The management of obstructive hypertrophic cardiomyopathy (HCM) has been transformed by the advent of cardiac myosin inhibitors (CMIs), such as mavacamten and aficamten. Unlike traditional pharmacotherapy, which primarily addresses symptoms, CMIs target the underlying mechanism of sarcomeric hypercontractility, offering significant reductions in left ventricular outflow tract (LVOT) gradients and improved functional capacity. This review evaluates the evolving role of CMIs in refining surgical candidate selection and postoperative care. Clinically, CMIs function as an in vivo “biological test” to distinguish between dynamic, functional obstruction—often manageable with medication—and fixed anatomical obstruction driven by complex septal or mitral substrates. While clinical trials demonstrate that CMIs can delay or prevent the need for SRT in a significant proportion of patients, surgery remains the definitive solution for those with dominant structural anomalies or drug intolerance. Consequently, the therapeutic paradigm is shifting from a binary “drugs or surgery” approach to a synergistic model. In this framework, CMIs optimize the identification of patients truly requiring structural myectomy while serving as a valuable adjunct for managing residual hypercontractility, ultimately facilitating a personalized, multidisciplinary approach to HCM treatment.

Donor heart preservation is still a critical determinant of outcomes after heart transplantation, particularly as transplant programs increasingly rely on extended-criteria and donation-after-circulatory-death donors. This narrative review provides an overview of the evolution of donor heart preservation, from conventional static cold storage to contemporary technologies designed to reduce ischemia–reperfusion injury, improve graft assessment, and expand organ utilization. We discuss the physiological rationale and clinical evidence supporting commonly used cardioplegic solutions, including University of Wisconsin, Celsior, and histidine–tryptophan–ketoglutarate solutions. We then examine advanced preservation strategies, including controlled hypothermic preservation systems and ex vivo normothermic machine perfusion, which allow improved temperature control, continuous monitoring, functional assessment, and, in the case of machine perfusion, potential metabolic optimization of the graft during transport. Current evidence suggests that these technologies could extend acceptable preservation times, facilitate long-distance procurement, and support the use of marginal and DCD grafts. However, their widespread adoption is limited by logistical complexity, costs, and the need for further independent studies evaluating long-term clinical outcomes. Modern preservation platforms can represent a major paradigm shift in heart transplantation, with the potential to improve graft availability and post-transplant outcomes.