The failure of saphenous vein grafts following coronary artery bypass grafting (CABG) remains a significant issue, as it limits the durability of vein-based surgical revascularisation compared to arterial conduits. Venous graft disease is a dynamic process that begins early in the perioperative period as a consequence of harvesting trauma, ex vivo preservation, and the sudden exposure of the conduit to the arterial haemodynamic environment. This narrative review summarises the available evidence on local graft protection strategies, focusing on intraoperative and perioperative approaches aimed at preserving endothelial integrity, attenuating initial inflammation, and limiting maladaptive remodelling. Specifically, the review analyses the role of endothelium-protective preservation solutions, external support devices, biodegradable drug-eluting biomaterials, and locally targeted RNA therapies. Preclinical and early clinical evidence suggests that local graft protection is biologically plausible and may reduce intimal hyperplasia, luminal irregularity and adverse graft remodelling. However, its impact on long-term clinical outcomes remains uncertain. An integrated approach combining harvest optimisation, conduit preservation, mechanical support, and local delivery of drugs or regulatory molecules may represent a promising framework for improving vein graft biology; however, its ability to translate into durable patency gains and improved clinical outcomes after CABG requires further clinical validation.

The management of obstructive hypertrophic cardiomyopathy (HCM) has been transformed by the advent of cardiac myosin inhibitors (CMIs), such as mavacamten and aficamten. Unlike traditional pharmacotherapy, which primarily addresses symptoms, CMIs target the underlying mechanism of sarcomeric hypercontractility, offering significant reductions in left ventricular outflow tract (LVOT) gradients and improved functional capacity. This review evaluates the evolving role of CMIs in refining surgical candidate selection and postoperative care. Clinically, CMIs function as an in vivo “biological test” to distinguish between dynamic, functional obstruction—often manageable with medication—and fixed anatomical obstruction driven by complex septal or mitral substrates. While clinical trials demonstrate that CMIs can delay or prevent the need for SRT in a significant proportion of patients, surgery remains the definitive solution for those with dominant structural anomalies or drug intolerance. Consequently, the therapeutic paradigm is shifting from a binary “drugs or surgery” approach to a synergistic model. In this framework, CMIs optimize the identification of patients truly requiring structural myectomy while serving as a valuable adjunct for managing residual hypercontractility, ultimately facilitating a personalized, multidisciplinary approach to HCM treatment.

The perioperative management of patients with end-stage renal disease on renal replacement therapy undergoing cardiac surgery presents significant clinical challenges and is associated with high morbidity and mortality. These patients frequently exhibit multiple comorbidities, including electrolyte disturbances, anemia, bleeding tendency, and cardiovascular instability, all of which complicate surgical management and postoperative recovery. Renal dysfunction markedly increases the risk of adverse postoperative events, even at mild stages, and is incorporated into established risk stratification models, including EuroSCORE II and the Society of Thoracic Surgeons score. Intraoperative renal injury may result from hypoperfusion, ischemia-reperfusion injury, systemic inflammation, hemolysis, and exposure to nephrotoxic agents. Preoperative optimization includes appropriate timing of dialysis-preferably within 24 hours before surgery-correction of electrolyte imbalances, optimization of hemoglobin levels, and careful assessment of bleeding risk. Intraoperatively, goal-directed fluid therapy guided by dynamic hemodynamic parameters and venous oxygen saturation monitoring is recommended. Integration of hemofiltration into the cardiopulmonary bypass circuit enables effective control of volume status and electrolyte levels. Postoperatively, early resumption of renal replacement therapy, ideally within 24 hours, is advised, with continuous modalities favored in hemodynamically unstable patients. Vasoplegic syndrome represents a frequent and severe complication requiring prompt recognition and targeted management. This review underscores the importance of a multidisciplinary, individualized perioperative approach involving cardiologists, nephrologists, anesthesiologists, and cardiac surgeons to reduce complications and improve outcomes in patients with end-stage renal disease undergoing cardiac surgery.

Infective endocarditis (IE) continues to represent a major challenge for global health systems. In 2019, its annual incidence was estimated at 13.8 cases per 100,000 individuals, contributing to approximately 66,300 deaths worldwide. Due to its high morbidity and mortality rates, enhancing preventive measures has become a priority in both clinical practice and ongoing research efforts. Since the publication of the 2015 ESC Guidelines for the management of IE, several pivotal studies have emerged, prompting a re-evaluation and potential update of the existing recommendations. One growing concern is the increasing antibiotic resistance among oral streptococci, particularly to macrolides such as azithromycin and clarithromycin, which now show higher resistance levels than penicillin. Changes in national antibiotic stewardship programs may have inadvertently contributed to a rise in IE incidence, in part due to altered prophylactic practices. At the same time, advances in diagnostic modalities—including more widespread and targeted use of echocardiography in patients with positive blood cultures for organisms like Enterococcus faecalis, Staphylococcus aureus, and various streptococci—have likely improved detection rates. Additionally, innovations in imaging, particularly computed tomography (CT) and nuclear medicine techniques, have enhanced the diagnosis of IE, especially among patients with prosthetic heart valves or implantable cardiac devices. This has allowed for better characterization of patient populations, aiding in the refinement of diagnostic criteria and therapeutic approaches. Furthermore, updated antibiotic treatment protocols, informed by EUCAST’s antimicrobial susceptibility data, have helped tailor antimicrobial regimens to current resistance trends. The combination of improved diagnostic sensitivity and evolving microbial resistance patterns has also led to an increased number of patients being considered for cardiac surgery as part of their treatment pathway. This review seeks to synthesize the latest findings and guideline revisions, offering an integrated overview of recent progress in the diagnosis, medical treatment, and surgical management of infective endocarditis. It will also explore current therapeutic strategies and operative indications in light of the most recent evidence.

Background:Heterotopic transcatheter caval valve implantation (CAVI) has emerged as a palliative yet promising therapeutic strategy for treating severe tricuspid regurgitation (TR), which aims to reduce systemic venous congestion by implanting bioprosthetic valves in the venae cavae rather than in the native tricuspid annulus. However, despite encouraging procedural success, clinical improvement and survival remain highly variable.Methods:A systematic review of published registries and case series was performed, focusing on the outcomes, procedural success, mortality, and safety of CAVI. Data were extracted from multicenter registries and observational series describing the use of transcatheter stented bioprosthesis or bioprosthesis alone.Results:Across published cohorts and registries, procedural success rates ranged from 90% to 100%, with 30-day mortality ranging from 5% to 25%. The TRICUS EURO study, which included 35 patients across 12 European centers, demonstrated significant improvements in New York Heart Association (NYHA) functional class and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores at 6 months, with minimal device-related complications and adverse events. The ongoing TRICAV-II pivotal trial (NCT06458907) and EuroTR registry (NCT06307262) are expected to provide larger real-world datasets. Smaller case series and individual reports, typically involving ≤10 patients, confirmed feasibility and symptomatic benefits, particularly reductions in peripheral edema and ascites. However, long-term outcome data remain limited. This study highlights right ventricle (RV) dysfunction, severe pulmonary hypertension, advanced end-organ failure, and clinical frailty as major determinants of unfavorable outcomes.Conclusions:Heterotopic CAVI represents a viable alternative for high-risk patients with severe TR, offering symptomatic improvement and reduced venous congestion when conventional surgery or orthotopic repair is not feasible. However, current evidence is derived primarily from non-randomized studies and limited registries. Ongoing prospective registries and pivotal trials are crucial for defining patient selection, procedural optimization, and long-term survival benefit. Early intervention and multidisciplinary patient selection appear crucial for avoiding futile procedures and identifying patients who may derive true symptomatic and prognostic benefit from CAVI.

The increasing interest in tricuspid regurgitation (TR) is due to the deep link between mortality and the severity of TR, as well as the limited application of surgical solutions in a setting marked by high in-hospital mortality, attributed to the late presentation of the disease. This delay in intervention is likely associated with a limited understanding of valvular and ventricular anatomy as well as the pathophysiology of the disease, leading to an underestimation of TR severity. With the rapid development of transcatheter solutions showing early safety and efficacy, there is a growing necessity to accurately understand and diagnose the valvular disease process to determine suitable management strategies. This review will outline the normal and pathological anatomy of the tricuspid valve, classify the anatomical substrates of TR, and present new risk stratification methods to determine the appropriate timing for both medical and surgical treatment.

BACKGROUND:Optimal sedation management is critical in the postoperative care of cardiac surgery patients admitted to the intensive care unit (ICU), where sedative choice may influence respiratory, hemodynamic, and recovery outcomes. Propofol is the most widely used sedative, but volatile anesthetics are gaining interest due to their pharmacologic advantages. This systematic review and meta-analysis was designed to compare volatile anesthetics with propofol for ICU sedation after cardiac surgery, focusing on time to extubation as the primary outcome, and ICU and hospital length of stay, hemodynamic support, and postoperative complications as secondary outcomes. METHODS:PubMed, Web of Science, and Scopus were searched from July to October 2024 without language or date restrictions. Eligible studies were randomized controlled trials comparing volatile anesthetics with propofol for postoperative ICU sedation in adult cardiac surgery patients. Studies without extractable data were excluded. Risk of bias was assessed using the Cochrane risk-of-bias 2.0 tool. Meta-analyses were performed using random-effects models. RESULTS:Five randomized controlled trials involving 384 patients were included. Sedation with volatile anesthetics significantly reduced time to extubation compared with propofol (weighted mean difference [WMD] = -55 minutes, 95% CI -93 to -17, p < 0.001), although heterogeneity was high (I² = 95.9%, τ² = 1,731.95, p < 0.001). No significant differences were observed for ICU (WMD = -4.26 hours, 95% CI: -17.07 to 8.55, I2 = 89.9%, t2 = 143.76, z = -0.65, p = 0.51) or hospital (WMD = -1.94 days, 95% CI: -4.17 to 0.30, I2 = 65.1%, t2 = 2.53) length of stay. Secondary outcomes (use of vasopressors and/or positive inotropes, postoperative atrial fibrillation, and nausea and/or vomiting) were inconsistently reported and showed no clear pattern. DISCUSSION:Volatile anesthetics reduce extubation time compared with propofol in adult cardiac surgery patients sedated in the ICU. However, evidence on secondary outcomes remains inconclusive due to limited and heterogeneous data.

Background: Infections following cardiac surgery are a significant cause of morbidity and mortality, particularly in intensive care units (ICUs). The role of antibiotic prophylaxis (AP) in preventing surgical site infections (SSIs) and other nosocomial infections is crucial; however, the optimal approach to agent selection, dosing, and duration remains controversial. Objective: This narrative review aims to summarise the current evidence and expert recommendations regarding the use of perioperative antibiotic prophylaxis (AP) in adults undergoing cardiac surgery, with a particular focus on intensive care settings, transplant recipients, and adult patients on extracorporeal membrane oxygenation (ECMO). Methods: A comprehensive review of recent literature was conducted, focusing on pharmacokinetic/pharmacodynamic (PK/PD) principles, microbial epidemiology, antimicrobial resistance (AMR), and practical strategies for tailored prophylaxis in high-risk populations. Results: Cefazolin remains the first-line agent for most procedures, with vancomycin or clindamycin reserved for patients who are allergic to β-lactams or who are colonised with MRSA. Redosing is recommended in cases of prolonged surgery or cardiopulmonary bypass. Evidence supports limiting prophylaxis to ≤24 h, with a potential extension to 48 h in select high-risk cases; however, continuation beyond this is discouraged due to the risk of resistance. In heart transplantation, multimodal prophylaxis against bacteria, fungi, and viruses is essential but must be tailored to the individual patient. In the ECMO setting, the current evidence does not support the routine administration of prophylaxis (AP), and therapy should be tailored based on pharmacokinetics (PK)/pharmacodynamics (PD) changes and the clinical context. A multidisciplinary, evidence-based approach to AP in cardiac surgery is essential. Prophylaxis should be patient-specific, microbiologically guided, and limited in duration to reduce the emergence of multidrug-resistant organisms. Integrating antimicrobial stewardship, non-pharmacological measures, and rigorous surveillance is crucial for optimising the prevention of infections in this vulnerable population.

Background and objectives: In cases of acute type A aortic dissection, including iatrogenic cases following transcatheter procedures, the choice of arterial cannulation site has a critical influence on early haemodynamics, organ protection and the risk of malperfusion. Transapical left ventricular cannulation has been suggested as a ‘central’ approach for rapidly establishing cardiopulmonary bypass with antegrade true-lumen flow. This review summarises the current evidence on TAC in acute type A dissection, focusing on indications, technical aspects and clinical outcomes. Materials and methods: We conducted a narrative review of observational studies and technical reports describing TAC for the surgical repair of acute type A aortic dissection. Particular attention was paid to patient selection, operative technique, perioperative complications, and early and mid-term results. Results: Across the published series, TAC is primarily employed in haemodynamically unstable patients or when the peripheral arteries are dissected, diseased, or unsuitable. A long arterial cannula is introduced through the left ventricular apex, crosses the aortic valve and is positioned in the true lumen of the ascending aorta under echocardiographic guidance. This configuration enables the rapid initiation of CPB, shortens skin-to-pump times, and provides reliable antegrade inflow. Early mortality and stroke rates are comparable to those associated with other cannulation strategies. Reported complications include malperfusion requiring site conversion, apical bleeding and rare local structural damage. These can be minimised through standardised technique and systematic imaging. Conclusions: TAC is a valuable bail-out option and, in selected patients, a primary cannulation option for acute type A aortic dissection when conventional arterial access is unsafe or ineffective. Although it offers fast and reproducible establishment of antegrade true-lumen flow, it requires specific expertise in apical exposure and intraoperative echocardiography. It should therefore be integrated into a structured perfusion and repair strategy.

BACKGROUND:Pain management in cardiac surgery remains a critical component of perioperative care, influencing recovery, patient satisfaction, and outcomes. Traditional opioid-based analgesia is associated with significant adverse effects, prompting the exploration of multimodal strategies, including regional anesthesia (RA), non-opioid analgesics, and enhanced recovery after surgery (ERAS) protocols.This review evaluates the evolution of cardiac surgery pain management, from conventional opioid-based regimens to multimodal approaches with regional anesthesia. METHODS:A comprehensive analysis of existing literature was conducted, assessing the efficacy, safety, and integration of different pain management strategies in cardiac surgery on PubMed, Google Scholar, MEDLINE, UpToDate, Embase and Web of Science until 1 November 2024. Studies on opioids, adjunct analgesics (e.g. NSAIDs, acetaminophen, ketamine, dexmedetomidine), RA techniques, and ERAS frameworks were reviewed to provide a comparative perspective. RESULTS:Multimodal analgesia significantly reduces opioid consumption, enhances pain control, and minimizes complications such as respiratory depression and postoperative nausea. RA techniques, including fascial plane blocks, offer promising opioid-sparing benefits. ERAS protocols further optimize recovery, yet challenges remain in standardizing approaches across institutions. CONCLUSIONS:The future of cardiac surgery pain management lies in individualized, multimodal strategies following ERAS principles. Standardized guidelines and further research are needed to refine these protocols for widespread adoption.

Background: The surgical treatment of chronic limb-threatening ischemia and optimal conduit choice are extensively debated. The presence of suboptimal autologous material, such as varicosities or venous aneurysms, might impair long-term outcomes. Therefore, kink-resistant external supports have been advocated in the recent literature to improve the conduit quality and outcomes. This study analyzes the FRAME external support in venous ectasic grafts in patients with chronic limb-threatening ischemia. Methods: From September 2017 to September 2023, a total of sixteen patients underwent CLTI surgery with FRAME external support for venous grafts. The inclusion criteria for FRAME applications were varicose or ectasic autologous material with a diameter ≥ 4.5 and ≤ 8 mm in an isolated segment or in the entire vein and a higher risk of bypass extrinsic compression (e.g., extra-anatomical venous bypass course). Results: Technical success and intraoperative patency were achieved in all cases. At 30 days, the limb salvage and survival rates were 100%. The primary bypass patency was 93.7% due to an early graft occlusion. No graft infection was registered. In one case, dehiscence of the surgical wound was treated by surgical debridement and antibiotic therapy. Minor amputation was required in four patients. Over a median follow-up of 32 months, two occlusions were observed; one was treated with reoperation and the other with major amputation. The primary patency was 68.7% and the assisted primary patency was 75%. Limb salvage rates observed during the entire follow-up period were 87.5%. No graft infections or dilatation of the reinforced veins were registered. Conclusions: For patients with CLTI undergoing infrainguinal bypass, satisfactory results in terms of patency and limb salvage rates were achieved using the autologous venous material, even if ectasic or varicose, with the vascular external support FRAME.

Recent spaceflights involving nonprofessional people have opened the doors to the suborbital space tourism business. However, they have also drawn public attention to the safety and hazards associated with space travel. Unfortunately, space travel involves a myriad of health risks for people, ranging from DNA damage caused by radiation exposure to the hemodynamic changes that occur when living in microgravity. In fact, the primary pathogenetic role is attributed to cosmic radiation, since deep space lacks the protective benefit of Earth's magnetic shielding. The second risk factor for space-induced pathologies is microgravity, which may affect organ function and cause a different distribution of fluid inside the human body. Both cosmic radiation and microgravity may lead to the alteration of cellular homeostasis and molecular changes in cell function. These, in turn, might have a direct impact on heart function and structure. The aim of this review is to draw attention to the fact that spaceflights constitute a novel frontier in biomedical research. We summarize the most important clinical and experimental evidence regarding the cardiovascular effects of cosmic radiation and microgravity. Finally, we highlight that unraveling the mechanisms underlying how space radiation and microgravity affect the cardiovascular system is crucial for identifying potential countermeasures and developing effective therapeutic strategies.

Dysfunctions in miRNA production have been recently investigated as predictors of neoplasms and their therapeutic strategies. In this review, we summarize the available knowledge on miRNAs and cardiac tumors (such as myxoma) and mediastinal tumors (such as thymoma) and propose new avenues for future research. MiRNAs are crucial for cardiac development through the expression of cardiac transcription factors (miR-335-5p), hinder the cell cycle by modulating the activity of transcription factors (miR-126-3p, miR-320a), modulate the production of inflammatory factors such as interleukins (miR-217), and interfere with cell proliferation or apoptosis (miR-218, miR-634 and miR-122). Current and future research on miRNAs is essential, as a deep understanding could lead to a revolution in the field of diagnostics and prevention of neoplastic diseases.

INTRODUCTION:Spinal anesthesia is a common anesthetic technique for lower limb and abdominal surgery. Despite its efficacy, its use is limited because of its duration and potential severe side effects, especially in high-risk patients undergoing major surgery. Adjuvants such as dexamethasone offer the potential to prolong the anesthetic effect and reduce the need for local anesthetics while reducing the incidence of serious adverse events. The purpose of this systematic review is to evaluate the efficacy of dexamethasone as an intrathecal adjuvant in prolonging anesthetic duration, delaying pain onset, and minimizing adverse events (PROSPERO registration: CRD42022350218). EVIDENCE ACQUISITION:We included randomized controlled trials conducted in adult patients undergoing spinal anesthesia for lower limb or abdominal surgery and comparing the performance of dexamethasone with alternative spinal treatments. A comprehensive systematic search was conducted on PubMed/MEDLINE, Scopus, CINAHL, EMBASE, CENTRAL, and Cochrane Library from February to June 2023 without language restriction. Risk of bias was assessed using the Cochrane Risk of Bias Tool (RoB2). EVIDENCE SYNTHESIS:Ten studies, nine of which were at high risk of bias, were included (N.=685 patients). Overall, intrathecal dexamethasone was associated with a longer duration of sensory block, improvement in the duration or extent of postoperative analgesia, and significant shortening of block onset. The role of dexamethasone in prolonging motor block was not clear. The incidence of adverse events was low. Intrathecal dexamethasone has been shown to be a potentially valuable adjuvant to prolong the duration of sensory block and improve postoperative analgesia without increasing adverse events. CONCLUSIONS:Given the wide heterogeneity of methodological approaches, further investigation is needed. Considering the limitations of the included studies and awaiting more conclusive evidence, the prudent use of dexamethasone could be recommended in those specific situations where general anesthesia or higher local anesthetics should be avoided.

The high incidence of atrial fibrillation (AFib) following cardiac surgery (postoperative atrial fibrillation, POAF) relies on specific surgical features. However, in the setting of POAF, the role of the microbiome in the modulation of cardiac fibrosis is still not clear. This study aimed to analyze the effect of the microbiome and its main metabolic product (trimethylamine-N-oxide, TMAO) in the fibrosis of myocardial tissue, to investigate its role in POAF. Patients undergoing elective cardiac surgery with cardiopulmonary bypass, central atrio-caval cannulation and no history of AFib, were included. A fragment of the right atrium was analyzed for qualitative and mRNA-quantitative evaluation. A preoperative blood sample was analyzed with enzyme-linked immunosorbent assay (ELISA). A total of 100 patients have been included, with POAF occurring in 38%. Histologically, a higher degree of fibrosis, angiogenesis and inflammation has been observed in POAF. Quantitative evaluation showed increased mRNA expression of collagen-1, collagen-3, fibronectin, and transforming growth factor beta (TGFb) in the POAF group. ELISA analysis showed higher levels of TMAO, lipopolysaccharide and TGFb in POAF, with similar levels of sP-selectin and zonulin. TMAO ≥ 61.8 ng/mL (odds ratio, OR 2.88 [1.35–6.16], p = 0.006), preoperative hemoglobin < 13.1 g/dL (OR 2.37 [1.07–5.24], p = 0.033) and impaired right ventricular function (OR 2.38 [1.17–4.83], p = 0.017) were independent predictors of POAF. Also, TMAO was significantly associated with POAF by means of increased fibrosis. Gut microbiome product TMAO is crucial for myocardial fibrosis, which is a key factor for POAF. Patients in preoperative sinus rhythm who will develop POAF have increased genetic expression of pro-fibrotic genes and enhanced fibrosis in histological staining. Elevated TMAO level (≥61.8 ng/mL) is an independent risk factor for POAF.

Background/Objectives: Multiple-drug-resistant (MDR) bacteria are pathogens resistant to three or more antibiotic classes, and infection with these bacteria is associated with increased mortality, morbidity, and hospital management costs. Given the rise in antibiotic resistance, selecting appropriate antimicrobial drugs and avoiding the unnecessary use of new antibiotics are crucial. Due to their nosocomial nature, monitoring and preventing MDR infections are essential. Methods: This study enrolled patients who underwent cardiac surgery from January 2020 to May 2022. The patients included were those 18 years or older who tested positive for MDR intestinal colonization before surgery. Excluded were patients who tested positive after surgery, or were younger than 18, pregnant, or lactating. For each positive patient, the National Surgical Quality Improvement Program (NSQIP) score was calculated. The data collected included age, gender, body mass index (BMI), the type of surgery, the intensive care unit (ICU) length of stay, ICU readmission, mortality, and other infections (pneumonia, bacteremia, or surgical site infection) to establish a control group and postoperative outcome measures. Results: No statistically significant differences were found between the groups regarding the ICU length of stay, new ICU admissions, or mortality. Additionally, there were no differences in the infection rates, such as bacteremia, wound infections, and pneumonia. Conclusions: Preoperative rectal colonization by MDR bacteria does not appear to worsen postoperative outcomes for cardiac surgery patients. These findings suggest that patients with a preoperative MDR-positive rectal sample might undergo cardiac surgery without significantly increased risk. Besides the limitations of this study, pre-surgical antibiotic prophylaxis may not need to be adjusted for patients with preoperative MDR positivity.

Despite cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) being the current gold standard for non-invasive myocardial characterization and fibrosis quantification, its accessibility is limited, particularly in acute settings and in certain patient populations with contraindications to magnetic resonance imaging. Late iodine enhancement (LIE) in computed tomography (CT) imaging has emerged as a potential alternative, capitalizing on the similarities in the contrast kinetics between gadolinium and iodinated contrast agents. Studies have investigated LIE-CT’s effectiveness in myocardial infarction (MI) detection, revealing promising outcomes alongside some disparities compared to LGE-CMR. LIE-CT also proves beneficial in diagnosing non-ischemic heart diseases such as myocarditis, hypertrophic cardiomyopathy, and sarcoidosis. While LIE-CT demonstrates good accuracy in detecting certain myocardial pathologies, including acute MI and chronic fibrotic changes, it has limitations, such as the inability to detect diffuse myocardial enhancement. Nonetheless, thanks to the availability of optimized protocols with minimal radiation doses and contrast medium administration, integrating LIE-CT into cardiac CT protocols could enhance its clinical utility, particularly in acute settings, providing valuable prognostic and management insights across a spectrum of cardiac ischemic and non-ischemic conditions.

Median sternotomy and steel wires for sternal closure are the standard approach for cardiac surgery. An incomplete repair associated with chest wall motion, especially in the presence of predisposing factors, can lead to life-threatening deep sternal wound infection, also known as mediastinitis, in 2–5% of cases. Despite current antibiotic and surgical treatments, mediastinitis is associated with a 10–40% mortality rate and a significant increase in morbidity and hospital stay. High mortality and difficult treatment appear to be due to bacterial biofilm, a self-produced extracellular polymeric product that incorporates host tissue and is responsible for the failure of immune defenses and standard antimicrobial therapies. Nanostructures are an effective strategy to enhance the healing process, as they establish a favorable environment for the neosynthesis of the extracellular matrix, supporting tissue development. Synthetic polymers have been proven to exhibit suitable biodegradable and mechanical properties, and their biofunctionalization to enhance cell attachment and interaction with the extracellular matrix is being widely investigated. The use of antibiotic treatments suspended in poly-D,L-lactide and polyethylene oxide and electrospun into nanofibers, or in sponges, has been shown to inhibit bacterial biofilm production. Additionally, growth factors can be incorporated into 3D bioresorbable scaffolds with the aim of constituting a structural and biological framework to organize and expedite the healing process. Therefore, these combined approaches may change the treatment of mediastinitis in the near future.

AIMS:The use of mechanical valve prostheses in cardiac surgery remains a necessary and indicated intervention in a large number of patients. However, predicted results associated with their use, on which current guideline recommendations have been developed, are based on dated studies at risk of bias (e.g. use of old generation models, very high international normalized ratio regimes). METHODS:A comprehensive search in multiple electronic databases was conducted from January 1995 to January 2024 using predefined criteria. The primary outcomes included all-cause death, bleeding events and thromboembolic events (i.e. stroke) at follow-up. RESULTS:Overall, 38 studies were included in the meta-analysis. Cumulative meta-analysis results for mortality, thromboembolic events and bleeding events were initially extremely variable and tended to become more consistent over time. A meta-regression for the impact of age and sex on mortality showed no difference, whereas a meta-regression for the impact of age and sex on thromboembolic events and on bleeding events showed a higher risk in the elderly and in female patients, respectively. CONCLUSION:The lack of fundamental information on the type of anticoagulant treatment (e.g. dosage, monitoring method) in the studies published to date does not allow us to draw any definitive conclusions on the outcomes of mechanical valve prostheses. The most recent studies have provided more consistent results, which in the past were highly variable, probably due to overcoming the bias in the use of prosthetic models of different generations.

Circle of Willis (CoW) variations are present in a significant number of patients. In patients undergoing non-emergent surgery for aortic dissection (e.g., chronic dissection or planned complex aortic arch surgery), an extensive preoperative examination is warranted as anatomic completeness, variation, patency, and functional assessment of CoW is crucial to optimize neuroprotection strategies. In non-emergent clinical presentations, unilateral or bilateral selective cerebral perfusion should be tailored to patient’s anatomy to minimize intraoperative risk and improve outcomes. A new classification system provides a simple and comprehensive ontology of the described anatomical variations of the CoW. An accurate preoperative assessment might indicate the need for adjunctive perfusion in selected CoW configurations.