A significant improvement was observed in preoperative functional capacity (endurance time 281 vs. 728 s, p < 0.001) and quality-of-life (Minnesota score 58 vs. 47, p = 0.046) after the program. No exercise-related events were registered. The prehabilitation cohort showed a lower rate and severity of postoperative complications (comprehensive complication index 37 vs. 31, p = 0.033), lower mechanical ventilation time (37 vs. 20 h, p = 0.032), ICU stay (7 vs. 5 days, p = 0.01), total hospitalization stay (23 vs. 18 days, p = 0.008) and less need for transfer to nursing/rehabilitation facilities after hospital discharge (31% vs. 3%, p = 0.009). A cost-consequence analysis showed that prehabilitation did not increase the total surgical process costs. (4) Conclusions: Multimodal prehabilitation before heart transplantation has benefits on short-term postoperative outcomes potentially attributable to enhancement of physical status, without cost-increasing.

Heart transplantation from donors after the circulatory determination of death (DCDD) is expanding worldwide. Thoraco-abdominal normothermic regional perfusion (TA-NRP) allows the validation and recovery of the DCDD heart, but there is limited evidence on the results of heart transplants performed with this approach. This multicenter, nationwide, prospective study describes the short-term outcomes of adult patients receiving a DCDD heart transplant obtained via TA-NRP followed by static cold storage in Spain. Recipients of hearts from donors after the neurological determination of death (DNDD) were used as controls. The primary outcome was a composite of 1-year all-cause death or severe primary graft failure (PGF). During 2020-2023, 98 adult DCDD and 347 DNDD heart transplants were performed across 11 centers. The primary outcome was met by 21 (21.4%) and 77 (22.2%) patients, respectively (p=0.87). Thirty-day and 1-year survival were 94.9% and 88.8% in the DCDD vs 93.7% and 87.3% in the DNDD group (p=0.70). Severe PGF was observed in 13 (13.3%) vs 52 (15.0%) patients (p=0.67). By inverse probability weighting, the DCDD heart was not associated with the primary outcome (HR 0.97;95%CI 0.58-1.62;p=0.91). In conclusion, adult DCDD heart transplantation based on TA-NRP and static cold storage provides similar short-term outcomes than DNDD heart transplants.

OBJECTIVES: Robotic-assisted mitral valve repair surgery has a steep learning curve, and it is not clear whether previous experience in minimally invasive mitral valve surgery (MIMVS) facilitates this process. We aimed to investigate the initial experience of 2 cardiac centres starting their robotic programmes, evaluating the impact of previous MIMVS experience. METHODS: Retrospective analysis was performed for the 1st consecutive cases operated due to severe degenerative mitral valve regurgitation using the robotic surgical platform in 2 European centres, 1 transitioning from conventional surgery (centre 1) and the other from mini thoracotomy MIMVS (centre 2). Cumulative sum analysis was used to evaluate the learning process using both surgical times and a combined primary outcome including relevant intra- and postoperative results. RESULTS: First 62 patients in each centre were included. All median surgical times were shorter in centre 2: cardiopulmonary bypass: 238 vs 115 min, P < 0.001; cross-clamp: 143 vs 82 min, P < 0.001; and total intervention: 313 vs 228 min, P < 0.001. The combined primary outcome showed no significant differences (9.7% vs 8%; P = 1). However, the turning point making the end of the learning phase was detected at the 60th case in centre 1 and at the 50th in centre 2. Regarding surgical time, the learning curve was steeper in centre 1 with both cardiopulmonary bypass and cross-clamp overcoming the learning phase after 32 cases, as compared to 16 cases in centre 2. CONCLUSIONS: A successful robotic-assisted mitral repair programme can be safely started coming from either conventional open approach or mini thoracotomy MIMVS. However, previous mini thoracotomy MIMVS experience had positive impact on the initial learning curve.