Objectives Perioperative fluid resuscitation in cardiac surgery is vital, yet the optimal strategy remains debated. This review evaluates the current evidence on colloid versus crystalloid fluid resuscitation and considers whether alternative outcome measures may help us better identify optimal methods of fluid resuscitation for patients. Methods A search of electronic databases PubMed, Medline and Google Scholar was performed from inception to June 2025 to synthesise findings on the perioperative fluid management of patients undergoing cardiac surgery. Results Thirteen studies, involving a total of 34,935 patients, were included in this narrative review. Evidence comparing colloids and crystalloids perioperatively in cardiac surgery is mixed. Colloids, particularly albumin, show advantages in fluid balance, reduce vasopressor use and shorten ICU stays, but carry a higher risk of acute kidney injury, especially with synthetic colloids like hydroxyethyl starch. Crystalloids are less associated with renal complications yet contribute to increased fluid retention and longer hospital stays. Few studies, however, report on fluid balance, renal function and preservation of microcirculation, limiting the understanding of fluid strategies on these relevant postoperative outcomes. Conclusions Mortality alone may be an insufficient measure for evaluating fluid resuscitation strategies in cardiac surgery. Expanding outcome measures to include fluid balance, preservation of microcirculation and a standardised assessment of renal function could yield more clinically relevant actionable insights and support safer, more individualised fluid management. Further research is warranted to assess these outcomes and establish more holistic, patient‐centred standards in postoperative care.
Purpose We evaluated whether the weekday of surgery was associated with postoperative length of stay (LOS) or 30‐day readmission after elective and urgent isolated coronary artery bypass grafting (CABG) and identified patient‐ and procedure‐level predictors. Methods Elective and urgent isolated CABGs performed at Loma Linda University Medical Center and AdventHealth Cardiovascular Institute from 1/1/2014 to 12/31/2024 were retrospectively reviewed. LOS was compared across weekdays using one‐way ANOVA, and readmission rates were compared using Chi‐square testing. Predictors of LOS were evaluated using a generalized linear model with gamma distribution and log link, with exponentiated coefficients reported as LOS ratios. Predictors of readmission were assessed using multivariable logistic regression. Covariates were selected a priori and entered simultaneously. Results There was no difference in LOS by day among 8543 isolated CABGs ( p = 0.241). Age increased LOS by 0.8% per year ( p < 0.001), and BMI increased LOS by 0.4% per unit ( p = 0.001). Renal failure increased LOS by 92%, diabetes by 11%, and each additional graft by 4%; male sex decreased LOS by 8% (all p < 0.001). Treatment at Site 2 was associated with a 44% longer LOS ( p < 0.001).For readmission, increasing age ( p = 0.004) and diabetes ( p < 0.001) increased odds, whereas male sex was protective ( p < 0.001). Site 2 was associated with higher odds of readmission ( p = 0.039). Although the weekday of surgery was associated with readmission in unadjusted analysis, the association was not significant after adjustment. Conclusion LOS and readmissions after CABG hinge on comorbid burden and institutional practices, not surgical timing.
Background The bicavopulmonary connection (BCPC) is a crucial palliation for single‐ventricle physiology, improving haemodynamics by alleviating ventricular volume overload. While traditionally performed at 4–6 months, the optimal timing is debated, with a trend toward earlier intervention to reduce interstage mortality. This meta‐analysis compares outcomes of early versus late BCPC. Methods A systematic search of PubMed, EMBASE and Cochrane Central identified studies comparing early (< 6 months) and late (≥ 6 months) stage 2 palliation. Primary outcomes were early, late and interstage mortality. Secondary outcomes included operative parameters, ICU/hospital stay, duration of mechanical ventilation, Fontan completion rates, postoperative haemodynamics and complications. Pooled risk ratios (RR), odds ratios (OR), or mean differences (MD) with 95% confidence intervals were calculated using random‐effects models. Results Ten studies (2220 patients: 841 early, 1379 late) were included. The incidence of early mortality was significantly greater in the early BCPC group (RR = 2.28, CI = 1.29–4.05, p = 0.005), though late and interstage mortality were similar. Operative parameters and haemodynamics (atrial pressure, SVC pressure, oxygen saturation) were comparable. However, the early group had significantly longer hospital stay (MD = 5.21 days, p = 0.02), ICU stay (MD = 2.03 days, p = 0.02) and duration of mechanical ventilation (MD = 36.19 h, p < 0.0001). Time to Fontan, age at Fontan, Fontan completion rates and complications were indifferent. Conclusion Early BCPC is associated with a higher risk of short‐term mortality, with similar interstage and long‐term survival. Postoperative recovery is prolonged with earlier intervention. Fontan completion and postoperative complications are otherwise comparable. Future randomised multicentre studies are needed to establish optimal timing for BCPC surgery.
Objective Outcomes after surgical management of infective endocarditis (IE) for male and female patients is controversial, with some studies suggesting worse outcomes for female patients. The aim of this systematic review was to assess postoperative outcomes after surgery for IE in all studies reporting by patient gender. Methods A systematic review and meta‐analysis was conducted in accordance with Preferred Reporting in Systematic Review and Meta‐Analysis (PRISMA) guidelines. A comprehensive search of MEDLINE, Embase and Scopus databases was conducted from inception until 15th September 2025. Two authors independently conducted study screening and data extraction. Outcomes included mortality (< 30 day and > 1 year), postoperative (< 30 day) stroke, sepsis, acute kidney injury (AKI) and length of stay (LOS). Results Database search yielded 3102 results, and 13 studies were included with 20,824 patients (14,479 male and 6345 female). Women had increased risk of 30‐day mortality compared with men (odds ratio (OR): 1.36, 95% confidence interval (CI): 1.15–1.61 and p < 0.01), increased risk of > 1‐year mortality (OR: 1.34, 95% CI: 1.04–1.73 and p = 0.02) and of developing postoperative (< 30 day) AKI (OR: 1.20, 95% CI: 1.03–1.41 and p = 0.02). No significant differences were found in postoperative stroke (OR: 1.12, 95% CI: 0.95–1.30 and p = 0.17), sepsis (OR: 1.03, 95% CI: 0.62–1.71 and p = 0.92) or LOS (standardised mean difference: −0.06 days, 95% CI: −0.71‐0.59 and p = 0.78). Conclusions Female patients had significantly worse short‐ and long‐term mortality and increased risk of developing AKI than men; however, stroke, sepsis and LOS outcomes were comparable. Further research is needed to determine the reasons for worse mortality outcomes in females.
Objectives This systematic review and meta‐analysis evaluate clinical and haemodynamic outcomes between small (≤ 21 mm) and large (≥ 23 mm) prosthetic valves in surgical aortic valve replacement (SAVR). Methods A comprehensive literature search was conducted from inception to March 2025. Studies comparing outcomes between small and large aortic valve prostheses were included. Primary outcome was all‐cause mortality. Secondary outcomes included short‐term mortality, stroke, reoperation, endocarditis, haemodynamic parameters and patient‐prosthesis mismatch (PPM). Random‐effects models calculated pooled risk ratios (RRs) or mean differences (MDs). Mediation analysis explored the relationships between prosthesis size, PPM and mortality. Results Twelve studies comprising 9896 patients were included. Small prostheses were associated with increased all‐cause mortality (RR 1.23, 95% CI 1.07–1.41, p = 0.004) and short‐term mortality (RR 1.73, 95% CI 1.11–2.68, p = 0.015). No significant differences were observed for stroke, reoperation or endocarditis. Small prostheses demonstrated significantly lower indexed effective orifice area (MD −0.13 cm 2 /m 2 , 95% CI ‐0.24 to −0.01, p = 0.030) and higher incidence of PPM (RR 2.02, 95% CI 1.36–3.00, p < 0.0001). Mediation analysis revealed a strong correlation ( r = 0.904) between PPM and all‐cause mortality effect sizes. Very small prostheses (< 19 mm) exhibited elevated mean gradients (20.8 mmHg) and substantial PPM incidence (33.2%). Conclusions Small aortic valve prostheses are associated with increased mortality and PPM. The strong correlation between PPM and mortality effects suggests PPM may be the key mechanism underlying adverse outcomes. Alternative strategies such as root enlargement may be warranted in patients requiring small prostheses.
Background Posterior ventricular rupture (PVR) is an uncommon but often fatal complication of mitral valve surgery, with reported incidence between 0.6% and 1.8% and mortality rates approaching 86%. Recognized risk factors include posterior mitral annular calcification, advanced age, female sex, extensive decalcification, and infective endocarditis. Despite advances in surgical techniques, this catastrophic complication continues to pose a major challenge. We reviewed published reports of successful repair strategies to outline practical approaches and propose a management framework. Methods A PubMed search identified 25 reports describing 34 successful repairs of posterior LV rupture. Only cases in which patients survived were included for analysis. Results Most patients (21 of 34) presented with mitral stenosis, usually associated with posterior annular calcification. The circumstances of rupture varied, occurring intraoperatively, during attempts to wean from cardiopulmonary bypass (CPB), or in the intensive care unit. Thirty cases required reinitiation of CPB to enable definitive repair. External repair methods, such as Teflon patch reinforcement and surgical sealants, were reported in 13 patients. Internal approaches most often used pericardial patch reinforcement secured with Teflon‐buttressed sutures, both to restore ventricular integrity and to support the prosthetic valve. In six situations, repair was undertaken using autotransplant techniques on an explanted heart. Mechanical circulatory support was frequently required: 14 patients received intra‐aortic balloon pump therapy, and one patient was supported with an Impella device, both aiming to reduce LV workload during recovery. Conclusion Posterior LV rupture following mitral valve surgery demands immediate recognition and rapid reinstitution of CPB. The choice of repair—internal or external—should be guided by rupture timing, location, and patient stability. Adjunctive mechanical circulatory support can be life‐saving by unloading the injured ventricle. While experience remains limited to isolated reports, systematic accumulation of cases is needed to refine treatment strategies for this highly lethal complication.
ObjectivesRight-sided infective endocarditis (RSIE) is a rare entity seldom requiring surgical therapy. This study compares the outcome following surgery in cases of isolated RSIE (iRSIE) and cases with concomitant left-sided infective endocarditis (LSIE).MethodsA retrospective analysis was performed on the database of the Clinical Multicenter Project for Analysis of Infective Endocarditis in Germany (CAMPAIGN) for the time period 2011-2018 at 6 German centres, comprising 2225 consecutive patients undergoing heart valve surgery. RSIE were further stratified according to the presence of LSIE: iRSIE and concomitant LSIE (RLSIE). Primary outcomes were 30-day mortality and estimated 5-year survival.ResultsThe 103 (4.6% of all IE) patients who underwent surgery for RSIE were divided into iRSIE (n = 56, 54.4%) and RLSIE (n = 47, 45.6%). Patient age was 56.7 vs. 62.9 years, p = 0.07 in RSIE and RLSIE, respectively. Further baseline characteristics including gender distribution, left ventricular ejection fraction and comorbidities did not differ significantly. The most common causative microorganisms were Staphylococcus species (58.9% vs. 46.8%, p = 0.24). Despite the higher operative complexity of the RLSIE group, postoperative course and long-term outcomes did not differ significantly-perioperative mortality was 16.8% vs. 16.7%; 29.8% vs. 35.2% at 1 year and 46.7% vs. 59.9% at 5 years in RSIE and RLSIE, respectively (p = 0.57).ConclusionsIn a cohort of elderly patients with high preoperative risk factors undergoing surgical therapy for RSIE, outcome is not substantially determined by the presence of concomitant LSIE.
ObjectiveTo evaluate the surgical strategy and midterm outcomes of a conduit-less right ventricle-to-pulmonary artery (RV-PA) reconstruction using the left atrial appendage (LAA) for posterior wall augmentation.MethodsWe retrospectively reviewed 17 consecutive patients (median age: 15.2 months; weight: 8.4 kg) who underwent conduit-less RV-PA reconstruction between 2007 and 2025. The LAA was utilized to reconstruct the posterior wall of RV-PA route via two distinct techniques selected according to native anatomy: Type A (augmentation of the diminutive PA trunk), used when native PA tissue was available, where the LAA was attached to augment the left side of the longitudinally incised PA trunk (n = 8); and Type B (interposition), used when native PA tissue was absent, requiring the LAA to be interposed as a bridge between the pulmonary bifurcation and the RV incision (n = 9). The anterior wall was completed with a monocusp-incorporated transannular patch.ResultsPrimary diagnoses included pulmonary atresia with ventricular septal defect (n = 11), double-outlet right ventricle (n = 3), truncus arteriosus (n = 2), and tetralogy of Fallot with hypoplastic PA (n = 1). The median follow-up was 3.8 years (up to 11.9 years). There were no technique-specific complications. The median diameter of the reconstructed route was 12 mm. One noncardiac death occurred due to pneumonia. While four patients required catheter interventions for peripheral branch PA stenosis (5-year freedom from intervention: 61.6%), only one patient required reoperation due to a restrictive monocusp. No interventions were required for the LAA posterior wall itself. The estimated 5-year freedom from reoperation was 90.9%.ConclusionsStrategic use of the LAA for reconstruction of a new RV-PA route-either by augmentation (Type A) or interposition (Type B)-is a promising conduit-less approach that achieves favorable midterm freedom from surgical reoperation. Long-term follow-up is warranted to evaluate the cumulative lifetime reintervention burden and the theoretical growth potential of this autologous tissue.
Background The predictive value of platelet indices, including the platelet count (PLT), mean platelet volume (MPV), platelet distribution width (PDW), plateletcrit (PCT), and platelet–lymphocyte ratio (PLR) for postoperative atrial fibrillation (POAF) following cardiac surgery remains undetermined. Methods MEDLINE, Embase, and the Cochrane Library were searched from inception to October 2024. For each included study, median differences (MDs) and odds ratios (ORs) were tabulated with 95% confidence intervals (CIs). Pooled estimates were generated using random‐effects inverse‐variance modeling. Statistical analysis focused on cases of POAF. Results Six thousand five hundred and seventeen unique studies were screened and included 23 studies involving 12,375 patients in the subsequent analysis. Compared with patients who did not develop POAF, patients with POAF had higher preoperative MPV (MD: 0.30 fL, 95% CI: 0.07–0.53, and p = 0.0112) and PLR (MD: 40.42, 95% CI: 7.49–73.33, and p = 0.0161). Preoperative PLT (MD: 3.32, 95% CI: −5.87–12.51, and p = 0.4785) was not significantly different between groups. Study numbers were insufficient to assess the association between PCT with POAF. Conclusion Elevated preoperative MPV and PLR were associated with POAF after cardiac surgery. Further research is required to investigate the roles of these indices in the risk stratification of POAF in patients undergoing cardiac surgery.
BackgroundCardioplegia is essential for myocardial protection during cardiac surgery with cardiopulmonary bypass (CPB). Histidine-tryptophan-ketoglutarate (HTK) solution, an intracellular-type cardioplegia, offers prolonged myocardial protection with single-dose administration, whereas Plegisol, an extracellular-type crystalloid cardioplegia solution that can be mixed with blood, requires repeated dosing. However, their distinct ionic compositions may differentially affect intraoperative biochemical stability and neurological outcomes. This study aimed to compare the effects of HTK and blood cardioplegia using Plegisol on intraoperative biochemical parameters, brain injury markers, and postoperative cognitive function.MethodsFrom January 2023 to May 2025, 58 adult patients undergoing open-heart surgery with CPB were prospectively enrolled. Patients received either HTK (n = 24) or blood cardioplegia with Plegisol (n = 34) according to surgeon preference. Serum electrolytes, glucose, osmolality, and brain injury biomarkers were measured hourly during CPB. Bilateral frontal cerebral oxygen saturation was continuously monitored. Cognitive function was assessed preoperatively and at 3 months postoperatively using the Montreal Cognitive Assessment (MoCA), which evaluates attention, executive function, memory, language, visuospatial skills, and orientation.ResultsCompared with Plegisol, HTK cardioplegia was associated with significantly lower intraoperative sodium levels and transient hypoosmolality. Intraoperative glucose levels were unexpectedly higher in the HTK group after 2 h of CPB. S100 calcium-binding protein B (S100 beta) levels increased significantly over time, with a greater rise in the HTK group (group & times; time interaction: p = 0.029), whereas neuron-specific enolase levels showed no intergroup differences. Despite these intraoperative biochemical variations, 3-month postoperative MoCA scores were comparable between groups (p = 0.746), and no significant differences were observed in postoperative clinical outcomes, including delirium incidence (12.5% vs. 17.6%, p = 0.722), agitation, brain events, or length of stay.ConclusionsHTK cardioplegia induces expected intraoperative hyponatremia and is associated with greater S100 beta elevation during CPB, suggesting transient neuronal stress. However, these biochemical differences did not translate into differences in postoperative cognitive function, delirium, or other clinical outcomes at 3 months. Intraoperative electrolyte monitoring remains important during HTK administration.
Background Postoperative drainage is essential in cardiac surgery to prevent tamponade, monitor bleeding, and maintain hemodynamic stability. Although large‐bore chest tubes have been traditionally used, small‐bore drains are gaining interest because of their potential benefits in reducing pain and improving recovery. However, their clinical impacts remain unclear. Objective To systematically map and evaluate the available evidence on the clinical outcomes of small‐bore versus conventional large‐bore chest tubes in adult patients undergoing cardiac surgery. Methods A scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews guidelines. Four databases (PubMed, Embase, Cochrane CENTRAL, and Web of Science) were searched for studies published between January 2000 and July 2025. Eligible studies included randomized controlled trials (RCTs) and observational comparative studies comparing small‐bore drains (such as Blake, Jackson–Pratt, and Redon) and conventional chest tubes after cardiac surgery. The outcomes included drainage effectiveness, pain, complications (such as tamponade and reoperation), atrial fibrillation, and hospital stay. Two reviewers independently extracted the data, and the levels of evidence were assigned using the Oxford Center for Evidence‐Based Medicine 2011 framework. Owing to clinical heterogeneity, a qualitative synthesis was performed. Results Twelve studies comprising 3206 patients were included, of which nine were RCTs and three were retrospective studies. Most studies used Blake drains as the small‐bore device. Two studies reported significantly reduced postoperative pain in the small‐bore group and two reported lower analgesic use. Drainage volumes, reoperation rates, and late effusion rates did not significantly differ between groups in most studies. Cardiac tamponade and atrial fibrillation were less frequent in the small‐bore group in two studies. Hospital and intensive care unit stays showed no consistent trends. No studies demonstrated inferiority of small‐bore drains in clinical outcomes. Conclusion This scoping review found that small‐bore drains are safe and clinically comparable alternatives to large‐bore chest tubes in cardiac surgery. Given the potential advantages of patient comfort, the broader use of small‐bore drains may be justified.
Objective Postmyocardial infarction ventricular septal defect (PMIVSD) is one of the most lethal mechanical complications of acute myocardial infarction, yet contemporary data on its regional distribution and real‐world management remain limited. Methods We analyzed the Texas Inpatient Discharge Database (TIDD) from 2015 to 2024 to characterize the incidence, institutional distribution, resource utilization, and outcomes of PMIVSDs across Texas. Adult patients with an emergent or urgent PMIVSD admission (ICD‐10 I23.2) were stratified by operative versus nonoperative management; hospitals were categorized into tertiles by PMIVSD volume. The primary outcome was in‐hospital mortality. Results A total of 139 patients were identified, representing an incidence of 0.16% of all myocardial infarction admissions. Care was distributed across 60 unique hospitals, with 35 centers managing only a single admission during the study period. Mechanical circulatory support (MCS) was utilized in 58% of patients, with no significant temporal trend across the study period. Practice variation in Impella use, transcatheter VSD closure, and cardiac surgery was observed across volume tertiles. The overall in‐hospital mortality was 47%. Overall in‐hospital mortality differed across volume tertiles (log‐rank p < 0.001), reflecting early divergence with the highest mortality at middle‐volume centers (64%); this difference did not persist among patients surviving to a 2‐week landmark ( p = 0.81). Operative patients at high‐volume centers demonstrated significantly improved survival ( p = 0.0015). On conventional multivariable Cox regression, cardiac surgery was associated with decreased mortality (adjusted HR: 0.37; 95% CI: 0.19–0.69; p = 0.002); however, landmark analyses accounting for immortal time bias attenuated this association to nonsignificance (HR range: 0.69–0.78; all p > 0.4). Hospital day 30 survival was 68.8% (95% CI: 54.9%–86.2%) for operative patients versus 35.1% (95% CI: 22.8%–51.8%) for nonoperative patients ( p < 0.001). Conclusions Management of PMIVSDs in Texas is highly fragmented, with most institutions managing fewer than two cases over the decade. High‐volume centers demonstrated superior operative survival and greater procedural diversity, whereas middle‐volume centers had the highest early mortality. The association between surgery and lower mortality on conventional modeling was attenuated and nonsignificant in landmark analyses, consistent with—but not confirming—a surgical benefit at this sample size. These findings are hypothesis‐generating and support prospective evaluation of regionalized care pathways for PMIVSD.
Postpump chorea is a rare but potentially disabling movement disorder that arises days to weeks after cardiopulmonary bypass, most often following deep hypothermic circulatory arrest in pediatric patients undergoing repair of complex congenital heart defects. Clinically, postpump chorea presents as involuntary, nonrhythmic, choreiform, and athetotic movements after an initial asymptomatic period. We present a detailed case of a two‐year‐old male with an interrupted aortic arch and a large ventricular septal defect who developed persistent chorea four days after deep hypothermic circulatory arrest repair at 18°C for 145 min. A focused literature review was conducted in May 2025 via PubMed, MEDLINE, Scopus, and Google Scholar. Our patient’s structural neuroimaging and metabolic/autoimmune workups were unremarkable. Initial treatment with clonazepam yielded partial improvement; addition of haloperidol provided further relief but did not fully resolve chorea, which persisted intermittently at the last follow‐up. Antegrade cerebral perfusion through the innominate artery was not used due to anatomic constraints and the need for complete arch reconstruction. Literature review confirms postpump chorea onset typically 3–14 days postcardiopulmonary bypass, frequent normal findings on CT/MRI, and variable responses to benzodiazepines, dopamine antagonists, and VMAT‐2 inhibitors. Identified risk factors include prolonged deep hypothermic circulatory arrest time, lower target temperatures, pH‐stat management, and cyanotic shunts. Postpump chorea demands high clinical vigilance despite normal imaging. Prevention through optimized cardiopulmonary bypass techniques, including moderate hypothermia, controlled rewarming, pH‐stat blood gas management, emboli filtration, and real‐time cerebral monitoring, is paramount. First‐line medical therapy (clonazepam and haloperidol) should be initiated promptly, with VMAT‐2 inhibitors or corticosteroids reserved for refractory cases. Future multicenter studies are needed to refine neuroprotective strategies and define long‐term neurodevelopmental outcomes.
Aortic valve repair in children remains an important strategy to preserve native valve tissue, avoid prosthetic valve replacement, and accommodate somatic growth. However, outcomes vary substantially across repair techniques, valve morphologies, and patient subgroups. We performed a systematic review with quantitative synthesis of outcomes to provide a contemporary overview of surgical strategies and long‐term results of pediatric aortic valve repair. PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library were searched for studies published between January 2000 and January 2026 reporting outcomes of surgical aortic valve repair in patients aged ≤ 18 years. Thirty‐four studies, including 2684 children, were analyzed. Repair strategies included commissurotomy, leaflet plication, cusp extension or tricuspidization, annuloplasty‐based techniques, pericardial leaflet reconstruction, and aortic valve neocuspidization. Early mortality after pediatric aortic valve repair was low overall (1.3%; 95% confidence interval [CI]: 0.7%–2.1%) but higher in neonates and infants. Long‐term durability differed by technique and underlying pathology. Autologous pericardial cusp extension and tricuspidization demonstrated favorable long‐term durability in selected patients, with freedom from reoperation approaching 75% at 15 years in some series. Valve neocuspidization was associated with excellent early hemodynamics and no early mortality in the included studies, but currently available pediatric data suggest less certain mid‐term durability, with estimated freedom from reintervention of 44% at 10 years; however, interpretation is limited by small sample sizes and relatively short follow‐up. Younger age at repair and the use of treated xenograft material were associated with increased risk of reintervention. Pediatric aortic valve repair provides low operative mortality and favorable valve preservation in carefully selected patients, but outcomes depend strongly on patient age, valve morphology, surgical technique, and institutional experience. Pooled estimates should be interpreted cautiously in view of substantial clinical heterogeneity. Surgical decision‐making should remain individualized and lesion‐specific, with a strong emphasis on valve preservation whenever feasible.
BackgroundFunctional tricuspid valve (TV) disease progression and reoperation risk can be reduced through concomitant TV repair during left-sided cardiac surgery. However, the optimal annuloplasty ring choice remains unclear; relevant studies have exhibited bias or had limited long-term follow-ups. This study compared the short-term and long-term outcomes of flexible and rigid ring annuloplasty in patients with functional tricuspid regurgitation (TR).Materials and MethodsWe recruited 615 patients who underwent tricuspid surgery from 2008 to 2020. Patients with primary TR, suture annuloplasty, or valve replacement were excluded. We adopted inverse probability of treatment weighting (IPTW) to balance baseline variables, reducing bias. The primary endpoint was 10-year cumulative TR recurrence; the secondary endpoints were left-heart redo surgery, right ventricular dysfunction, cardiac-related mortality, and overall survival.ResultsThe final cohort comprised 277 and 85 patients receiving rigid ring and flexible ring annuloplasty, respectively. After IPTW adjustment, no significant differences were observed in short-term outcomes in those with moderate TR (aOR = 0.78, 95% CI: 0.39-1.58) or severe TR (aOR = 0.47, 95% CI: 0.16-1.33). The groups demonstrated comparable 10-year cumulative incidences of TR recurrence (15.1% rigid vs. 18.9% flexible; sHR = 0.82, p = 0.60), redo left-heart surgery (19.4% vs. 26.6%; sHR = 0.76, p = 0.46), right ventricular dysfunction (9.4% vs. 19.6%; sHR = 0.46, p = 0.07), and cardiac-related mortality (12.3% vs. 10.8%, sHR = 1.10, p = 0.86). The overall survival rates were also similar (75.4% vs. 83.3%, p = 0.34).ConclusionIn this single-center retrospective cohort adjusted by IPTW, flexible and rigid ring annuloplasties were associated with similar short-term and long-term outcomes; however, residual confounding and limited power, particularly in the flexible-ring group, preclude definitive claims of equivalence.
ObjectiveA robotic approach to primary structural cardiac operations has been established, but there are fewer reports regarding its use in a reoperative setting. Our primary aim was to retrospectively compare outcomes between patients who underwent a robotic approach versus resternotomy for reoperative mitral valve interventions.MethodsA retrospective propensity-score matched observational study was performed at one large volume referral center with an advanced robotic cardiac surgery program from 2019 to 2024. Adults who had prior sternotomy for cardiac operations and were undergoing mitral valve surgery were included. Propensity scores were calculated using 14 preoperative clinical variables. An optimal algorithm was used to generate pairs in a 1:2 fashion between patients who underwent robotic approach or resternotomy. Continuous and categorical variables were compared using the Wilcoxon two-sample test and chi-square or Fisher's exact test, respectively.Results172 patients met the inclusion criteria, with 137 patients in the resternotomy group and 35 patients in the robotic approach group. 1:2 matching resulted in 35 patients in the robot approach and 70 patients in the resternotomy group. Preoperative demographics and clinical characteristics were well matched between the groups. The robotic approach was associated with higher cardiopulmonary bypass times. There was no significant difference in total transfusion requirements, ICU or postoperative length of stay, or in-hospital mortality.ConclusionsOur observational study suggests that in experienced hands, a robotic approach to mitral valve operations in a reoperative field can provide noninferior outcomes to resternotomy. Patient selection and surgeon experience are critical to achieving these outcomes.
Objective This study aimed to evaluate the long-term efficacy of a standardized triple procedure-coronary artery bypass grafting (CABG), chordal-sparing mitral valve replacement, and tricuspid annuloplasty-in high-risk patients with end-stage ischemic dilated cardiomyopathy (IsDCM) for whom heart transplantation was not an option. Primary endpoints were survival, reverse ventricular remodeling, and functional recovery. Methods We prospectively analyzed 42 consecutive patients (mean age 64.7 +/- 9.1 years; 85.7% male) with end-stage IsDCM. All presented with severe secondary mitral and tricuspid regurgitation, left ventricular ejection fraction (LVEF) < 30% (mean 26.4% +/- 3.1%), left ventricular end-diastolic diameter > 7.0 cm (mean 7.3 +/- 0.3 cm), and coaptation depth > 1.0 cm. Mean STS-predicted mortality risk was 22.0% +/- 1.5%, and mean EuroSCORE II was 7.0% +/- 1.0%. Results Thirty-day operative mortality was 2.4% (n = 1). Significant reverse remodeling occurred: LVEF improved from 26.4% +/- 3.1% to 34.6% +/- 4.2% (p < 0.001), and end-systolic sphericity index decreased from 86.1% to 66.3%. NYHA class improved from 3.5 +/- 0.5 to 1.8 +/- 0.6 among survivors at 1 year (p < 0.001). Long-term survival was 78.5% +/- 4.0% at 5 years and 54.8% +/- 5.2% at 10 years. Conclusions In high-risk end-stage IsDCM patients, CABG with chordal-sparing mitral valve replacement and tricuspid annuloplasty facilitates substantial reverse remodeling, durable functional improvement, and excellent long-term survival. This anatomy-preserving strategy offers a viable alternative to transplantation or destination therapy for selected patients with advanced heart failure.
Preclinical data from the peculiar animal model of "synthetic torpor" (ST), a reversible hypothermic condition resembling natural torpor but pharmacologically induced in rats (a nonhibernating mammal), suggest that in hypothermic conditions, the neuroprotective effects of melatonin are strongly enhanced. As a protection technique, during aortic-arch surgery, patients are induced a hypothermia similar to ST. Since in ST, systemic melatonin was found particularly high, our aim was to assay serum melatonin in patients (N = 8) undergoing aortic surgery, either during hypothermia or in the following four recovery days. Serum markers of blood-brain barrier (BBB) integrity (the astrocytic protein S100B) and neuronal damage (neuronal-specific enolase [NSE]) were also measured. Results show that, in contrast to what observed in ST, in hypothermic patients, melatonin was dramatically reduced with respect to the preanesthesia level, slowly recovering during the postsurgery period. Also, S100B and NSE were raised during surgery, indicating a compromised BBB integrity and some ongoing neuronal damage, though both markers returned closer to preanesthesia levels within the recovery period. Together, the present results show that, in aortic-arch surgery, hypothermic patients totally lack the systemic melatonin peak that was observed in ST, the BBB was temporarily compromised, and some acute neuronal damage occurred. A main implication of this work is that, exploiting the low BBB efficiency that makes easier to reach brain parenchyma, by administering melatonin during the hypothermic stage of the surgery, the observed gap could be filled, possibly triggering the neuroprotective mechanism seen in preclinical observations and leading to better neurological outcomes for this surgical procedure.
Objective Multiarterial grafting during coronary artery bypass grafting (CABG) has been associated with improved long-term outcomes, but analyses of short-term outcomes have been limited by selection bias. We sought to assess this gap using a propensity-matched dual-institution cohort. Methods We performed a retrospective study of patients undergoing isolated CABG between 2011 and 2024 at two academic centers. Patients were categorized into single-arterial and multiarterial grafting groups. We used multivariable logistic regression to identify predictors of multiarterial use. Propensity score matching (1:1, caliper 0.05) was then used to compare short-term outcomes. A subgroup analysis examined outcomes among high- vs. low-probability patients receiving multiarterial grafting. Results In the unmatched cohort, multiarterial recipients were younger with fewer comorbidities. Predictors of reduced odds of multiarterial grafting included female sex (OR: 0.54, 95% CI: 0.41-0.73, p < 0.0001), Black race (OR: 0.43, 95% CI: 0.19-0.98, p = 0.04), diabetes (OR: 0.56, 95% CI: 0.46-0.69, p < 0.0001), dialysis dependence (OR: 0.35, 95% CI: 0.13-0.91, p = 0.03), low ejection fraction < 40% (OR: 0.58, 95% CI: 0.39-0.88, p = 0.009), and prior myocardial infarction (OR: 0.63, 95% CI: 0.50-0.77, p < 0.0001). After matching (607 pairs), there were no significant differences in mortality, stroke, renal failure, or deep sternal wound infection (DSWI). In our "low-probability" multiarterial grafting group, we noted longer operative times but no differences in mortality (0.19% vs. 0%, p = 0.11). Conclusions After propensity matching, multiarterial grafting was not associated with worse short-term outcomes compared to single-arterial grafting. Disparities in multiarterial grafting by sex and race exist and warrant targeted interventions to ensure equitable delivery.
BackgroundDistal side-to-side anastomosis is an effective technique for coronary artery bypass grafting; however, restrictive suturing may adversely affect graft patency. In this study, we evaluated ex vivo side-to-side models through numerical simulations of fluid dynamics to compare varying degrees of anastomotic stenosis and predict their hemodynamic consequences.MethodsA carotid artery was grafted onto a porcine coronary artery in a side-to-side configuration, with the vessels filled with liquid silicone. Ultra-high-resolution computed tomography was employed to acquire the reference side-to-side image, and stenotic models were developed with longitudinal shortening and bilateral narrowing at 25%, 50%, and 75% stenosis, alongside 90% coronary artery stenosis. Hemodynamic analysis was conducted using computational fluid dynamics simulations to calculate streamlines, wall shear stress, and oscillatory shear index.ResultsIn the reference model, graft inflow impinged on the coronary artery floor, generating a recirculating vortex at the heel and blind end of the graft while maintaining laminar flow. Longitudinal stenosis resulted in a steeper graft flow angle, whereas bilateral stenosis induced helical flow along the lateral arterial wall, exacerbating with increased stenosis. At 75% longitudinal or 50% bilateral stenosis, a region of flow separation was observed, characterized by low wall shear stress and high oscillation regions distal to the toe of the anastomosis.ConclusionsComputational fluid dynamics simulations indicate that anastomotic stenosis with longitudinal length ratios less than 1.6 and bilateral width ratios less than 0.73 relative to coronary diameter is at risk of intimal hyperplasia leading to graft failure, whereas larger ratios suggest acceptable hemodynamics. Future research should investigate long-term clinical outcomes associated with suboptimal side-to-side anastomotic construction.
