A 7-year-old cyanotic child with unrepaired tetralogy of Fallot, a single coronary artery arising from the left coronary sinus, and suspected pulmonary thromboembolism underwent complete intracardiac repair. This video tutorial demonstrates a comprehensive surgical strategy that simultaneously addresses intracardiac repair and pulmonary thromboendarterectomy while safely managing a rare coronary anomaly. Following median sternotomy and establishment of cardiopulmonary bypass, the pulmonary arteries were carefully inspected because preoperative imaging suggested thrombotic material within the pulmonary artery. Pulmonary arteriotomy revealed organized thromboembolic material, which was meticulously removed, restoring pulmonary arterial patency. Attention was then directed to correction of the congenital cardiac defect. The large malaligned ventricular septal defect was closed with a polyester patch through the right atrial approach. Severe right ventricular outflow tract obstruction caused by infundibular and valvular pulmonary stenosis was relieved by extensive muscle resection and pulmonary valvotomy.

An adolescent boy with a history of chronic rheumatic heart disease (RHD) and severe mitral regurgitation presented with progressive exertional dyspnoea and palpitations. Echocardiography revealed preserved left ventricular function preoperatively, and the patient underwent mechanical mitral valve replacement (MVR). Postoperative management included anticoagulation and RHD prophylaxis. 4 months later, he developed acute heart failure (New York Heart Association class IV) secondary to atrial fibrillation (AF) with rapid ventricular rate despite a normally functioning prosthetic mitral valve. Echocardiography showed significant left atrium and ventricle dilatation, with severe left ventricle dysfunction (left ventricle ejection fraction (LVEF) ~14%), severe tricuspid regurgitation and pulmonary hypertension. The patient was stabilised with rate control, diuretics, inotropes, digoxin, anticoagulation and intravenous amiodarone. Notably, the LVEF improved to 30%, and he was discharged in stable condition.This case highlights the challenges in managing a paediatric patient with AF and severe LV dysfunction following MVR.

Abstract Blood cysts are rare benign intracardiac lesions predominantly observed in neonates and infants, most commonly arising from the mitral or tricuspid valves. Interventricular septal blood cysts are exceedingly rare, particularly in children and in association with double-chambered right ventricle (DCRV). A 3-year-old girl with DCRV was admitted for elective surgical repair. Preoperative transthoracic echocardiography demonstrated hypertrophied anomalous muscle bundles causing right ventricular outflow obstruction, without evidence of any intracardiac cystic lesion. During surgery, a previously undetected spherical bluish cystic lesion measuring approximately 2 cm was identified arising from the interventricular septum and protruding into the right ventricular cavity. The lesion was punctured intraoperatively, yielding blood-filled contents without daughter cysts or membranous material. Because of the proximity of the lesion to the interventricular septum and potential risk to the conduction system, complete excision was avoided. The cyst was aspirated and decompressed, followed by successful DCRV repair. The postoperative course was uneventful, with no rhythm disturbances or evidence of recurrence on short-term follow-up. Interventricular septal blood cysts are extremely rare intracardiac lesions that may remain occult on routine preoperative imaging. This case highlights the diagnostic challenges associated with unusual intracardiac cystic lesions in children and demonstrates that conservative surgical management may be appropriate when lesions are located near the cardiac conduction system.

Background: Virtual reality (VR) has emerged as an innovative tool in perioperative medicine, with its growing interest in its potential to improve patient outcomes. This systematic review and meta-analysis aimed to critically assess the effectiveness of VR interventions in perioperative medicine, focussing on anxiety reduction, pain management, patient education, and satisfaction. Methods: A comprehensive search was conducted across PubMed, Cochrane Library, Scopus, Web of Science, Embase, and ClinicalTrials.gov for peer-reviewed studies published between January 2000 and December 2024. Studies involving adult and paediatric surgical patients, utilising VR interventions compared to standard care or alternative approaches, were included. Data extraction and risk of bias assessment were performed using standardised forms and appropriate tools. Meta-analysis was conducted for continuous outcomes using mean differences (MDs) and standardised mean differences (SMDs). Results: From 193 identified records, 47 studies were included in qualitative synthesis, with 15 studies providing quantitative data for meta-analysis. VR interventions consistently reduced perioperative anxiety {MD − 1.53 on visual analogue scale (VAS), 95% confidence interval (CI) −2.21 to −0.85; MD −3.85 on State-Trait Anxiety Inventory (STAI), 95% CI −5.69 to −2.01} and procedural anxiety in paediatric populations (SMD −0.70, 95% CI −0.94 to −0.47). VR also demonstrated a modest but significant effect on postoperative pain (MD −0.67, 95% CI −1.31 to −0.04) and significantly improved patient satisfaction (SMD 0.70, 95% CI 0.45 to 0.95). Immersive VR modalities and therapeutic content were most effective, especially in minor surgical procedures and paediatric populations. No significant adverse events were reported. Conclusion: VR interventions are effective in reducing perioperative anxiety and pain, improving patient satisfaction, and are well tolerated across diverse surgical settings.

Cardiac myxomas are the most common primary benign tumors of the heart, with the majority occurring in the left atrium. They are typically composed of gelatinous connective tissue, but rare cases exhibit unusual histological features, including glandular differentiation, which can mimic malignant neoplasms and pose diagnostic challenges. While these tumors are benign, rare cases of tumor embolism to the brain have been reported. Surgical resection remains the treatment of choice, with excellent long-term outcomes in most cases. A 27-year-old woman presented with progressive palpitations, shortness of breath, chest pain, and cough. Transthoracic echocardiography revealed a large, mobile mass in the left atrium. Surgical excision was performed, revealing a gelatinous tumor with areas of glandular differentiation. Immunohistochemical analysis confirmed the epithelial origin of the glandular structures, with a diagnosis of cardiac myxoma with glandular differentiation. Cardiac myxomas with glandular differentiation are rare but important entities that require careful histological and immunohistochemical evaluation to avoid misdiagnosis as primary or metastatic adenocarcinoma. Patients should be monitored for recurrence and potential embolic complications.

Background: A variety of new methods and strategies have been developed and adopted for myocardial preservation during an open-heart surgery; the ideal method is still uncertain. Recently, there have been attempts to find pharmacological ways to create ischaemic preconditioning with adenosine. A lot of research has been undertaken but the issue is still controversial and there is no clear consensus. This study was undertaken to evaluate the potential myocardial protective effects of adenosine administered in conjunction with Del-Nido-based cold cardioplegia, with the aim of contributing further insight into this evolving area of cardiac surgical practice. Aim: To evaluate the effects of adenosine on Troponin I and Creatine phosphokinase (CPK)-MB levels in open-heart surgery patients. Patients and Methods: A total of 44 consecutive adult patients of both sexes, aged between 18 and 70 years undergoing open-heart surgery in a tertiary care hospital from April 2021 to December 2021, were enrolled in this prospective observational study. They were categorised into two groups of 22 each, based on the delivery of adenosine into the aortic root after aortic cross-clamping. Venous blood samples were withdrawn pre-operative, intra-operative, and postoperatively to measure cardiac biomarkers. Results: The groups were comparable with respect to age, sex, aortic cross-clamp (73.68 ± 35.3 vs. 89.64 ± 55.2 min, P = 0.26) and bypass times (121.7 ± 44.1 vs. 111.6 ± 42.6 min, P = 0.41). Patients who received adenosine had a significantly shorter arrest time than the non-adenosine group (16 ± 4.54 s vs. 28.68 ± 7.88 seconds, P = 0.01). There was no significant difference in the levels of cardiac troponin I between the two groups, at any time point-baseline (0.68 ± 2.5 vs. 0.15 ± 0.4, P = 0.34), after release of aortic cross-clamp (8.97 ± 11.6 vs. 8.09 ± 6.6, P = 0.76) and 12 h later (7.76 ± 11.3 vs. 10.94 ± 11.2, P = 0.35). Similarly, there was no significant difference in the levels of Creatine phosphokinase-MB between the two groups at any time point-baseline (30. 09 ± 17.0 vs. 35.27 ± 12.2, P = 0.27), after release of aortic cross-clamp (45.82 ± 3 vs. 55.32 ± 26.9, P = 0.27) and 12 h later (54.23 ± 35.6 vs. 64.45 ± 28.9, P = 0.32). The difference in post-operative left ventricular ejection fraction, duration of ventilation and intensive care stay was also not statistically significant. Conclusions: The administration of a low bolus dose of adenosine (6 mg) into the aortic root prior to cold Del-Nido cardioplegia did not demonstrate any additional cardioprotective effects during cardiac surgery. While adenosine significantly reduced the time required to achieve cardiac arrest, no clinically meaningful benefit was observed in terms of myocardial preservation, as assessed by post-operative cardiac biomarkers and recovery parameters. Further randomised trials with larger, diverse populations and optimised dosing are needed to better define adenosine’s role in myocardial protection during cardiac surgery.

Abstract Thymolipoma is a rare benign tumor of the anterior mediastinum, exceptionally uncommon in children. These slow-growing lesions often remain asymptomatic until they reach a significant size, which may cause compressive symptoms. Surgical excision is the definitive treatment, as thymolipomas are unresponsive to chemoradiotherapy. Here, we present a case series of three pediatric patients with large thymolipomas extending into bilateral thoracic cavities. Two patients underwent successful resection via median sternotomy, avoiding more extensive thoracic incisions, and one infant with asymptomatic thymic hyperplasia is under surveillance. This case series highlights the diagnostic challenges, perioperative considerations, and the adequacy of median sternotomy for even massive lesions in children.