Primary malignant cardiac tumors represent (PMCTs) a very rare disease with an incidence of 0.009%1 (up to 10% of primary cardiac neoplasms) and are related to a very poor prognosis. The study by Mohamed Rahouma tries to give us information on sex differences in PMCTs, their incidence, behavior, and outcomes. Females were significantly older and had a lower stage of cancer. Males are known to have a more aggressive course and present at an earlier age. Sarcoma is the most common type of PMCTs in both males and females. There was no gender disparity in late mortality and patients who underwent surgery had a better prognosis than those who did not undergo surgery. Significant predictors of late mortality were found to be patients’ high comorbidity index, angiosarcoma histology, and Stage III/IV. A challenge for cardiac surgeons is to improve survival in patients with cardiac malignancies, involving a multidisciplinary approach with oncologists, cardiologists, and radiologists. To pave the way for a significant improvement in survival in the future, more advanced sex‐specific medical therapies for cancer such as novel chemotherapy agents, targeted immune therapies, genetic engineering need to be standardized to PMCTs and combined with radiological therapies such as gamma‐knife and very advanced surgery to effectively treat even very aggressive forms of malignant tumors, with a significant impact on the patient's quality of life and survival.

Introduction Coronary artery bypass graft is considered the most frequently performed cardiac surgery and involves the use of different types of grafts: internal mammary artery, saphenous vein, radial artery. The venous graft is often subject to early failure due to various factors such as thrombus formation, intimal hyperplasia or formation of atherosclerotic plaques. Several studies have highlighted various mechanisms that may be responsible for these processes. This study aims to find a statistically significant correlation between the use of hyperkalaemic cardioplegic solutions and endothelial damage. Materials and methods For sample collection, saphenous vein segments were taken from each patient: one was taken when it was isolated to take the graft, and a second sample was taken after administration of St. Thomas no. 2 cardioplegic solution. Both collected specimens were stored in formalin and analyzed by light microscopy following hematoxylin–eosin staining and staining with monoclonal antibodies targeting CD31 and CD34. Discussion From the study with hematoxylin and eosin staining, it was observed that in the vein taken before the infusion of cardioplegia, the endothelium was present, continuous, clearly visible and without lesions. In the specimens taken after the infusion of hyperkalaemic cardioplegic solution, it is noted that the endothelium, although present, is more difficult to visualize and is discontinuous to a variable extent from 20 to 60%. This reduction in the percentage of visible continuous endothelium was confirmed by analysis with CD31 and CD34 immunohistochemical stains. Previous studies already confirm that the venous endothelium is affected by a high concentration of potassium, producing acute and chronic lesions. This result would seem to demonstrate how the endothelial tissue is also susceptible to hyperacute damage following short–term exposure to potassium. Conclusions The short–term results of this study would seem to confirm the initial hypothesis of a relationship between the use of hyperkalemic cardioplegia and the formation of acute or hyperacute lesions in the saphenous vein graft at the endothelial level. This conclusion could be one of the explanations of the high failure rate of the venous bypass, which in fact has a 10–year occlusion rate of 60/65%.

Introduction We report the case of a 52–year–old patient with a history of multiple myeloma undergoing chemotherapy treatment according to the DaraRD scheme and currently in remission. Associated with haematological pathology, infiltrative hypertrophic cardiomyopathy of ndd is highlighted. Following haematological and instrumental screening tests, the patient underwent a heart transplant for frequent exacerbations of heart failure. Case Report A 52–year–old patient, suffering from multiple myeloma for about 1 year, for which he began chemotherapy treatment with DaraRD scheme and good response to therapy. The patient also presented dyspnoic symptoms and declining edema with echocardiographic finding of infiltrative hypertrophic heart disease for which he undergoes diagnostic investigations. He performs: • Serial echocardiograms which showed marked uniform hypertrophy with ground glass appearance of the left ventricle and severely reduced systolic function; • PET–CT with no hyperaccumulation of the radiopharmaceutical; • Cardiac MRI with evidence of severely hypocontractile left ventricle and wall changes which could be associated with amyloid infiltration; • myocardial scintigraphy that does not give evidence for the deposit of the amyloid substance of the ATTR type in the heart; • biopsy of umbilical fat and cardiac biopsy, both negative for deposition of substance AL with Congo Red staining; • Right cardiac catheterization with evidence of post–capillary pulmonary hypertension. The patient was subjected to several exacerbations of heart failure which required continuous infusion therapy with inotropes and, ultimately, heart transplantation. At the time of surgery, the heart appeared enlarged, extremely hypocontractile and with rigid walls, with poor compliance of the ventricular muscle wall. The patient responded well to the surgical procedure, in the absence of signs and symptoms of rejection, with improvement of general clinical condition. Conclusions At the end of the surgical procedure and the rehabilitation period, the patient was discharged home, without showing signs and symptoms of graft rejection or multiple myeloma exacerbations, in stable and satisfactory general clinical conditions.

PIRCHE–II is an algorithm used to estimate the risk for developing alloreactivity towards HLA mismatches. A 35–year–old man with idiopathic dilated cardiomyopathy with several previous hospitalizations for heart failure is admitted to our unit for a new episode in August 2021. After evaluation, the patient was placed on the waiting list for transplant. The following month the patient underwent heart transplant. The donor had a compatible CDC crossmatch and was negative for anti–HLA antibodies. After 46 days, the patient was discharged at home in stable conditions after 2 negative endomyocardial biopsies (EMB): ISHLT’04 0. In January 2021, the patient was newly admitted for dyspnea and oliguria. Imaging revealed bilateral severe pleural effusion, biventricular cardiac disfunction; EMB showed acute rejection (ISHLT’04 3R). Panel–reactive antibody (PRA) screening found 93 % of class I PRA, 3 % of class II PRA with IgM and IgG donor–specific antibodies (DSA), C1q–positive. After 2 months, the patient was placed again on the transplant waitlist for a persistent severe biventricular disfunction, massive tricuspid regurgitation and diffuse myocardial fibrosis; class I PRA was decreasing (41 % in March 2022, 31 % in April 2022). Unfortunately, the patient died of infection before re–transplantation. After the event, which was recognized as AMR caused by class I DSA, a form rarely described in literature, we employed the PIRCHE (Predicted Indirectly Recognizable HLA Epitopes) algorithm to predict indirect donor–recipient alloreactivity: PIRCHE–II was 54. Is a high PIRCHE–II score a reliable predictor of AMR following heart transplant? More data and deeper understanding is surely needed. A correct after–transplant serologic monitoring is definitely needed to search for de–novo DSA.

During SARS–CoV2 pandemic, transplant programs had to devise strategies to deal with the possibility of COVID–19–positive donors and recipients. In March 2022, a 60–year–old man with dilated cardiomyopathy on the transplant waitlist was admitted to our Unit as a possible donation was presented. On arrival, he tested positive for SARS–CoV2. The patient had no clinical evidence of COVID–19; he had completed the vaccination cycle; chest X–rays did not show interstitial pneumonia. Aware of the increased risk, we proceeded with the transplant. Sotrovimab, a novel anti–viral agent specific for COVID–19, was administered. Prophylactic antibiotics were started. He received anti–thymocyte immunoglobulins 125 mg for 2 days and methylprednisolone 1 g after aortic declamping and then 125 mg TID for 2 days for induction immunosuppression. Maintaining therapy included corticosteroids and tacrolimus. On the 7th day the patient tested negative at SARS–CoV2 swab. As kidney function worsened, hemodialysis was started. On the 17th day signs of cellulitis of the left thigh appeared, and inflammation indices (CRP, PCT) rose. A hemoculture positive for A. baumannii (MDR–AB) was obtained; hence the patient was treated with Cefiderocol and Colistine. A Cytosorb filter was added to the hemodialysis and Pentaglobin was started. After 3 weeks, hemodynamics started to improve, inotrope support was suspended, with reduction of inflammation indices, negative hemocultures, recovering kidney function. After two weeks, the patient abruptly presented fever, marked hypotension and dyspnea. He underwent intubation, inotrope therapy, broad–spectrum antibiotic therapy, intravenous Immunoglobulins and a cycle of Polymyxin B Hemoperfusion. Nevertheless, hemodynamics decidedly failed. Chest X–rays showed bilateral pneumonia. Hemocultures were positive for MDR–AB. Leukopenia developed (WBC 0,10). Three days after the first signs of a new infective episode, the patient had died. Notwithstanding the difficulties of SARS–CoV2 pandemic, tempestive diagnosis and treatment allow transplant programs to proceed unhindered.