ObjectivesTo evaluate maternal and fetal outcomes of aortic surgery during pregnancy.MethodsWe retrospectively analyzed eight pregnant patients undergoing aortic intervention between 2012 and 2025.ResultsThe mean age was 30 years, and the mean gestational age was 19.5 weeks. Seven underwent open surgery in the second trimester, while one underwent thoracic endovascular aortic repair in the third trimester. Pathologies included aortic root aneurysm, often associated with Marfan syndrome. Procedures included valve-sparing root replacement (n = 4), Bentall (n = 3), and thoracic endovascular aortic repair (n = 1). There was no maternal mortality. Six pregnancies resulted in live births, while two were complicated by intrauterine fetal demise.ConclusionAortic surgery during pregnancy is associated with excellent maternal outcomes, though fetal risk remains significant.
IntroductionBlood lactate level (LL) is a useful predictor of physiological issues during extracorporeal circulation (ECC) treatment. To determine variations in LL depending on the hemocompatible coatings used for ECC, in vitro experiments were performed using whole human blood samples.MethodsThree types of experimental circuits were used, consisting of polymer-coated (PC), heparin-coated (HC), or noncoated (NC) membrane oxygenators (n = 5), in which blood was circulated while heparin diluted with a glucose solution was continuously administered. Blood was collected at 0, 1, 3, 6, 12, and 24 h of circulation to measure LL, glucose level (GL), partial pressure of oxygen (PO), and oxygen saturation (SA) in each experiment. Each value was categorized according to coating type and compared using two-way repeated-measures or one-way analysis of variance.ResultsThe mean LL values at each time point were significantly lower in the PC circuits than in the HC and NC circuits, whereas those in the HC and NC circuits were not significantly different. The mean GL values at each time point were significantly lower in the NC circuits than in the PC and HC circuits, whereas those in the PC and HC circuits were not significantly different. The mean PO and SA values at each time point were not significantly different among the different coating types.ConclusionsIn ECC circuits, PC may inhibit lactate production because of its hemocompatibility. Additionally, NC may enhance glucose consumption; however, the underlying mechanism remains unclear. Further research on the relationship between NC and GL is warranted.
A 2-month-old male infant weighing 2.8 kg developed a deep sternal wound infection on postoperative day 16 following repair of an atrial septal defect, ventricular septal defect and patent ductus arteriosus. Staphylococcus aureus was isolated on wound swab, and culture-sensitive antibiotics were given for 14 days. The infant remained intubated with an unstable chest wall, so conventional higher negative pressures were considered unsafe near the exposed mediastinum. After debridement, polyurethane-foam vacuum-assisted closure (VAC) was applied at a deliberately low -40 mmHg on day 1, increased to -50 mmHg thereafter, and changed every third day. Four cycles were completed over 12 days. The wound granulated progressively ( Figure 1) and healed by secondary intention; the infant was extubated, recovered well and was discharged on postoperative day 42. This case illustrates that stepwise low-pressure VAC is a safe, effective option for deep sternal wound infection in the ventilated, very-low-weight infant.
BackgroundNorwood surgery is the first stage in the surgical palliation of hypoplastic left heart syndrome (HLHS) and its variants. Postcardiotomy extracorporeal membrane oxygenation (ECMO) may be required in some patients undergoing the Norwood procedure given its complexity.MethodsKids Inpatient Database (2000-2022) and National Inpatient Sample (2016-2022) datasets were used. 2284 patients underwent a Norwood procedure. The cohort was dichotomized into ECMO (EG, n = 147) and Non-ECMO (NEG, n = 2137) groups; Survivor and Nonsurvivor. Demographic and clinical characteristics were extracted. Overlap weights were used to attain covariate balance and perform overlap-weighted analysis.ResultsPostcardiotomy ECMO utilization was 6% (147/2284). The EG was more likely to have HLHS as compared to its variants, total anomalous pulmonary venous return, small for gestational age, congestive heart failure, and arrhythmias. Overall discharge mortality for the entire cohort is 10%. The EG experienced higher mortality compared to NEG "44% versus 8%" and higher morbidity such as cardiac arrest, pericardial complication, cardiogenic shock, respiratory complications, acute kidney injury (AKI), postoperative bleeding, sepsis and reoperation, longer length-of-stay, and higher hospital charges than NEG. ECMO utilization rose over time, peaking after 2015, while mortality progressively declined. The Midwest had the highest ECMO use (8.93%). In multivariate analysis, ECMO use and AKI were independent predictors of mortality.ConclusionsPostcardiotomy ECMO utilization for the Norwood procedure remains rare, but utilization is increasing with regional variation. Postoperative AKI and ECMO utilization were independent predictors of mortality among Norwood.
Thoracoabdominal aortic aneurysm (TAAA) repair remains associated with significant morbidity and mortality, especially in elderly and comorbid patients. Although total endovascular repair using fenestrated or branched endografts has broadened therapeutic options, anatomical limitations, patient frailty, and logistical constraints still prevent a purely endovascular approach in many cases. For this subset, hybrid repair with visceral debranching has emerged as an alternative strategy, though its role remains controversial. This narrative review explores the rationale, indications, technical approaches, perioperative management, and outcomes of visceral debranching in hybrid TAAA repair. Particular attention is given to frailty assessment, anatomical complexity, staging strategies, and quantitative outcome data, with the goal of defining the position of hybrid repair within current algorithms compared with open and fully endovascular techniques. Hybrid repair is mainly used in high-risk patients who are unsuitable for open surgery and anatomically unfit for total endovascular reconstruction. Reported early mortality varies widely from 5% to over 20%, reflecting heterogeneity in aneurysm extent, operative strategies, and patient selection; elective series from experienced centres more commonly report mortality between 5% and 10%. Long-term bypass durability is generally good, with overall graft patency around 85%-90% at 5 years. Superior mesenteric artery grafts show the highest durability, while renal bypasses - particularly right-sided - have lower patency rates. Acute kidney injury occurs in 20%-40% of patients, with permanent dialysis dependence in 5%-15%. Mesenteric ischaemia is uncommon but highly lethal, while spinal cord injury occurs in 5%-15%, with permanent deficits in 3%-10%. Staged hybrid approaches may reduce physiological burden and neurological risk but require careful surveillance due to interval risks. Overall, visceral debranching remains a relevant and durable option when applied selectively, particularly in patients with hostile anatomy or prior aortic interventions. Optimal outcomes depend on careful patient selection, meticulous technique, appropriate staging, and structured long-term follow-up.
ObjectiveSurgical access to the mitral valve can be achieved through various techniques, with the transseptal (TS) and left atrial (LA) approaches being the most commonly used in mitral valve surgery (MVS). However, the optimal approach remains a subject of debate, as studies report differing perioperative and postoperative outcomes associated with each technique. This meta-analysis aims to systematically compare the clinical outcomes of TS versus LA approaches in MVS.MethodsThis meta-analysis followed the PRISMA guidelines. A comprehensive literature search of PubMed, Embase and Scopus databases was performed until June 2025. The primary outcome was permanent pacemaker (PPM) implantation.ResultsTwenty-five studies were included. The TS approach was associated with higher risk of PPM implantation (risk ratio: 1.44, 95% confidence interval [1.07-1.95]; P = 0.01), postoperative atrial fibrillation, postoperative junctional rhythm, atrioventricular block, need for temporary pacing and longer cardiopulmonary bypass time, aortic cross-clamp time (CCT), hospital-stay and bleeding. No significant differences were found in intensive care unit stay, mortality, infections, stroke and renal failure. Subgroup analysis of isolated MVS showed no differences in most outcomes except for a higher risk of PPM implantation and postoperative atrial fibrillation in the TS group.ConclusionOur meta-analysis demonstrates that the TS approach is associated with longer operative times and a higher risk of postoperative conduction disturbances and PPM implantation. However, no significant differences were observed in other major clinical outcomes. These findings do not support the overall superiority of either approach, and surgical access should be individualized according to patient anatomy, procedural requirements, and surgeon experience. Further high-quality studies are needed to strengthen the available evidence.
Surgical left atrial appendage (LAA) exclusion has transitioned from a disease-specific therapy for atrial fibrillation (AF) to an increasingly routine adjunct during cardiac surgery, including in patients who present in sinus rhythm. This shift has occurred not through definitive evidence, but through a convergence of technical feasibility, biologic plausibility, and expanding clinical momentum. Contemporary studies in non-AF populations have largely focused on risk-enriched cohorts and suggest a possible reduction in late cerebrovascular events, yet these findings remain heterogeneous and context-dependent. At the same time, real-world data highlight a consistent early clinical burden, including postoperative AF, anticoagulation exposure, and variability in downstream management. The central issue is therefore not simply one of efficacy or safety, but of sequencing and definition: a preventive intervention has entered routine use before its net clinical value and care pathway have been clearly established. In this setting, prophylactic LAA exclusion in sinus rhythm should not be viewed as a settled extension of surgical practice, but as an evolving strategy that warrants selectivity, transparency, and disciplined evaluation.
A 73-year-old male developed early prosthetic aortic valve endocarditis complicated by haemorrhagic cerebral lesions 45 days after tissue valve replacement. Transesophageal echocardiography revealed bulky vegetations and an annular abscess. Urgent surgical valve replacement with extensive debridement was performed, while broad-spectrum antifungal therapy was initiated. Aspergillus terreus was subsequently confirmed. Postoperatively, the patient experienced acute hydrocephalus, subarachnoid haemorrhage, and recurrent vegetations, ultimately precluding further surgery. He died on postoperative day 57. This case highlights the diagnostic and therapeutic challenges of early fungal prosthetic endocarditis with intracranial haemorrhage, emphasizing individualized management by multidisciplinary teams and the high mortality associated with Aspergillus infections.
Over the last two decades, there have been dramatic advancements in fenestrated and branched technology for endovascular repair of the thoracoabdominal aorta. The global development of these minimally invasive techniques decreased their short-term morbidity and mortality, compared to open aortic replacement. However, the need for secondary reinterventions remains frequent, although they are typically percutaneous. Continual device modifications, improved implantation techniques, and greater understanding of the endovascular tenets constantly improve rates of long-term success. Challenges exist in endovascular repair of post-dissection thoracoabdominal aortic aneurysms (PD TAAAs) with narrow paravisceral true lumen, and our institutional experience evolved from fenestrated to inner/outer branched technology to mitigate the long-term risk of target vessel instability. Refined strategies in bridging stent grafts, particularly in target vessels off the false lumen, lowered target vessel reintervention rates. Prophylactic and therapeutic management of the false lumen is essential to prevent continued aortic degeneration and to mitigate the risk of spinal cord ischemia. Over the next decade, endovascular management of PD TAAAs will continue to evolve, further improving long-term outcomes.
Background This study determined the incidence of major adverse cardiovascular events and identified independent predictors of in-hospital mortality in patients with acute limb ischemia undergoing revascularization.Methods A retrospective cohort study was conducted on 240 consecutive patients with acute limb ischemia who underwent revascularization at a tertiary-care academic hospital between February 2014 and February 2022. Perioperative adverse events were recorded, and multivariable logistic regression was used to identify independent predictors of in-hospital mortality.Results In-hospital major adverse cardiovascular events occurred in 42 patients (17.5%), while cardiovascular death accounted for 1.7%. All-cause in-hospital mortality was 13.3% (32 patients). On univariable analysis, markers of physiological stress including leukocytosis and elevated neutrophil-to-lymphocyte ratio, renal dysfunction, and multiple postoperative complications were significantly associated with mortality. Multivariable analysis identified four independent predictors: preoperative leukocytosis with white blood cell count greater than 15,000 per microliter (adjusted odds ratio 4.05, 95% confidence interval 1.52-10.75), intraoperative vasopressor use (adjusted odds ratio 4.00, 95% confidence interval 1.48-10.83), postoperative respiratory failure (adjusted odds ratio 8.44, 95% confidence interval 3.20-22.27), and postoperative bowel ischemia (adjusted odds ratio 15.24, 95% confidence interval 2.40-96.90).Conclusions Major adverse cardiovascular events are frequent but not independently associated with in-hospital mortality in patients with acute limb ischemia undergoing revascularization. Mortality is determined by a cascade of perioperative systemic insults rather than isolated cardiovascular events. Postoperative surveillance should prioritize early recognition of respiratory failure and bowel ischemia, particularly in patients presenting with leukocytosis or requiring intraoperative vasopressor support.
Scimitar syndrome is a rare congenital anomaly characterized by abnormal pulmonary venous drainage. This report describes the case of a 15-year-old girl with scimitar syndrome in which the scimitar vein drained into the hepatic vein. Surgical correction was successfully performed using an intra-atrial tunnel technique with right atrial anastomosis of the scimitar vein to reroute the scimitar vein to the left atrium. This case demonstrates the efficacy of this technique in managing complex cases of scimitar syndrome.
BackgroundThe Ross procedure, introduced in 1967, transformed cardiac surgery. This study presents one of the first global bibliometric analyses, to the best of our knowledge, mapping research trends, collaborations, and authorship to identify future directions in this field.MethodsA global bibliometric analysis of Ross procedure publications (1967-2025) was performed using Scopus and PubMed. Data processed in R (bibliometrix, biblioshiny) explored productivity, collaborations, authorship, and thematic evolution. Future publication trends to 2050 were forecast using a linear extrapolation model with 95% confidence intervals.ResultsA total of 2370 Ross procedure publications were identified (1967-2025), showing an 8.1% average annual growth rate. Original articles dominated (65%), followed by reviews/meta-analyses (13.9%) and case reports (13.5%). Among 6228 authors (69.5% male), collaboration averaged 4.9 coauthors/document, with 12.6% international partnerships. The USA (32.3%), the Netherlands (19.3%), and Germany (14.5%) led in productivity. Top institutions were Erasmus University Medical Center (4.3%), Mount Sinai Health System (3.0%), and University Heart Center Lübeck (2.2%). Major journals included Annals of Thoracic Surgery (13.5%), Journal of Thoracic and Cardiovascular Surgery (12.2%), and European Journal of Cardio-Thoracic Surgery (7.6%). Faculty surgeons authored 66% of first-author papers. Main research themes involved allograft reintervention, durability, suture technique, failure, and postoperative complications. Linear regression predicted 164 annual publications by 2050.ConclusionsThis analysis reveals an exponentially increasing and sustained global interest in the Ross procedure, which continues to shape cardiac surgery worldwide. The findings highlight growing research output, robust international collaboration, and a focus on clinical innovation, ensuring ongoing advancements in surgical techniques, patient outcomes, and global cardiovascular surgical excellence.
Background Acute type B aortic dissection (TBAD) has traditionally been classified as either complicated or uncomplicated, guiding management toward urgent intervention or optimal medical therapy with surveillance. However, growing evidence suggests that this binary framework inadequately captures the biological and haemodynamic heterogeneity of the disease. A subset of patients initially classified as uncomplicated demonstrates clinical or radiological features associated with adverse outcomes, commonly described as "high-risk" uncomplicated TBAD.Methods A structured narrative review was conducted to synthesise contemporary evidence relating to clinical predictors, imaging markers, and outcome data in TBAD. Major observational studies, meta-analyses, guideline statements, and recent registry data were evaluated to examine the pathophysiological basis and prognostic significance of high-risk features and their implications for disease classification and management.Results Accumulating data indicate that TBAD represents a dynamic continuum of haemodynamic and morphological instability rather than discrete clinical categories. Clinical markers such as refractory pain and persistent hypertension provide early indicators of potential instability but demonstrate limited specificity. In contrast, imaging findings, including false lumen diameter, entry tear geometry, true lumen compression, and aortic diameter, more reliably reflect underlying biomechanical stress and risk of progression. Contemporary outcome studies and meta-analyses suggest that thoracic endovascular aortic repair promotes favourable aortic remodelling and may improve survival in selected patients with high-risk disease, although heterogeneity in patient selection remains substantial.Conclusions High-risk uncomplicated TBAD likely represents a transitional phenotype within a broader spectrum of disease progression. Moving beyond binary classification toward integrated clinical, imaging, and haemodynamic risk stratification may enable more precise identification of patients who would benefit from early intervention while avoiding overtreatment in stable disease.
BackgroundArterial cannulation during cardiopulmonary bypass (CPB) significantly alters native aortic hemodynamics by generating a high-velocity jet that interacts with the ascending aorta and aortic arch geometry. These flow disturbances may influence wall shear stress (WSS), turbulence intensity, embolic trajectories, and cerebral perfusion. Cannula depth, orientation, and tip design have emerged as potentially important determinants of intra-aortic flow behavior.Materials and methodsA structured narrative review of the literature was conducted. PubMed/MEDLINE, Scopus, and Web of Science were searched from January 1990 to April 2025. Keywords included combinations of "aortic cannulation," "cardiopulmonary bypass," "computational fluid dynamics," "wall shear stress," "turbulence," "atherosclerotic plaque," "cerebral perfusion," "microembolization," "gaseous emboli," "NIRS," and "transcranial Doppler." Studies were included if they evaluated hemodynamic effects of cannulation strategies using computational, in vitro, or clinical models. Articles not directly related to CPB intra-aortic flow dynamics were excluded.ResultsThe available evidence suggests that cannula positioning significantly influences intra-aortic flow behavior. Centrally aligned cannulation directed toward the descending thoracic aorta promotes axial flow and is associated with reduced jet-wall impingement and lower peak WSS. This configuration decreases arch turbulence and limits embolic transport toward supra-aortic vessels.ConclusionArterial cannulation strategy during CPB is a modifiable determinant of flow behavior and potential cerebral embolic exposure. Hemodynamically informed cannulation principles may contribute to intraoperative neuroprotection, although prospective clinical validation is still required.
Sutureless aortic valves, such as the Perceval (Corcym) valve, provide important procedural advantages and favorable mid- to long-term outcomes; however, potentially serious aortic complications related to their self-expanding stent structure remain incompletely understood. Thus, we report the case of an 85-year-old woman who developed early-onset localized ascending aortic dissection after aortic valve replacement with a sutureless valve. The entry tear was located at the level of the stent edge, slightly proximal to the aortotomy suture line, and the dissection extended only between these two points, suggesting a localized stent-aortic wall interaction with external mechanical stress as a potential trigger.
BackgroundThis study aimed to evaluate the effect of lymph node dissection technique on survival outcomes in patients who underwent surgery for clinical stage I non-small cell lung cancer.MethodsA total of 442 patients with stage I non-small cell lung cancer who underwent surgical resection at multiple centers between 2011 and 2022 were retrospectively analyzed. Patients were divided into two groups according to the lymph node dissection technique: lobe-specific lymph node dissection and systematic lymph node dissection. Survival outcomes and postoperative complications were compared between the groups. Multivariate Cox regression analysis was performed to identify prognostic factors affecting survival.ResultsPostoperative complications occurred in 86 patients (19.5%). Complications were significantly less frequent in the lobe-specific lymph node dissection group compared to the systematic lymph node dissection group (9.4% vs. 22.4%, respectively; p = 0.027). The overall annual survival rate was 68.3%. The 5-year survival rate was significantly higher in female patients than in male patients (83.6% vs. 61.7%, p < 0.001). The 5-year survival rate was 69.3% in patients who underwent systematic lymph node dissection and 64.8% in those who underwent lobe-specific lymph node dissection, with no statistically significant difference between the two techniques (p = 0.332). In multivariate Cox regression analysis, advanced age was not a significant predictor of survival (p = 0.119, HR = 0.714, 95% CI: 0.467-1.090), whereas male gender was identified as an independent poor prognostic factor (p = 0.01, HR = 2.781, 95% CI: 1.506-5.138).ConclusionsLymph node dissection remains a critical component of surgical treatment in early-stage lung cancer. The comparable survival outcomes and lower complication rates observed with lobe-specific lymph node dissection suggest that it may be a preferable option in selected patients with stage I non-small cell lung cancer. Nevertheless, prospective multicenter studies are required to confirm these findings.
Despite the technically challenging nature of valve-sparing root replacement, restoration of aortic valve competence can be achieved through a complete understanding of the aortic root anatomy and pathophysiology. In this review, we discuss the physiology of normal aortic root function as well as pathophysiologic mechanisms contributing to aortic valve incompetence. Preoperative planning for valve-sparing root replacement is discussed, including the use of imaging to guide surgical decision-making. Pitfalls and pearls of the critical technical steps for both valve-sparing root replacement and repair of both tricuspid and bicuspid aortic valves are provided. Finally, current evidence guiding best practices in valve-sparing root replacement and aortic valve repair is presented to support decision-making for patient selection.
Background The optimal extent of repair for DeBakey type I acute aortic dissection remains controversial, particularly in low- to medium-volume centers. We compared outcomes of ascending and arch replacement under a tear-oriented strategy in DeBakey type I dissection. Methods We retrospectively analyzed 114 consecutive patients with acute DeBakey type I dissection between April 2008 and July 2025 at a regional cardiovascular center. Ascending aortic replacement was performed in 55 patients, and arch replacement, including both partial and total arch replacement, in 59 patients. The primary endpoint was overall survival. Secondary endpoints included in-hospital mortality, major complications, and open aortic reoperation. Results Arch replacement required longer operative, cardiopulmonary bypass, aortic cross-clamp, and circulatory arrest times. In-hospital mortality was 5.5% after ascending aortic replacement and 13.6% after arch replacement ( P = 0.143). Rates of major complications were comparable between groups. Long-term survival was better after ascending aortic replacement than after arch replacement (5-year, 87.1% vs 69.4%; 10-year, 83.5% vs 59.8%; P = 0.015). Freedom from open aortic reoperation was similar between groups (5-year, 90.4% vs 88.3%; 10-year, 70.2% vs 88.3%; P = 0.201). In the subgroup analysis restricted to patients with an intimal tear in the aortic root or ascending aorta, there were no differences in the primary or secondary endpoints. Conclusions A tear-oriented limited replacement strategy appears reasonable in centers with limited volume of acute type A dissection repair.
BackgroundMulti-arterial coronary artery bypass grafting (maCABG) improves long-term outcomes compared to single internal thoracic artery grafting. Choosing the second arterial conduit-the right internal thoracic artery (RITA) or the radial artery (RA)-is critical. RITA offers superior biological integrity but raises deep sternal wound infection (DSWI) concerns; RA provides ease of harvest but is susceptible to vasospasm and patency issues.MethodsThis narrative review synthesizes recent high-quality clinical investigations, including propensity-matched cohort studies and meta-analyses, comparing RITA and RA as the second conduit in left internal thoracic artery-based CABG. We analyzed comparative long-term survival, graft patency, and complication rates.FindingsMultiple propensity score-matched studies demonstrate the superiority of RITA/bilateral internal thoracic artery (BITA) use, reporting significantly improved long-term survival and major adverse cardiac event-free survival compared to RA. BITA use was associated with a 35% reduction in the long-term hazard of death. Conversely, recent large-scale registries and randomized trials increasingly support the use of RA. The risk of DSWI with BITA use can be mitigated through skeletonized harvesting; however, this technique requires significant expertise to ensure graft patency.ConclusionThe second arterial graft selection must be individualized, balancing patient-specific risks-such as diabetes and obesity-against the surgeon's proficiency in multi-arterial revascularization.
