Background Temperature management during emergency surgery for acute aortic syndrome is critical for neurological, renal, and systemic protection. Recent European Association for Cardio-Thoracic Surgery (EACTS) guidelines recommend moderate hypothermia with antegrade cerebral perfusion for hemiarch procedures. Nevertheless, deep hypothermic circulatory arrest (DHCA) remains common. This study evaluates neurological and other postoperative outcomes across different intraoperative temperature ranges. Methods A single-centre retrospective study of consecutive patients undergoing surgery for acute aortic syndrome between 2018-2023. Demographic, intraoperative, and postoperative data on mortality, hospitalization, neurological, renal outcomes, and blood product usage were collected. Patients were stratified by intraoperative temperature: deep (<= 20 degrees C), low-moderate (20.1-24 degrees C), high-moderate (24.1-28 degrees C), and mild (>28 degrees C) hypothermia. Logistic regression identified predictors of binary adverse outcomes. A sensitivity analysis was conducted using 24.0 degrees C as the threshold in hemiarch surgery patients. Results A total of 175 patients (median age 64 years; 37% female) were included; of whom 89% underwent hemiarch replacement. Cardiopulmonary bypass duration decreased progressively with warmer intraoperative temperatures, ranging from 270.5 minutes in deep hypothermia to 164 minutes in mild hypothermia. The 30-day mortality was 18.9% (n = 33/175), and the overall stroke rate was 19.4% (n = 34/175). Among patients undergoing hemiarch repair, warmer temperatures were associated with lower stroke incidence (mild hypothermia 11%) compared with high-moderate (8.8%), low-moderate (26%), and deep hypothermia (27%) (p = 0.049), and with shorter intensive care admission (p = 0.036). However, multivariate regression showed that the four-category comparison did not reach significance for the assessed outcomes once adjusted for confounding variables. A sensitivity analysis at 24.0 degrees C showed an independent association with reduced stroke risk (OR 0.23, 95% CI 0.08-0.64, p = 0.005). Discussion Our findings support current EACTS recommendations favouring moderate-to-mild hypothermia for hemiarch replacement, with potential protective effects. Further studies should determine the optimal temperature strategy for patients undergoing total arch replacement.
Background Acute type A aortic dissection (ATAAD) is a surgical emergency associated with high mortality. While patient-related risk factors are well-established, beliefs persist regarding the influence of lunar phases, meteorological conditions, and astrological signs on disease occurrence and outcomes.Methods We retrospectively analysed all patients who underwent emergency surgery for ATAAD at Bordeaux University Hospital between 1996 and 2020. The primary objective was to assess the association between environmental factors (lunar phases, atmospheric pressure, temperature, and astrological signs) and ATAAD incidence. Secondary objectives included assessing their association with 30-day mortality and postoperative morbidity (intensive care unit length of stay, extracorporeal membrane oxygenation use, and mesenteric infarction). Meteorological data were available for 603 patients from 2010 onward.Results Among 920 patients (70% male; mean age 63 +/- 13 years), the 30-day mortality rate was 9.7%. Lunar phases were not associated with ATAAD incidence (first quarter 26%, last quarter 25%, new moon 25%, full moon 24%; p = 0.91), mortality, or complications. Atmospheric pressure showed no association with ATAAD occurrence or outcomes. Temperature showed a weak correlation with ATAAD incidence (r = 0.11, p = 0.01), but not with mortality. Astrological signs were not associated with ATAAD incidence, mortality, or morbidity. Longer cardiopulmonary bypass duration (odds ratio [OR] = 0.994 per minute; p = 0.01) and diabetes (OR = 4.63; p = 0.01) were associated with 30-day mortality.Conclusions Environmental factors were not associated with ATAAD incidence or outcomes. Established clinical factors remain the primary determinants of mortality.
Background Patients undergoing left ventricular assist device (LVAD) implantation often present with end-stage heart failure, severe pulmonary hypertension, and systemic inflammation. During this procedure, cardiopulmonary bypass (CPB) acts as a double-edged sword: it provides essential life support but can exacerbate right ventricular (RV) dysfunction and trigger severe vasoplegia. Despite the critical nature of the transition from CPB to mechanical support, there is a lack of standardized, phase-specific CPB management protocols. Methods Based on current guidelines, frontline perfusion experience, and an interdisciplinary approach integrating mechanical engineering principles with surgical practice, a comprehensive clinical framework for CPB management was developed. The protocol deconstructs the procedure into four distinct phases: pre-bypass assessment, on-bypass management, weaning, and post-bypass care. Results A four-stage standardized checklist and an intraoperative emergency quick reference card were created to facilitate clinical translation. Key interventions include identifying anatomical “minefields,” maintaining a golden balance of hemodilution, executing a dynamic flow-speed handover to prevent suction events, and managing hemodynamics cautiously during protamine administration to mitigate RV dysfunction. Conclusions Standardizing CPB management during LVAD implantation provides a practical tool to optimize hemodynamic stability and improve perioperative safety.
BackgroundVentricular septal rupture (VSR) is a rare but devastating complication of acute myocardial infarction, historically associated with extremely high mortality rates. The optimal timing of surgical repair-balancing the risks of operating on friable, acute necrosis against the dangers of progressive cardiogenic shock during a waiting period-remains a central clinical dilemma.MethodsA systematic narrative review was conducted following PRISMA guidelines. PubMed/MEDLINE, Embase, and Cochrane Library databases were searched from 2000 to 2024 for studies comparing early (≤7 days) versus delayed (>7 days) surgical repair of post-MI VSR. Data were extracted on patient characteristics, mechanical circulatory support (MCS) use, surgical techniques, and clinical outcomes, including operative mortality, reoperation rates, and long-term survival.ResultsEvidence from contemporary observational studies confirms that delayed surgical repair is associated with significantly lower operative mortality compared to early repair, primarily due to superior tissue integrity and lower rates of residual shunt. However, this mortality gap has substantially narrowed in the contemporary era with routine use of advanced MCS, particularly veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella devices. These technologies enable hemodynamic stabilization, transforming early repair from a salvage procedure to a more controlled intervention. Modern management has evolved from a rigid temporal dichotomy to a patient-tailored strategy emphasizing immediate stabilization, risk stratification, and selective MCS bridging to the optimal surgical window.ConclusionWhile delayed repair remains preferred for hemodynamically stable patients, early repair supported by advanced MCS represents a viable and often necessary strategy for patients with refractory shock. The decision paradigm has shifted toward "stabilize, support, then repair," requiring multidisciplinary heart team collaboration. Future directions include standardized MCS protocols, validated risk scores, and exploration of hybrid percutaneous-surgical approaches to further improve outcomes for this high-risk population.
