Importance:Ischemic heart disease (IHD), the leading cause of death in the US, is predominantly due to modifiable risk factors. Estimates of IHD mortality attributable to risk factors provide evidence for health policy decision-making. Objective:To estimate the burden of IHD death attributable to risk factors in the US from 1990-2023. Design, Setting, and Participants:The Global Burden of Disease Study 2023 (GBD 2023) used vital records and a broad set of epidemiologic data to estimate IHD death rates, risk factor exposure, and relative risk curves for risk-outcome pairs for 1990-2023 for the general population. Data analysis was performed from October 2024 to December 2025. Exposure:Twelve metabolic, behavioral, and environmental risk factors. Main Outcomes and Measures:The primary outcomes were IHD death rates per 100 000 persons, counts, and attributable risks from 1990-2023 by age, sex, and US state. Estimates include 95% uncertainty intervals (UI). IHD death rates were estimated using ensemble modeling methods. Risk exposures were estimated using bayesian meta-regression methods. Relative risks were estimated following the Burden of Proof framework. Results:In 2023, there were 473 000 IHD deaths (95% UI, 414 000-510 000) in the US, a decrease of 58.7% (95% UI, 56.8%-61.0%) in age-standardized rate since 1990. Between 2010 and 2023, there was a 19.0% decrease (95% UI, 15.0%-22.9%) for males and a 24.5% decrease (95% UI, 20.3%-29.7%) for females in IHD death rates. High systolic blood pressure (SBP), dietary risks, and high low-density lipoprotein cholesterol (LDL-C) were the leading risk factors for IHD deaths in 2023, accounting for 47.2% (95% UI, 36.4%-57.0%), 38.6% (95% UI, 17.2%-56.8%), and 28.5% (95% UI, 19.3%-39.6%) of IHD deaths, respectively. Increased exposure to several risk factors substantially increased their attributable burden for IHD deaths in 2023, with high fasting plasma glucose (FPG) increasing 38.8% (95% UI, 11.5%-81.1%) and high body mass index (BMI) increasing 54.5% (95% UI, 41.8%-66.3%) since 1990. Smoking and particulate matter pollution had the greatest decrease in attributable IHD mortality since 1990, at 33.3% (95% UI, 23.6%-41.7%) and 74.9% (95% UI, 46.7%-88.8%), respectively. Conclusion and Relevance:Per the results of this systematic analysis of GBD 2023, a total of 88.7% (95% UI, 83.4%-92.5%) of IHD deaths were attributable to modifiable risk factors in the US in 2023, with high SBP, dietary risks, and high LDL-C being the greatest contributors. High BMI and high FPG showed the largest attribution increases, while exposure to other risks did not increase significantly for the population.

Importance: Ischemic heart disease (IHD), the leading cause of death in the US, is predominantly due to modifiable risk factors. Estimates of IHD mortality attributable to risk factors provide evidence for health policy decision-making. Objective: To estimate the burden of IHD death attributable to risk factors in the US from 1990-2023. Design, Setting, and Participants: The Global Burden of Disease Study 2023 (GBD 2023) used vital records and a broad set of epidemiologic data to estimate IHD death rates, risk factor exposure, and relative risk curves for risk-outcome pairs for 1990-2023 for the general population. Data analysis was performed from October 2024 to December 2025. Exposure: Twelve metabolic, behavioral, and environmental risk factors. Main Outcomes and Measures: The primary outcomes were IHD death rates per 100 000 persons, counts, and attributable risks from 1990-2023 by age, sex, and US state. Estimates include 95% uncertainty intervals (UI). IHD death rates were estimated using ensemble modeling methods. Risk exposures were estimated using bayesian meta-regression methods. Relative risks were estimated following the Burden of Proof framework. Results: In 2023, there were 473 000 IHD deaths (95% UI, 414 000-510 000) in the US, a decrease of 58.7% (95% UI, 56.8%-61.0%) in age-standardized rate since 1990. Between 2010 and 2023, there was a 19.0% decrease (95% UI, 15.0%-22.9%) for males and a 24.5% decrease (95% UI, 20.3%-29.7%) for females in IHD death rates. High systolic blood pressure (SBP), dietary risks, and high low-density lipoprotein cholesterol (LDL-C) were the leading risk factors for IHD deaths in 2023, accounting for 47.2% (95% UI, 36.4%-57.0%), 38.6% (95% UI, 17.2%-56.8%), and 28.5% (95% UI, 19.3%-39.6%) of IHD deaths, respectively. Increased exposure to several risk factors substantially increased their attributable burden for IHD deaths in 2023, with high fasting plasma glucose (FPG) increasing 38.8% (95% UI, 11.5%-81.1%) and high body mass index (BMI) increasing 54.5% (95% UI, 41.8%-66.3%) since 1990. Smoking and particulate matter pollution had the greatest decrease in attributable IHD mortality since 1990, at 33.3% (95% UI, 23.6%-41.7%) and 74.9% (95% UI, 46.7%-88.8%), respectively. Conclusion and Relevance: Per the results of this systematic analysis of GBD 2023, a total of 88.7% (95% UI, 83.4%-92.5%) of IHD deaths were attributable to modifiable risk factors in the US in 2023, with high SBP, dietary risks, and high LDL-C being the greatest contributors. High BMI and high FPG showed the largest attribution increases, while exposure to other risks did not increase significantly for the population.

CLINICAL CONDITIONS:A 43-year-old woman presented with multiple coronary vascular wall irregularities, triple-vessel segmental stenosis, coronary aneurysmal dilatation, and coronary collateral arteries. She was diagnosed with polyarteritis nodosa (PAN) with coronary involvement. KEY QUESTIONS:What is the approach of management for coronary PAN? What role does a multidisciplinary approach play in optimizing the management and outcomes of patients with coronary PAN? OUTCOMES:The patient was treated with aggressive immunotherapy, including high-dose corticosteroids, mycophenolate, and later rituximab, to control inflammation and prevent vascular damage. Antithrombotic therapy (clopidogrel and rivaroxaban) and cardiovascular risk factor management (statins, angiotensin-converting enzyme inhibitors, and smoking cessation) were initiated. Although coronary artery bypass graft was considered because of triple-vessel disease, it was deferred as the patient remained stable. Regular follow-up demonstrated symptomatic improvement. TAKE-HOME MESSAGES:Coronary PAN requires a multidisciplinary approach for diagnosis and management. Medical therapy often takes precedence, with surgical interventions reserved for selected cases.

OBJECTIVES:Oxygen delivery (DO2) is a pivotal factor in maintaining adequate tissue protection during cardiopulmonary bypass (CPB). Despite its clinical significance, there is currently no global consensus regarding standardized DO2 monitoring or threshold strategies during CPB. This study aimed to evaluate current global practices related to DO2 monitoring during CPB and to assess awareness, implementation, and perceived clinical benefits, particularly in reducing acute kidney injury. DESIGN:A cross-sectional international survey. SETTING:Cardiac surgery centers globally, with distribution through platforms including the South West Asia and Africa Chapter of the Extracorporeal Life Support Organization. PARTICIPANTS:A total of 120 respondents including perfusionists, anesthesiologists, and cardiac surgeons. INTERVENTIONS:Not applicable (survey-based observational study). MEASUREMENTS AND MAIN RESULTS:The survey revealed 73.9% of centers actively practiced goal-directed perfusion (GDP), with significantly higher adoption in high-volume centers (>500 cases/year) (82% v 65% in low-volume centers). Monitoring methods varied, with 48.7% of respondents using continuous devices and 37.8% using intermittent calculations. For target parameters, more than 80% of respondents maintained specific DO2 thresholds, whereas hemoglobin management most focused on 80 to 90 g/L (32.8%), and cardiac index typically ranged from 2.4 to 2.6 L/min/m2 (65%). Clinical benefits include reduced acute kidney injury incidence reported by 55% of GDP users, although implementation barriers persisted, particularly financial constraints (45%) and limited resources (38%), preventing a wider adoption of continuous monitoring in resource-limited settings. CONCLUSIONS:These findings reveal significant global variability and underuse of DO2 monitoring during CPB. Despite emerging evidence supporting the benefits of GDP strategies, widespread adoption remains limited. Cost and limited access to advanced monitoring in low-resource settings were considered the major barriers that prevented continuous monitoring of DO2 during CPB. These insights highlight an urgent need for international guidelines and standardization to optimize patient outcomes in cardiac surgery.

Introduction: Type A aortic dissection (TAAD) management has markedly evolved in the last 20 years. However, the effect of patient demographics on TAAD presentation and outcomes has not been extensively studied worldwide. The aim of this study was therefore to investigate patient characteristics and their association with the perioperative parameters in a mixed population of the Gulf Cooperation Council (GCC) region. Methods: Consecutive patients presenting with TAAD (n=68) at a single centre between 2015 and 2021 were included. Seasonal variations in the occurrence of TAAD were described. Data on patient demographics, past medical history, presenting symptoms, operative techniques, postoperative complications, and in-hospital mortality were collected retrospectively and compared between patients with low (n=34) versus high (n=34) socioeconomic status (SES), and p<0.05 was considered statistically significant. Results: Of the 68 TAAD patients (mean age at presentation, 48.2 ± 15.6 years), 79.4% were male. Admissions for TAAD peaked in spring with 25 cases, contrasting with the lowest number of 12 events in summer (36.8 versus 17.6%; RR 2.1; p=0.03). A total of 75% of patients were non-GCC nationals, of whom 31.4% originated from Western Asia/Levant, 25.5% from Southeast Asia, and 23.5% from the Indian subcontinent. Compared with the high-SES group, patients with low SES were numerically more likely to present with syncope (17.6% versus 2.9%; p=0.1) and featured a notable trend toward requiring more complex aortic reconstruction (88.2% versus 67.6%; p=0.08). Additionally, the low-SES group had numerically more prolonged intensive care unit and hospital length of stay, and a lower rate of previously diagnosed connective tissue disease (0 versus 11.76%, p=0.1). However, the rate of postoperative complications and in-hospital mortality were comparable between the groups. Conclusion: In this study from the GCC region, a significantly younger age at presentation with TAAD compared to Western data was identified, with considerable seasonal variation in incidence. In addition, patients with low SES presenting with TAAD appear to have increased resource usage during hospitalisation.

Cardiovascular disease and its associated risk factors impose a huge morbidity, mortality, and disability burden on the UAE population, to an extent exceeding the global rates. In the last two decades, the UAE cardiovascular healthcare sector has undergone massive development, with the establishment of highly specialized centers, partnerships with world-renowned health institutions, high-quality clinical cardiovascular research, and the initiation of cardiovascular training programs. However, further efforts are warranted to increase public awareness of the burden of cardiovascular disease, promote healthy behaviors, tackle cardiovascular risk factors, and improve adherence to recent guidelines in order to improve patient outcomes. Here, we present epidemiological data on cardiovascular disease in the UAE, a historical perspective, major milestones in the care of cardiac patients, and current challenges and future directions in the field.

A 43-year-old woman presented with multiple coronary vascular wall irregularities, triple-vessel segmental stenosis, coronary aneurysmal dilatation, and coronary collateral arteries. She was diagnosed with polyarteritis nodosa (PAN) with coronary involvement. What is the approach of management for coronary PAN? What role does a multidisciplinary approach play in optimizing the management and outcomes of patients with coronary PAN? The patient was treated with aggressive immunotherapy, including high-dose corticosteroids, mycophenolate, and later rituximab, to control inflammation and prevent vascular damage. Antithrombotic therapy (clopidogrel and rivaroxaban) and cardiovascular risk factor management (statins, angiotensin-converting enzyme inhibitors, and smoking cessation) were initiated. Although coronary artery bypass graft was considered because of triple-vessel disease, it was deferred as the patient remained stable. Regular follow-up demonstrated symptomatic improvement. Coronary PAN requires a multidisciplinary approach for diagnosis and management. Medical therapy often takes precedence, with surgical interventions reserved for selected cases.

Tricuspid valve infective endocarditis (TVIE) is strongly associated with IV drug use (IVDU); device implants also represent significant risk factors. Congenital anomalies, including ventricular septal defect (VSD), predispose patients to TVIE.1 Streptococcus mitis is a mesophilic alfahaemolytic germ inhabiting the oroand nasopharyngeal cavities and has been implicated in cases of culture-negative endocarditis.2

71.759 surgical procedures were performed in 2019 with the aid of cardiopulmonary bypass in Germany. To adjust the patient's body temperature on extracorporeal circulation, the application of a heater-cooler unit (HCU) is mandatory. However, in case of insufficient sanitisation of HCU, life-threatening infections can be transmitted by the device to the patients, including Legionella bacteria, Mycobacterium chimaera, Pseudomonas aeruginosa. To avoid disease transmission, as a requirement for safe medical practice established by regulatory authorities, HCUs must be regularly disinfected by hazardous chemicals posing a danger for both handling humans and the environment. Therefore, to comply with regulations, HCU manufacturers have introduced both timely and financially extensive sanitisation procedures. Our paper describes a novel, effective and easy to handle disinfection method for the above problematics without utilising hazardous chemicals. The method's technical principle is electrolysis, resulting in drinking water quality regarding the analysed germs in the worldwide most commonly utilised heater-cooler device. The main aim of the study was to prove the efficacy and reliability of the device cleansing process. Furthermore, the economic impact of the novel method was evaluated. Therefore, we have undertaken 60 microbiological sampling series between December 2019 and November 2020 from a conventional HCU (3T LivaNova, Germany). During the total investigational period, no contamination with Pseudomonas aeruginosa or Legionellae could have been demonstrated in the HCU. The extreme slow-growing nontuberculous M. chimaera was detected only in one sample obtained from diamond electrode cleansed HCU water, and source of contamination was promptly eliminated by a simple technical modification of the device test-site. Additionally, the diamond electrode application is beneficial for eliminating potentially hazardous cleansing material from the process, which may affect otherwise both patients operated on cardiopulmonary bypass and the perfusionists.

Background: COVID-19 created a challenging situation for cardiac surgery and associated acute care programs around the world. While non-urgent cases might be postponed, operating on life-threatening conditions, including type A aortic dissection (TAAD), must be sustained despite the ongoing pandemic. Therefore, the authors investigated the impact of the COVID-19 pandemic on their urgent aortic program. Methods: The authors included consecutive patients presenting with TAAD ( n =36) in the years 2019 and 2020 [pre-pandemic period (2019; n =16) and the pandemic era (2020; n =20)] at a tertiary care centre. Patient characteristics, TAAD presenting symptoms, operative techniques, postoperative outcomes, and length of stay were determined retrospectively using chart review and were compared between both years. Results: An increase occurred in the absolute number of TAAD referrals during the pandemic era. Patients were featured by younger age of presentation (pre-pandemic group: 47.6±18.7, and the pandemic group: 50.6±16.2 years, P =0.6) in contrast to Western data but showed similar male predominance (4:1) in both groups. There was no statistical difference in baseline comorbidities between the groups. Length of hospital stay [20 (10.8–56) vs. 14.5 (8.5–53.3) days, P =0.5] and intensive care unit stay [5 (2.3–14.5) vs. 5 (3.3–9.3) days, P =0.4] were comparable between both groups. Low rates of postoperative complications were registered in both groups with no significant between-group difference. There was no significant difference in the rates of in-hospital mortality between both groups [12.5% (2) vs. 10% (2), P =0.93]. Conclusions: Compared with the pre-pandemic era (2019), there was no difference in resource utilisation and clinical outcomes of patients presenting with TAAD during the first year of COVID-19 pandemic (2020). Structural departmental re-configuration and optimal personal protective equipment utilisation warrant maintained satisfactory outcomes in critical healthcare scenarios. Future studies are required to further investigate aortic care delivery during such challenging pandemics.

An infectious aortic aneurysm is a rare disease entity. We report a challenging case of a 29-year-old male presenting with chest pain and constitutional symptoms. The patient was found to have three pseudoaneurysms of the aorta on imaging, significant pathological findings of necrotizing granulomatous lymphadenitis from a supraclavicular lymph node biopsy, and a highly suggestive clinical picture of tuberculous aortitis. He was referred to vascular surgery for intervention and discharged on antituberculous therapy for 6 months. To the best of our knowledge, only five cases of tuberculous aortic aneurysms have been reported from the Middle East and North Africa (MENA) region, all with favorable outcomes. A high index of suspicion, early detection, and prompt intervention are essential in managing such cases.

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is an established last line support for severe, acute cardiorespiratory failure. In the case of VA ECMO, peripheral cannulation via the femoral vessels is often advantageous when compared with the alternative central cannulation, and is associated with better clinical outcomes. One of the specific potential complications of peripheral femoral arterial cannulation for ECMO, however, is ipsilateral distal lower limb ischemia; a consideration especially when cannulating the vessel directly, as distal limb perfusion is invariably compromised by an occlusive effect of the arterial cannula within the femoral artery. The gold standard technique for lower limb reperfusion is a separate size 6-7 Fr cannula inserted proximally into the femoral artery, just below the insertion point of the ECMO return cannula, and connected directly to the ECMO circuit so that the blood flow is also directed distally to perfuse the entire limb. This functions well whether the ECMO cannula has been placed percutaneously or by surgical cut-down. Although proximal femoral arterial placement of the reperfusion cannula is the established and preferred technique, there are many technical challenges which may preclude its placement. Local haematoma or bleeding post ECMO insertion, peripheral vascular disease, constricted vasculature in severely shocked patients, or patient obesity are all common reasons why placement of the proximal reperfusion cannula may be difficult, or impossible. In such instances, our retrograde perfusion technique may maintain limb perfusion and may even be limb saving for patients on VA ECMO support.

A serious complication after cardiac surgery is sternal wound infection. Although incidence rates vary worldwide, this complication raises significant concern in a certain patient demographic. This article uses risk assessment strategies to identify a high-risk patient profile and draws parallels with positive predictors in the preoperative, intraoperative and postoperative setting. It describes the complexity of sternal wound infections and highlights guidelines on detection and treatment. The optimal goal of this article is to help minimise the incidence of sternal wound complications after sternotomy by discussing recommendations for preoperative, intraoperative and postoperative preventive measures.

Streptococcal bloodstream infections resulting in right-sided endocarditis are uncommon. Streptococcus mitis can demonstrate slow-growing potential leading to delayed endocarditis presentation or culture-negative endocarditis. Endocarditis accompanied by skin lesions represents a severe disease course. Heparin-induced thrombocytopenia and disseminated intravascular coagulopathy complicating the disease require a well-tailored multidisciplinary approach.

The coronavirus pandemic has spread globally and resulted in the registered deaths of over 5.5 million people, with nearly 380 million infected, straining health systems focused on transmission suppression and supportive care because specific treatment options are limited. COVID-19 is a microvascular disease with dominant respiratory representation, but a significant number of patients experience multisystem or extrarespiratory organ involvement. Although severe acute respiratory syndrome coronavirus-2 has some degree of a direct cytopathic effect on cardiomyocytes, the oxidative burst on a microvascular level seems to be the key for both short- and long-term adverse health effects. Targeted diagnostics and treatment without substantial delay may reduce the amplified immune response; otherwise, considerable tissue damage may occur with unfavourable consequences, including acute and chronic cardiac syndromes. This paper reviews the pathomechanisms relevant to the short- and long-term cardiac effects of COVID-19. Data were identified by searching the PubMed database and reviewing references from relevant articles published in English; abstracts and meeting reports were excluded.

Case Presentation: A 42-year-old female in her 24 th week of pregnancy was admitted to an outside hospital with respiratory failure due to COVID-19 pneumonia and was managed with Remdesivir, Dexamethasone, and pharmacological DVT prophylaxis. Her chest CT showed a massive PE. Due to instability, a cesarean section was necessitated, which resulted in delivering a stillborn baby. Two days later, she developed a severe circulatory shock with acute renal failure, not responding to conventional vasopressors/inotropic therapy. VA-ECMO was inserted for hemodynamic stabilization and the patient was transferred to our advanced ICU for further management. Upon arrival, the clinical picture was suggestive of COVID-19- induced thrombotic storm. Furthermore, the patient underwent several imaging studies which showed additional de-novo thromboembolic events in the brain (stroke), pulmonary circuit (PE), and portal circuit (hepatic thrombosis), which were managed medically. A transesophageal echocardiogram was done and revealed a large highly mobile echogenic structure, measuring up to 40 mm, crossing a patent foramen ovale (PFO) highly suggestive of thrombus in transit, in addition to the findings of significantly dilated RA and RV cavities (Figure 1 A, B). The team decided to perform an urgent surgical excision of that highly mobile thrombus accompanied by PFO closure to prevent catastrophic strokes. The thrombus in transit was extracted and was consistent with prior obtained imaging (Figure 1 C, D). Her postoperative course was uncomplicated. With advanced ICU and multidisciplinary care, she was finally discharged home hemodynamically stable on anticoagulation with Apixaban. Discussion: COVID-19 induced thrombus in-transit crossing a PFO is a rare finding and carries a high risk of paradoxical embolism. Multidisciplinary approach in integrating clinical and imaging findings can further help in a timely-manner decision making which improves patient's outcome.

A 30-year-old female who was 26 weeks pregnant, presented to an outside facility with acute hypoxic respiratory failure and was initially treated as an asthma exacerbation. Her chest X-ray and CT revealed extensive bilateral airspace disease of ground glass opacities (Figure 1A) and a main pulmonary artery diameter of 3.5 cm. Transesophageal echocardiogram revealed severe mitral stenosis (MS) with a high Wilkins-Abascal score of 11/16, a mean mitral gradient of 19 mmHg, and a right ventricular systolic pressure of 94 mmHg consistent with severe pulmonary hypertension (Figure 1B, 1C). Rapid COVID test was positive, patient clinically deteriorated and was emergently transferred to our facility. She rapidly required intubation and vasopressor support. Our multi-disciplinary team (MDT) decided to perform an emergent rescue percutaneous balloon mitral valvuloplasty, which led to an improvement of mitral stenosis, but with a resultant significant MR. Intraoperative decision was taken to proceed with an emergency cesarean section and a live male was delivered. Postoperatively, she was treated supportively for COVID pneumonia with rapid improvement in clinical status. She was extubated on the 3 rd postoperative day (POD), and was ambulating without any need for oxygen by the 7 th POD, and discharged home on the 11 th POD. Her infant continued to improve and was discharged 1 month later. Discussion: Rheumatic MS constitutes a major cause of acquired heart disease complicating pregnancy in the developing world. This case report features some of the challenges in the diagnosis and management of a complex condition in the pandemic environment and highlights the importance of MDT approach.