Background:In the context of cardiac surgery, morbid obesity poses several perioperative challenges. Some surgeons consider obesity a relative contraindication for minimally invasive aortic valve replacement (MIAVR) due to anatomical and technical complexities. Although MIAVR is increasingly used in standard-risk populations, evidence supporting its safety and efficacy in morbidly obese patients remains limited. Methods:This retrospective cohort consisted of 920 patients who underwent MIAVR via partial upper ministernotomy at a high-volume cardiac surgery center between 2010 and May 2025. Patients were categorized into three groups based on BMI: Class I obesity (BMI 30-35 kg/m2; n = 164), Class II-III obesity (BMI > 35 kg/m2; n = 54), and a non-obese control group (n = 702). Key clinical outcomes, echocardiographic parameters, postoperative complications, and long-term mortality rates were compared. Additionally, a pairwise meta-analysis was conducted, incorporating five studies to assess outcomes of MIAVR vs. conventional full sternotomy in obese individuals. Results:There were no significant differences in most of postoperative outcomes. However, higher rates of pneumothorax and arrhythmias were observed in Class II-III obesity. Multivariate regression did not identify obesity as an independent predictor of adverse outcomes. Meta-analysis confirmed comparable operative times and a trend toward shorter ICU stays and lower respiratory complications in the MIAVR group. Conclusion:This study argues that (i) obesity alone should not delay, deter, or preclude appropriate candidates from being referred for surgical aortic valve replacement, and (ii) partial upper ministernotomy should be considered the preferred access route in obese patients, as it consistently facilitates recovery without compromising safety.

BACKGROUND Decellularized aortic homografts (DAH) were introduced in 2008 as a further option for paediatric aortic valve replacement. Subcoronary DAH implantation may eliminate the need for aortic root replacement and coronary artery reimplantation in patients with sufficient left ventricular outflow tract dimensions. METHODS Ovine aortic xenografts were harvested from the slaughterhouse and decellularized using an approved detergent-based decellularization protocol. Two cardiac surgeons performed subcoronary implantation in explanted ovine hearts and results were compared regarding procedure time and procedural success. After these ex-vivo experiments four adult black-headed sheep were operated on in acute experiments. RESULTS The two surgeons were able to perform the ex-vivo subcoronary implantation of the decellularized ovine aortic allografts (DOAA) without technical problems within an hour. Mechanical strength of the processed ovine DOAA appeared comparable to that of native aortic tissue. Both surgeons stated that there were no differences with respect to appearance, haptics, trimability, and sewability.The initial two sheep operated on showed significant valvular incompetence. Following modification of the surgical protocol to a single-line suture technique, the next two sheep showed fully competent aortic valves with laminar flow across the subcoronary implanted DOAA. CONCLUSIONS We have developed a technique for subcoronary implantation of decellularized aortic homografts including acute large animal experiments. Long-term animal experiments will provide further insight into durability and recellularization.

Background/Objectives: Transcatheter aortic valve implantation (TAVI) has become the leading treatment option for patients suffering from aortic valve stenosis aged over 70, except in cases of specific contraindications like bicuspid valves, inappropriate access routes, or endocarditis. Minimally invasive aortic valve replacement (MIAVR) has emerged as a potential way to combine the durability of surgery with reduced procedural trauma. This study aims to assess the safety and feasibility of MIAVR in elderly patients. Methods: A total of 990 patients were included in this retrospective cohort study. Among them, 261 (26%) were aged 70 years or older (elderly cohort), and 729 (74%) were younger than 70 years (younger cohort). All patients were followed for at least 30 days postoperatively, with survival data collected through May 2025. Multivariable logistic regression, linear regression, and Kaplan-Meier survival analyses were performed. Results: Elderly patients were more likely to be female (51% vs. 40%, p = 0.001) and carried a heavier burden of vascular and renal comorbidity: renal impairment 33% vs. 17% and extracardiac arteriopathy 45% vs. 30% (both p < 0.001). Major bleeding occurred more frequently in the elderly cohort (7.7% vs. 4.1%; p = 0.02), as did new permanent pacemaker implantation (10% vs. 5.8%; p = 0.021) and sepsis (3.4% vs. 1.1%; p = 0.012). Rates of stroke, perioperative myocardial infarction, ECMO/right-heart failure, re-thoracotomy, and postoperative dialysis were low and comparable across age groups (all p > 0.20). Overall, 30-day mortality was 2.4% (24/990), with crude mortality approximately threefold higher among patients aged ≥70 years (4.6% vs. 1.6%). Conclusions: Our findings indicate that MIAVR is a feasible and safe surgical option across age groups; Elevated morbidity in elderly patients is primarily due to bleeding, pacemaker implantation, and sepsis, while rates of stroke, renal failure, and myocardial infarction are low.

Background and Objectives: Optimal myocardial protection during minimally invasive aortic valve replacement (MIAVR) is debated. We compared four cardioplegia strategies. Materials and Methods: Consecutive MIAVR patients (January 2010–April 2025) at a single centre were analysed retrospectively. Cardioplegia regimens were Buckberg (n = 131), Calafiore (n = 153), Custodiol HTK (n = 146) and St Thomas’ (n = 113). Because substantial baseline imbalances were present in the unadjusted cohort, inverse probability of treatment weighting (IPTW) based on a multinomial propensity score was applied to achieve covariate balance between groups. IPTW was performed using a comprehensive propensity model that incorporated (1) baseline demographic and clinical characteristics, (2) anatomical factors, including bicuspid valve morphology. Procedural time variables were assessed in secondary sensitivity analyses. After IPTW application, all variables, including procedural times, achieved balance (ASMD < 0.1). Postoperative outcomes were then compared in this fully balanced pseudo-population. The Scheffé post hoc test was performed. Results: Groups were demographically comparable except for more bicuspid valves in Buckberg. New-onset paroxysmal atrial fibrillation occurred in 31.2% (Buckberg) and 26.5% (St Thomas’) versus 7.1% (Calafiore) and 2.0% (Custodiol) (p < 0.01). Respiratory insufficiency followed a similar pattern (p = 0.02). Intensive-care and hospital stay, major complications, left-ventricular ejection fraction, and 30-day mortality (0.6–3.0%) were equivalent. Bicuspid anatomy independently prolonged operative metrics but did not influence biomarkers. Conclusions: After comprehensive inverse probability weighting that balanced groups on all baseline characteristics and anatomical factors, Calafiore and Custodiol cardioplegia strategies maintained significantly lower rates of new-onset atrial fibrillation (9.3% and 3.8% vs. 28.5% for Buckberg, p < 0.01), reduced myocardial injury biomarker release (peak CK 520 and 510 vs. 920 U/L, p < 0.01), and decreased respiratory complications (7.8% and 8.1% vs. 16.2%, p = 0.01), while mortality, stroke, and resource utilisation measures remained comparable across strategies.

Abstract Background Minimally invasive approaches have gained immense importance in surgery of the aortic valve, aortic root, and ascending aorta over the last decades. Despite this, data concerning impact factors of the postoperative outcome and especially investigations regarding sex-specific outcome parameters for minimally invasive aortic surgery are still lacking to date. Methods We present a single-center analysis of 387 patients undergoing supracoronary ascending aorta replacement, Wheat procedure, David procedure, or Bentall procedure through a minimally invasive access. A multivariate linear model was developed to identify predicting factors for a prolonged intensive care unit stay. Subsequently, the impact of the patients sex on perioperative complications and outcome as well as short- and long-term survival was investigated using a propensity score matched analysis of each 118 women and men undergoing minimally invasive ascending aortic procedures. Results Female sex, patients age at operation, and operation times were identified as independent patient-specific predictors for ICU length of stay after minimally invasive ascending aortic surgery. The perioperative stroke-rate was significantly higher in women compared to men (7.6% vs. 1.7%, p = 0.031). Erythrocyte concentrate transfusion requirement was significantly higher in females (4 (IQR 2–5) vs. 2 (QR 0–4), p < 0.001). No significant differences were found between male and female patients with respect to short- and long-term survival. Conclusions Sex impacts outcome after minimally invasive ascending aortic surgery. In particular, female patients had worse short-term outcome compared to men with respect to perioperative stroke, ICU length-of-stay, and transfusion requirements.

We would like to report the first-in-human implantation of the novel DuoCor-BiVAS biventricular assist device (BiVAD). This system features a single driveline and compact peripheral components, offering a promising mechanical support option for patients with terminal biventricular heart failure ineligible for heart transplantation.

BACKGROUND:Geometry of LVAD implantation is a determinant of pump performance and hemocompatibility. Despite technically successful operations, avoidable geometric errors may produce characteristic imaging patterns and clinically relevant device dysfunction. OBJECTIVES:To determine the frequency, diagnostic pathway, and clinical impact of preventable geometry-related failure modes after HeartMate 3 implantation in a single-center referral cohort, specifically inflow cannula malposition, outflow graft kinking/excessive length, and aortic anastomotic stenosis. METHODS:Retrospective, single-center analysis of 21 consecutive HeartMate 3 recipients implanted between 2016 and 2025 at external centers and subsequently evaluated in our department. All patients underwent CT/CTA when device dysfunction was suspected. Failure modes were predefined and adjudicated using standardized imaging criteria. CT/CTA was the primary modality used to confirm geometric failure modes following triggers such as low-flow alarms, hemolysis, and abnormal chest radiography. RESULTS:Among 21 HeartMate 3 recipients, inflow cannula malposition was identified in 7 patients, outflow graft kinking/excessive length in 12, and aortic anastomotic stenosis in 2. CONCLUSIONS:In this single-center referral cohort, geometric failure modes were identified in 15 of 21 patients (71.4%) after HeartMate 3 implantation and showed reproducible CT/CTA signatures. A standardized imaging-driven diagnostic pathway may improve recognition of correctable geometric problems in patients referred for suspected device dysfunction; given the referral-based design, these frequencies should not be interpreted as the true incidence in an unselected HeartMate 3 population.

Background: Minimally invasive approaches for multivalve surgery have attracted increasing interest; however, data on combined aortic and mitral valve replacement or repair using via right anterior minithoracotomy remain quite limited. This study aimed to evaluate the feasibility, safety, and early outcomes of minimally invasive concomitant aortic and mitral valve replacement or repair using this approach. Methods: This retrospective study included 24 patients who underwent simultaneous aortic and mitral valve procedures via right anterior minithoracotomy. We collected preoperative, intraoperative, and postoperative data, assessing echocardiographic parameters. Early clinical outcomes, complications, and mortality rates were analyzed, with correlations between EuroSCORE II and outcomes explored. Results: The median follow-up was 412 days. All procedures were completed successfully without conversion to sternotomy. Postoperative echocardiography demonstrated a significant reduction in transvalvular gradients, with aortic mean pressure gradient decreasing from 51.3 ± 23.0 mmHg to 6.7 ± 1.7 mmHg (p < 0.001) and mitral mean pressure gradient from 19.3 ± 26.7 mmHg to 4.0 ± 1.4 mmHg (p < 0.001), while left ventricular ejection fraction remained unchanged (p = 0.67). During the study period, one patient died from a non-cardiac cause. EuroSCORE II showed a moderate positive correlation with intensive care unit length of stay (p = 0.011) but not with hospital stay or operative times. Conclusions: Minimally invasive aortic and mitral valve replacement or repair via right anterior minithoracotomy is feasible and was associated with favorable early hemodynamic and clinical outcomes in this single-center cohort.

ObjectiveGrowing evidence suggests major outcome and risk factor disparities between men and women undergoing cardiovascular surgery. Thus, sex-specific approaches are increasingly being adopted in cardiovascular medicine. However, data on sex-specific outcomes and risk stratification in complex thoracoabdominal aortic repair remain limited.MethodsWe present a retrospective single-center analysis of 311 consecutive patients, including 99 women (31.8%), who underwent open surgical thoracoabdominal aortic repair between 2000 and 2024. Propensity score matching was performed prior to a comparative analysis of intraoperative parameters, postoperative outcome, and complications, as well as short- and long-term mortality between female and male patients.ResultsIn the initial study population, men had a significantly higher BMI (26.3 vs. 23.1 kg/m2, p < 0.001) and greater prevalence of coronary artery disease (37.7% vs. 21.2%, p = 0.004) and hyperlipidemia (27.8% vs. 12.1%, p = 0.002) compared to women. Postoperatively, wound infections were more frequent in women in the unmatched cohort (12.1% vs. 4.3%, p = 0.01), but no sex-related differences in mortality, ICU length of stay, or long-term survival were observed after propensity score matching. Multivariate regression revealed highly distinct predictors of early mortality in each sex: prior cardiac surgery and urgency in men versus hypertension, chronic kidney disease, coronary artery disease, and older age at the time of operation in women.ConclusionOverall outcomes and survival following thoracoabdominal aortic repair were comparable between men and women. However, underlying risk factors for early mortality differed fundamentally between sexes. These findings underscore the importance of a sex-specific preoperative risk assessment in the surgical decision-making process prior to open thoracoabdominal aortic repair.

BACKGROUND:Stone heart syndrome was first described by Denton Cooley in 1972 and represents an extremely rare but severe complication following cardiac surgery. The condition is characterized by an irreversible, concentric, spastic contracture of the myocardium occurring during reperfusion which does not respond to either pharmacological or mechanical interventions. The underlying pathophysiology remains poorly understood, but an association with suboptimal cardioprotection and prolonged ischemia time has been suggested. CASE PRESENTATION:A 22-year-old otherwise healthy patient was admitted for elective mitral valve surgery due to severe mitral regurgitation caused by bileaflet prolapse and a history of cardiomyopathy of unclear etiology. Upon weaning from cardiopulmonary bypass, the patient developed biventricular heart failure requiring veno-arterial extracorporeal membrane oxygenation. Transesophageal echocardiography showed a stone heart. In the following days, temporary mechanical circulatory support was escalated to veno-arterio-venous extracorporeal membrane oxygenation and Impella. On postoperative day 5, a durable left ventricular assist device was implanted. Due to refractory stone heart syndrome, the patient was evaluated for heart transplantation which was successfully performed on postoperative day 23. The subsequent course was largely uneventful. The patient was discharged to rehabilitation at 6 weeks post transplantation. CONCLUSION:Acute terminal heart failure due to perioperative stone heart is rare. In cases of irreversible global myocardial injury, orthotopic heart transplantation remains the only curative treatment option.

The concomitant repair of severe pectus excavatum and mitral valve regurgitation presents distinct technical and physiological challenges. Although staged or open combined procedures have been described, a truly single-stage, minimally invasive strategy remains uncommon. We report the case of a 22-year-old woman with a “Grand Canyon–type” pectus excavatum and bileaflet mitral valve prolapse who successfully underwent a concomitant operation combining a modified cross-bar Nuss repair and minimally invasive mitral valve repair. This integrated approach allowed optimal cardiac exposure, restoration of thoracic geometry, and effective valve reconstruction through a right mini-thoracotomy. The patient experienced an uneventful recovery with excellent cosmetic and functional results. This case highlights the feasibility and advantages of a single-stage, single-recovery minimally invasive approach for the correction of concurrent chest wall deformity and valvular disease. Background Pectus excavatum (PE) is the most common anterior chest wall deformity and may lead to significant cardiopulmonary compromise from cardiac compression and displacement. Severe PE can exacerbate right ventricular dysfunction and is frequently associated with mitral valve pathology, including mitral valve prolapse (MVP). Although the Nuss procedure is well established1 for minimally invasive PE repair (MIPER), its use alongside mitral valve surgery in a true single-stage, fully minimally invasive approach is rarely reported. We describe a combined modified cross-bar Nuss repair and minimally invasive mitral valve repair (MIMVR) performed in a single operation to optimize exposure and restore thoracic geometry.

OBJECTIVES:To assess short-term outcomes of coronary artery bypass grafting (CABG) with adjunct coronary endarterectomy (CE) compared with isolated bypass grafting, and to synthesize available confounder-adjusted effect estimates. METHODS:We conducted a systematic review and meta-analysis following PRISMA guidelines. MEDLINE, Embase, and CENTRAL were searched from January 2000 to June 2025. Eligible studies compared adult patients undergoing CABG with CE versus isolated CABG. Two reviewers independently screened studies, extracted data, and assessed quality. Random-effects meta-analysis was performed. The primary outcome was 30-day or in-hospital mortality. RESULTS:Sixteen studies (119 458 patients) were included. CABG with CE was associated with higher mortality (RR 1.84, 95% CI 1.65-2.04). Pooling adjusted odds ratios from 3 studies yielded OR 1.76 (95% CI 1.55-2.00), with 2 of 3 individual estimates not reaching significance. Secondary outcomes showed increased risks of perioperative myocardial infarction (RR 1.99, 95% CI 1.29-3.07), stroke (RR 1.37, 95% CI 1.08-1.75), renal failure (RR 1.62, 95% CI 1.44-1.82), and intra-aortic balloon pump use (RR 1.96, 95% CI 1.41-2.70). Sensitivity analyses confirmed consistency across all the subgroups. CONCLUSIONS:CABG with CE is associated with higher short-term mortality and morbidity compared with isolated bypass grafting; however, confounder-adjusted analyses suggest this excess risk is partly attributable to greater baseline disease severity rather than an independent procedural effect. The scarcity of data and absence of randomized evidence preclude definitive causal conclusions. These findings provide benchmarking data for counselling when endarterectomy is necessary to achieve complete revascularization.

BACKGROUND:The HeartMate 3 left ventricular assist device (HM3, Abbott, U.S.A.) (LVAD) was first implanted in humans in 2014 at Hannover Medical School, Germany. This report presents the most extended single-center follow-up, ten years after HM3 implantation, focusing on survival rates and adverse events. METHODS:We analyzed heart failure patients who received LVAD implantations with HM3 at our institution in 2014. The primary endpoint was 10-year survival. The secondary endpoint included evaluating adverse events. Follow-up for survival was censored in case of heart transplantation (HTx). RESULTS:A total of eight HM3 patients were included in the study. We observed a total of 18,744 days-on-device (approx. 39 patient-years). The mean duration of device support was 2343 days (6.4 years). Ten years after LVAD implantation, the survival rate was 62.5% (5/8). Three patients underwent HTx (postoperative day (POD) 101, 646, 1917), three patients died, and two patients are on-going on device. The cause of death was sepsis in two patients (POD 2974 and 3018), while one patient died due to COVID-19-associated respiratory failure (POD 2642). No pump thrombosis, stroke, or technical malfunctions were observed. Outflow graft compression syndrome required surgical revision in 50% of patients. Six patients (75%) experienced driveline infections. CONCLUSIONS:The HM3 has shown excellent long-term outcomes ten years after implantation, with no technical malfunctions and a low incidence of hemocompatibility-related adverse events. This study highlights the strong performance of assist devices and excellent outcomes for heart failure patients, especially when LVADs are timely and appropriately used in selected patients.

Background: Advancing age is incorporated as a strong risk variable in EuroSCORE II and is consistently associated with adverse outcomes after conventional coronary artery bypass grafting (CABG). Whether minimally invasive direct coronary artery bypass (MIDCAB)-which avoids both sternotomy and cardiopulmonary bypass-modifies this age-related risk in patients with single-vessel or LAD-predominant coronary artery disease remains insufficiently characterised. Methods: We retrospectively analysed 350 consecutive patients who underwent MIDCAB at Hannover Medical School between July 1999 and April 2025 (follow-up to April 2025). Elderly patients (age ≥70 years; n = 117) were compared with younger patients (age <70 years; n = 233) before and after 1:1 propensity score matching using greedy nearest-neighbour matching with a caliper of 0.2 × SD of the logit propensity score; age was excluded from the propensity model as it represented the exposure variable. A pre-specified sensitivity propensity model that additionally excluded EuroSCORE II (because EuroSCORE II contains an age component) was also evaluated. The primary endpoint was all-cause long-term mortality; secondary endpoints included perioperative complications and in-hospital outcomes. Long-term survival was assessed by Kaplan-Meier analysis and multivariable Cox proportional hazards regression, with a pre-specified parsimonious Cox model (age, LVEF, renal impairment) and cluster-robust standard errors on matched-pair identifiers. Results: Matching produced 109 pairs with excellent covariate balance (all standardized mean differences < 0.20). MIDCAB was completed without intraoperative conversion in all patients. No 30-day mortality, perioperative stroke, or new postoperative dialysis was observed in either age stratum (Clopper-Pearson 95% CI 0.00-3.33% for each zero-event outcome). Perioperative complications-including new-onset atrial fibrillation, re-exploration for bleeding, and intensive care unit and hospital length of stay-did not differ significantly between elderly and younger patients in the matched cohort (Newcombe 95% CI for risk differences all crossing zero; McNemar's exact tests non-significant for all matched-pair binary endpoints; Hodges-Lehmann median difference for hospital length of stay +1.0 day, bootstrap 95% CI 0.0-1.0 days). At a median follow-up of 19.0 years (IQR 11.5-24.3; reverse Kaplan-Meier potential median 19.7 years), all-cause mortality was higher in the elderly (20.2% vs. 5.5%, p = 0.002; log-rank p = 0.001; exact McNemar's p = 0.0025 for the matched-pair mortality endpoint). After multivariable adjustment, elderly age (≥70 years) was independently associated with long-term mortality (adjusted hazard ratio 4.48, 95% CI 1.79-11.20, p = 0.001), as was EuroSCORE II (HR 2.40 per unit, p = 0.034); a pre-specified parsimonious model (age, LVEF, renal impairment) with pair-cluster robust standard errors yielded an essentially identical adjusted HR for elderly age of 4.08 (95% CI 1.65-10.04, p = 0.002), and a sensitivity propensity model without EuroSCORE II yielded HR 3.95 (95% CI 1.68-9.29, p = 0.002). Conclusions: In this propensity-matched analysis with a median follow-up of ~19 years, MIDCAB was associated with excellent observed perioperative outcomes in appropriately selected elderly patients (no 30-day mortality, stroke, or new dialysis observed; upper 95% CI 3.3%) and no evidence of an excess of major in-hospital complications compared with younger patients within the statistical resolution of the cohort. The long-term mortality excess in the elderly is consistent with age-related life-expectancy curves in the source population; cause-specific mortality was not available in this cohort. External benchmarks from large MIDCAB cohorts in which long-term survival approximates that of the age-matched general population support this interpretation indirectly. These findings support MIDCAB as a feasible revascularization strategy associated with favourable observed early outcomes and long-term survival consistent with published MIDCAB literature, in appropriately selected elderly patients with single-vessel or LAD-predominant coronary artery disease treated at experienced centres.

Background and objectives:With the overall aging population, the demand for thoracoabdominal aortic repair in elderly patients will continue to increase. With rising frequency, surgeons and physicians will have to decide whether this highly invasive procedure is appropriate and rational for their elderly patients. However, data focused on the outcomes of thoracoabdominal repair in elderly patients is still lacking to date. Methods:We here report a propensity score-matched, single-center analysis of 309 consecutive patients who underwent open surgical thoracoabdominal aortic repair from 2000 to 2024. Of those, 72 patients (23.3%) were 70 years of age or older. Matching for preoperative characteristics, burden of disease, and extent of repair revealed 68 one-on-one matches of patients below or above 70 years of age. These were then analyzed for intraoperative characteristics as well as postoperative events, complications, and mortality. Results:Elderly patients had longer intensive care unit stay times, with 6 days [interquartile range (IQR) 3-14] versus 3 days (IQR 2-8, P = 0.007), as well as higher rates of postoperative complications. Among these complications, respiratory failure (47.1% vs. 25.0%, P = 0.007), acute kidney failure (30.9% vs. 14.7%, P = 0.025), and new-onset atrial fibrillation (14.7% vs. 4.4%, P = 0.041) were found significantly more often in patients aged 70 years or older. In contrast, 30-day mortality did not differ significantly between the two groups (17.6% vs. 13.2%, P = 0.636). Conclusion:Elderly patients were more frequently prone to a prolonged and complicated postoperative course. However, this did not result in excessive short-term mortality. Thus, elderly patients should be critically evaluated before undergoing thoracoabdominal aortic repair, and both patients and surgeons should be prepared for prolonged ICU times. However, age alone should not be an exclusion criterion for thoracoabdominal aortic repair, which can be performed with acceptable short-term mortality rates.

BACKGROUND:Frailty, marked by increased vulnerability and reduced physiological reserve, is common in end-stage heart failure patients. Continuous flow left ventricular assist devices (LVADs) have improved outcomes, but the impact of frailty on these outcomes is unclear. This systematic review and meta-analysis investigate the effect of frailty on clinical outcomes in patients undergoing LVAD therapy. METHODS:Following PRISMA guidelines, we searched PubMed, Cochrane, EMBASE, MEDLINE, and Google Scholar up to September 2023 for studies comparing frail and non-frail patients undergoing LVAD implantation. Data on mortality, hospital length of stay, intubation duration, bleeding, infection, and readmission rates were extracted and analyzed using the Mantel-Haenszel random-effects model, with heterogeneity assessed by the I2 statistic. RESULTS:Fifteen studies involving 3458 patients were included. Frailty was significantly associated with higher long-term mortality (OR: 2.12; 95% CI: 1.17-3.83; p = 0.01), but not with short-term mortality (OR: 1.61; 95% CI: 0.71-3.65; p = 0.26), hospital length of stay (MD: 1.93; 95% CI: -9.83 to 13.68; p = 0.75), or intubation duration (MD: 34.28; 95% CI: -1.15-69.71; p = 0.06). No significant differences were found in bleeding (OR: 1.76; 95% CI: 0.76-4.10; p = 0.19), infection (OR: 0.44; 95% CI: 0.11-1.84; p = 0.26), or readmission rates (OR: 1.07; 95% CI: 0.78-1.46; p = 0.68). CONCLUSION:Frail patients with LVADs have higher long-term mortality but similar short-term outcomes, hospital stays, intubation times, bleeding, infection, and readmission rates compared to non-frail patients. These findings highlight the need for tailored strategies to improve outcomes in frail LVAD patients and suggest further research on frailty interventions.

Background: Animal models are essential for translating diagnostic and therapeutic strategies into clinical practice and offer valuable insights into the pathophysiology of diseases such as aortic dissection. This study presents a novel acute in vivo large animal model of Stanford type A aortic dissection, combining open surgical access with endovascular techniques to leverage the advantages of both. The model aims to reproducibly simulate acute dissections in swine, providing a standardized platform for evaluating diagnostics, disease mechanisms, and treatment strategies. Methods: Six pigs underwent a standardized protocol to induce aortic dissection. Arterial pressure was monitored via femoral and carotid catheterization. A conventional sternotomy was performed, followed by tangential cross-clamping of the ascending aorta and a controlled incision proximal to the brachiocephalic trunk. The intima and the media were separated using a guidewire and catheter-based technique to create a false lumen. A re-entry tear was also established to allow for controlled intraluminal access. Animals were monitored for 12 h post-intervention, with serial blood sampling. At the end of the experiment, the animals were euthanized and the aortas harvested for macroscopic and histological analysis. Results: In all 6 animals, the placement of arterial catheters in femoral and carotid arteries, as well as the sternotomy, was established without any complications. The dissection model was successfully created in 5 out of 6 animals by clinical signs such as adventitial hematoma, macroscopic wall separation and/or decreased femoral blood pressure. One animal experienced complete aortic perforation. Five animals completed the full observation period of 12 h. Conclusion: A standardized, reproducible, and robust large animal model of acute Stanford type A aortic dissection using a hybrid approach was developed. This model closely simulates the clinical and pathological features of human aortic dissection, making it a valuable tool for preclinical research in diagnostics, pathophysiology, and treatment development.

OBJECTIVES:Postoperative steroids after Kasai portoenterostomy (KPE) for biliary atresia (BA) patients remains controversial. We established a postoperative protocol with selective corticosteroid usage depending on postoperative stool color assessment. Herein, we report outcomes in KPE before and after implementation of our tailored steroid protocol. METHODS:At our institution, 28 infants underwent KPE between 2015 and 2025. Group A had 16 infants managed without steroids between 2015 and 2021, while Group B included 12 infants managed under the new tailored steroid protocol between 2021 and 2025. Under the new protocol, infants with postoperative stool color ≤3 based on Japanese Tochigi Stool card received corticosteroids and antibiotics for 5 weeks if they were ≤45 days old or >45 days old with acute inflammation on liver biopsy obtained during operation. Postoperative total bilirubin (TB) levels at 3 months, 2-year native liver survival (NLS), length of stay (LOS) of surgical admission, postoperative reoperations, readmissions, and complications were compared between groups. RESULTS:Preoperative liver function tests were similar between groups. The 3-month post-KPE TB levels were significantly lower in Group B compared to Group A (0.9 [0.3, 1.9] mg/dL vs. 6.5 [0.6, 10.4] mg/dL, p = 0.036). The 2-year NLS was also significantly higher in Group B (72.9% vs. 37.5%, p = 0.046). LOS, readmissions, reoperations, and complications in the 90-day postoperative period were not different between both groups. CONCLUSIONS:Infants with BA managed with a tailored steroid protocol based on postoperative stool colors and histologic evidence of inflammation had significantly lower 3-month TB levels and better 2-year NLS.

AIMS:Non-pharmacological therapies for acute decompensated heart failure (HF) and cardiogenic shock have evolved considerably in recent decades. Short-term mechanical circulatory support (MCS) devices can be used as circulatory backup. While nearly all available devices use continuous flow, evidence indicates that pulsatile flow can be more effective. This study presents the first experimental use of a novel counter-pulsatile left ventricular (LV) assist device (LVAD) with a primary focus on assessing its feasibility and effectiveness. METHODS:The pulsatile ventricular assist platform (pVAP) was applied in six porcine models of acute ischaemic HF with the inlet in the left atrium and the outlet in the aorta. HF was induced through stepwise ligation of the left anterior descending artery and its diagonal branches. The pVAP functioned driven by a conventional IABP console while LV pressure-volume (PV) loops and standard haemodynamics with the device OFF and ON were recorded. Absolute values and percent variations were compared using Mann-Whitney's U test and Wilcoxon's sign-rank test. RESULTS:The device's output flow is frequency dependent, with an output flow of 2.64 ± 0.22 L/min at 80 bpm. Activation reduced the EDV [132 (90-145) vs. 118 (83-130) mL, P < 0.05], EDP 9 (6-10) vs. 6 (5-9) mmHg, P < 0.001], native cardiac output [CON, 3.64 (2.88-6.71) vs. 1.67 (1.24-2.48) L/min, P < 0.001] and myocardial oxygen consumption [pressure-volume area * heart rate (PVA*HR), 4592 (2944-9272) vs. 2901 (1915-4437) mJ, P < 0.001]. Contractility decreased, with right-shifting the end-systolic PV relationship (ESPVR) while ESP and forward cardiac output COF were constant. The mean arterial pressure increased [54 (48-60) vs. 49 (42-55) mmHg, P < 0.001] and mPAP decreased [10 (8-11) to 9 (7-10) mmHg, P < 0.01]. The PV loop shifted left and downward. No changes occurred in the passive-elastic properties of the LV in diastole. CONCLUSIONS:The pVAP reduced the LV mechanical load while increasing systemic pressures and reducing pulmonary pressures. Its functionality as an LVAD is characterised by consistent and predictable performance. Further research is necessary to elucidate the physiological and clinical impact of the device in animals and, subsequently, in humans.