T he strict criteria that define a heart ideal for transplantation have contributed to the severe shortage of donor organs. A large fraction of patients on the heart-transplant waiting list never receive one. This issue is exacerbated by the fact that one-year mortality rates without transplantation are 8.1%, 10.1%, and 14% for patients listed as United Network for Organ Sharing status 2, 1B, and 1A, respectively.1 Historically, surgeons have used "non-ideal" donor hearts that do not meet all donor criteria. 2 The fact is that recent technical advances can support the relaxation of donor-heart criteria in certain circumstances. We report a successful instance of orthotopic heart transplantation (OHT) performed with concurrent bioprosthetic aortic valve replacement (AVR). Case ReportThe patient was a 71-year-old man with a history of type 2 diabetes mellitus, hypertension, 5-vessel coronary artery bypass grafting, paroxysmal ventricular tachycardia (VT), and the implantation of a cardioverter-defibrillator/biventricular pacemaker. He was admitted to our hospital for symptomatic recurrent VT and heart failure. Initially, right-and left-sided heart catheterization showed severely diminished left ventricular (LV) function with cardiac output of 2.3 L/min, elevated filling pressures, increased pulmonary artery pressure (74/46 mmHg), and diffuse coronary artery disease not amenable to repeat revascularization.Because of the advanced heart failure and very high-risk nature of the alternative VT ablation, the patient was presented to the cardiac transplantation medical review board at our institution, where he was assigned 1A status for OHT. Until the donor heart became available, he was hospitalized for 51 days on intra-aortic balloon pump support with bumetanide, lidocaine, and procainamide drips.A transthoracic echocardiographic report on the donor heart showed moderate aortic valve regurgitation. We discussed this finding with the patient and his family,

a b s t r a c tMitochondrial disorders are genetic diseases that result in a deficiency of energy metabolism (ATP production). A "mitochondrial crisis" can occur in the setting of infection, dehydration, or physiologic stress. The hallmark of a mitochondrial crisis is failure of multiple individual organ systems. The mortality of mitochondrial crisis is high and therapy is supportive but involves a specific strategy of hydration with dextrose-containing IV fluids, avoidance of many medications known to worsen mitochondrial function, and limitations of oxygenation as this can promote free radical production. We report a case of a patient with known mitochondrial disease that presented with a mitochondrial crisis with prominent and life-threatening cardiac manifestations including long QT, ventricular arrhythmias, and acute left ventricular systolic dysfunction in addition to rhabdomyolysis, lactic acidosis, and an acute kidney injury. This patient was managed successfully with a specifically tailored supportive strategy, a high-dose metabolic cocktail, permissive hypoxia, and low-protein diet. At 10 weeks post discharge all electrocardiographic abnormalities resolved and ventricular recovery has been observed. Given the increased survival of this population of patients into adulthood it is important that these adjunctive therapeutic strategies require consideration by clinicians treating this group of patients.Published by Elsevier Ltd. on behalf of Japanese College of Cardiology.

The combination of ticagrelor and phenytoin may represent a potentially clinically significant drug-drug interaction because of phenytoin induction of ticagrelor metabolism and reduced P2Y12 receptor inhibition in patients who have recently undergone percutaneous coronary intervention and cardiac stent placement.

This report describes a 42-year-old man with a history of lymphoma who is admitted with symptoms of chest pain, ST elevation changes, and elevated troponins. Immediate bedside echocardiographic evaluation led to an aborted urgent coronary angiography and a diagnosis of presumed endocarditis. Transesophageal echocardiography (TTE) subsequently revealed an aortic noncoronary cusp aneurysm masking as vegetation. The rapid assessment by TTE and transesophageal echocardiogram prevented an alternate course for this patient's management. We reviewed the necessity of heart catheterization in patients with significantly elevated troponins, pericarditis symptoms, and the rare sighting of aortic valve cusp aneurysms.

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