BACKGROUND:The Medtronic Freestyle is widely used for full-root aortic valve replacement, offering excellent hemodynamics. However, structural valve deterioration, including pseudoaneurysm formation, raises concerns. METHODS:Our single-center retrospective and prospective cohort study of adult patients who underwent modified Bentall procedures with the Medtronic Freestyle between September 2015 and November 2023 analyzed early and late complications, echocardiographic results, and survival. A cross-sectional computed tomographic angiography (CTA) evaluation assessed postoperative structural abnormalities. RESULTS:Included were 153 patients (median European System for Cardiac Operative Risk Evaluation 2011 revision, 3.4%). The 1- and 5-year actuarial survival rates were 96.7% and 87.2%, respectively. Postoperative mean and maximal transvalvular gradients were 5.8 mm Hg (interquartile range, 4.3-7.6 mm Hg) and 11.1 mm Hg (interquartile range, 8.2-14.9 mm Hg). Of the 98 patients (77.8% of eligible patients) who underwent CTA imaging, 23.5% had structural abnormalities. Pseudoaneurysms were the most common (15.3%) and warranted reintervention in 3 cases. Routine echocardiography failed to detect the pseudoaneurysms. Multivariate analysis identified previous cardiac surgery as an independent predictor of pseudoaneurysm development (odds ratio, 4.32; P = .046). The cumulative risk of CTA-detectable structural abnormalities may reach 22.7% at 5 years. CONCLUSIONS:The Medtronic Freestyle displays excellent hemodynamic performance. However, silent structural deterioration is not rare. Routine echocardiography may miss these lesions, supporting the role of systematic postoperative CTA imaging, especially for redo patients. Further studies are needed to guide optimal imaging surveillance protocols.

Abstract Background In patients with refractory cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (ECMO) provides temporary circulatory support, but optimal strategies to promote myocardial recovery and facilitate ECMO weaning remain uncertain. Levosimendan is a calcium-sensitizing inotrope and vasodilator that improves cardiac performance and may support cardiac function and shorten the duration of ECMO support. Discussion The recent multicenter randomized placebo-controlled LEVOECMO trial demonstrated no benefit of early levosimendan infusion on ECMO weaning or clinical outcomes, providing robust evidence against routine and early use. Several pharmacokinetic factors may have attenuated levosimendan efficacy in this setting. Levosimendan is prone to sequestration within the ECMO circuit, particularly early after cannulation. Moreover, its short half life and its reliance on hepatic and intestinal metabolism for the generation of the long-acting active metabolite may limit its effectiveness during the early phase of cardiogenic shock, when high incidence of hepatic dysfunction and mesenteric hypoperfusion may contribute to reduced active metabolite production. In addition, renal replacement therapy is frequently required in ECMO patients and may further reduce plasma concentrations of active metabolites. Taken together, and in the absence of therapeutic drug monitoring, these factors may result in highly variable and unpredictable exposure to active metabolites among patients. These considerations raise the hypothesis that alternative strategies such as delayed initiation with therapeutic drug monitoring might improve exposure to levosimendan and its active metabolites. Conclusion While recent evidence discourages routine early levosimendan use during ECMO for cardiogenic shock, a personalized, pharmacology-driven approach needs further investigation before a definitive conclusion.

Abstract Background Postoperative pulmonary complications (PPCs) remain the most frequent adverse events after cardiac surgery. Enhanced Recovery After Surgery (ERAS) programs aim to reduce postoperative morbidity, and data describing the incidence, patterns, and protective factors associated with PPCs within cardiac ERAS pathways remain limited. Methods We analyzed 500 consecutive adult patients undergoing cardiac surgery within a standardized ERAS program at a tertiary center. PPCs included respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, or aspiration pneumonitis. Results PPCs occurred in 130 of 500 patients (26%). The most frequent events were atelectasis (28.5%), respiratory failure (23.8%), and pneumonia (20%). Independent preoperative and intraoperative factors included age ≥ 70 years (OR 1.86, 95% CI 1.14–3.03), BMI ≥ 35 kg/m2 (OR 2.37, 95% CI 1.18–4.76), active smoking (OR 1.95, 95% CI 1.13–3.37), frailty (OR 2.21, 95% CI 1.12–4.33), and redo surgery (OR 3.09, 95% CI 1.52–6.26). Patients with PPCs had longer ICU and hospital length of stay, higher ICU readmission rates, and increased postoperative complications, without a significant difference in 30-day mortality. Exploratory analyses identified early extubation and shorter chest drain duration as variables associated with a lower incidence of PPCs, whereas postoperative delirium and transfusion were associated with an increased risk of PPCs. Conclusion PPCs affected one in four patients in this ERAS cardiac surgery cohort and were associated with significant morbidity. Preoperative factors including age, obesity, frailty, and redo surgery were the main associated factors. Among these, frailty and active smoking emerged as key modifiable associated factors that remain incompletely addressed and represent important targets for optimization. Several postoperative factors, including early extubation, delirium, transfusion, and chest drain management, were potential targets for optimization. Further studies are needed to better clarify their causal role and to guide targeted interventions.

BACKGROUND:An aorto-right ventricular fistula (ARVF) secondary to membranous septum rupture is an exceptionally rare complication after surgical aortic valve replacement (SAVR). While sutureless prostheses such as the Perceval valve have gained wide acceptance due to reduced cross-clamp times and procedural simplification, the reported adverse events predominantly include conduction disturbances and paravalvular leaks. Structural septal disruption remains sparsely described. We report a case of an early ARVF after Perceval implantation and review the pathophysiological and procedural mechanisms implicated in septal injury following sutureless and transcatheter aortic valve interventions. CASE DESCRIPTION:A 66-year-old woman with severe bicuspid aortic valve stenosis underwent SAVR via a median sternotomy using a Perceval XL prosthesis after meticulous annular decalcification and sizing. Immediate intraoperative transesophageal echocardiography (TEE) confirmed optimal seating without any paravalvular regurgitation. Within 24 h, the patient developed a complete atrioventricular block followed by cardiogenic shock. A repeat TEE revealed a large ARVF with significant left-to-right shunt. Emergent re-exploration identified a membranous septum tear. The Perceval prosthesis was explanted, the defect was closed with a reinforced patch repair, and a 27 mm Inspiris Resilia bioprosthesis was implanted. Peripheral veno-arterial ECMO support was required temporarily. The patient recovered and remained free of prosthetic dysfunction at the two-year follow-up. DISCUSSION:Membranous septum rupture after AVR has an estimated incidence of 0.4-1.5% in TAVR cohorts but is virtually unreported with Perceval valves. The mechanisms are thought to be chronic radial stress from oversized or malpositioned prostheses. Case reports with TAVR devices emphasize oversizing as a risk factor. Predictive factors for septal injury in sutureless AVR mirror those for conduction disturbances: valve oversizing, shallow infra-annular septal length, heavy calcification, and prior valve surgery. Preventive measures, such as strict sizing protocols, the avoidance of balloon dilation, and optimized implantation depth, have reduced conduction complications and may mitigate septal trauma. The treatment choice, whether percutaneous or surgical closure, depends on hemodynamic stability, defect size and anatomy, and operative risk. CONCLUSIONS:Early ARVF after Perceval implantation is exceedingly rare but potentially catastrophic. Strict adherence to sizing principles, awareness of septal anatomy, and prompt management, percutaneous in selected stable cases or surgical in acute large defects, are essential to optimize outcomes in sutureless AVR.

Whether longer cold ischemic time (CIT) increases early hemodynamic support after heart transplantation (HTx) with histidine-tryptophan-ketoglutarate (HTK) preservation is unclear. We examined the association between CIT and the vasoactive-inotropic score (VIS), a marker of circulatory support. We studied consecutive adults transplanted with HTK-preserved grafts at Lausanne University Hospital (January 2016-March 2025). VIS was calculated hourly for 48 h after ICU admission, and its association with CIT modeled using restricted cubic splines. Among 130 recipients (75% male, aged 52±12 years), mean CIT was 152±50 min. Longer CIT was associated with higher 24-hour VIS (Poverall=0.048), rising steeply beyond ≈200 min. Patients with CIT ≥200 min (n=14) had higher VIS (difference at 48 h 10.2 points, p=0.024), more post-transplant ECMO (43% vs 9%, p<0.001), and longer ICU stay (11.0 vs 6.1 days, p=0.014). The CIT-VIS relationship was non-linear, supporting CIT as a potentially modifiable determinant of early hemodynamic status after HTx.

Abstract Background Extracorporeal cardiopulmonary resuscitation (ECPR) can improve survival in patients with refractory cardiac arrest (CA). However, defining optimal selection criteria for ECPR remains a major challenge. Methods We retrospectively analyzed all ECPR treatments for refractory in-hospital CA (IHCA) and out-of-hospital CA (OHCA) in adult patients from January 1, 2010 through December 31, 2024 at our tertiary 35-bed Intensive Care Unit. Before July 2017 (Period 1), ECPR was implemented at physician discretion. From July 2017 (Period 2), a dedicated protocol recommended physicians to implement ECPR based on four criteria: age < 70 years, shockable rhythm, no-flow duration < 5 min, and total low-flow duration < 80 min. The primary outcome was hospital mortality. The secondary outcome was good neurological outcome at 3 months, defined by a cerebral performance category (CPC) score of 1 or 2. Results A total of 166 patients (45 in period 1, 121 in period 2), including 80 IHCAs and 86 OHCAs, were included. The proportion of patients fulfilling the 4 criteria was low yet significantly greater in period 2 than in period 1 (35.0 vs. 17.8%, p = 0.027). Hospital survival was improved in period 2 (26.5% vs. 8.9%, p = 0.015), whereas good neurological outcome was not (14.9 vs. 6.7%, p = 0.157). When evaluating the impact of the 4 criteria over the whole study period, patients with 4 criteria vs. those with < 4 criteria displayed marked improvements in survival (48.0 vs. 9.6%, p < 0.001) and good neurological outcome (30.0 vs. 5.2%, p < 0.001). In multivariable analysis, only the simultaneous presence of the 4 criteria was independently associated with a decreased risk of death (OR = 0.11, 95% CI 0.01–0.87, p = 0.037), whereas no single criterion alone was significantly predictive. Conclusion Implementing a clinical ECPR protocol in our institutional practice improved meaningful survival in patients with refractory IHCA and OHCA fulfilling four predefined criteria including an age < 70 years, a shockable rhythm, a no-flow < 5 min, and a low-flow < 80 min.

OBJECTIVES:To explore how early mechanical reperfusion impacts outcomes in high-risk pulmonary embolism (PE) patients supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS:This retrospective international study included adult patients treated with VA-ECMO for high-risk PE at 39 ECMO centers (2014-2024). Early mechanical reperfusion was defined as catheter-directed therapy or surgical embolectomy within 48 hours of ECMO initiation. Patients dying within 12 hours or receiving delayed reperfusion were excluded. The primary outcome was 90-day mortality, assessed using propensity-matched groups. MEASUREMENTS AND MAIN RESULTS:Among 492 patients on VA-ECMO (median age, 53 years), 69% had cardiac arrest, and 28% received early mechanical reperfusion. After propensity matching, 137 patients were compared in each group. Ninety-day mortality was 32% with early mechanical reperfusion on ECMO versus 39% with ECMO stand-alone (HR, 0.68 [95% CI, 0.45-1.03]; P = .07). Overall, ECMO duration and weaning rates were similar; however, early mechanical reperfusion improved ECMO weaning in patients without prior thrombolysis (subdistribution HR, 1.56 [95% CI, 1.03-2.36]; P = .04). Bleeding occurred in 50% of patients, with no significant difference between groups. CONCLUSIONS:In this large international cohort of patients with high-risk PE on VA-ECMO, early mechanical reperfusion therapy was not associated with a reduction in 90-day mortality or ECMO duration. These findings may support a stepwise, individualized approach favoring initial ECMO stand-alone support, although a certain clinical benefit from early mechanical reperfusion in selected patients cannot be excluded.

Background Postoperative care with ERAS programs resulted in a reduction in the incidence of postoperative delirium (POD). This study aims to evaluate the incidence of POD, describe the postoperative course of patients managed exclusively within an ERAS pathway after cardiac surgery, and explore potential factors associated with the occurrence of delirium. Methods We enrolled patients managed within an ERAS program in cardiac surgery. The primary outcome was the incidence of delirium. Secondary outcomes included the impact of POD on the postoperative course and perioperative factors associated with its occurrence. Results Among 500 patients included POD occurred in 30 patients (6%). Patients with POD were older (70 vs. 64years, p = 0.006), had a lower BMI. Patients with POD experienced significantly more postoperative complications, longer ICU (3 vs. 1 days, p < 0.001) and hospital stays. In multivariable analysis, older age, lower BMI and ICU readmission were associated with POD, whereas early extubation and opioid discontinuation before postoperative day 3 were associated with lower odds of POD. Conclusion POD remains a persistent complication despite implementation of a mature ERAS pathway and is associated with a more complex postoperative recovery. Exploratory analyses identified early extubation and shorter postoperative opioid exposure as potentially modifiable perioperative factors.

Background/Objectives: Postoperative atrial fibrillation (POAF) is the most frequent arrhythmic complication following cardiac surgery and is associated with increased morbidity and prolonged recovery. This study aimed to evaluate the impact of an enhanced recovery after surgery (ERAS) program on the incidence of POAF and broader perioperative outcomes. Methods: In this monocentric, observational cohort study, we compared a retrospective pre-ERAS cohort (n = 162) with a prospective ERAS cohort (n = 321). The primary outcome was the incidence of POAF, assessed using two definitions: (1) the American Association for Thoracic Surgery (AATS) 2014 clinical definition, identifying POAF as atrial fibrillation requiring treatment; and (2) the European Society of Cardiology (ESC) 2024 definition, describing new-onset atrial fibrillation occurring immediately after surgery. Secondary outcomes included compliance with POAF prophylaxis measures, length of hospital stay, and the occurrence of postoperative complications. Statistical analyses included propensity score matching and multivariate logistic regression to identify independent predictors of POAF. Results: ERAS implementation was associated with a significant reduction in POAF incidence across both definitions. According to the AATS 2014 definition, POAF occurred in 20% of ERAS patients vs. 39% in the pre-ERAS group (p = 0.001), and 23% vs. 39% in the matched cohort (p = 0.004). Using the ESC 2024 definition, POAF was observed in 21% vs. 37% (p = 0.001) in unmatched and 20% vs. 36% (p = 0.005) in matched populations. Compliance with POAF prophylaxis improved markedly in the ERAS group (70% vs. 21%, p = 0.001). ERAS patients also experienced shorter hospital stays and fewer postoperative complications (26% vs. 38% in the matched cohort, p = 0.033). Conclusions: The implementation of a structured ERAS protocol significantly reduced POAF incidence, improved compliance with preventive strategies, and enhanced key aspects of postoperative recovery.

Background: Enhanced Recovery After Surgery (ERAS) protocols have been implemented in various surgical specialties to improve patient outcomes and reduce opioid consumption. In cardiac surgery, the traditionally high-dose opioid use is associated with prolonged ventilation, intensive care unit (ICU) stays, and opioid-related adverse drug events (ORADEs). This study evaluates the impact of an ERAS® Society-certified program on opioid consumption in patients undergoing elective cardiac surgery at Lausanne University Hospital. Methods: A retrospective, monocentric observational study was conducted comparing two patient cohorts: one treated with ERAS protocols (2023-2024) and a retrospective control group from 2019. Data were collected from the hospital's electronic medical records and the ERAS program database. The primary outcome was total opioid consumption, measured intraoperatively and postoperatively (postoperative day (POD) 0-3). Secondary outcomes included pain control, length of stay, complications, and recovery parameters. Statistical analyses included multivariate logistic regression to identify factors associated with reduced opioid consumption. Results: Patients in the ERAS group demonstrated significantly lower total opioid consumption, whether intraoperatively (median sufentanil: 40 mcg vs. 51 mcg, p < 0.0001) or postoperatively (POD 0-3: p < 0.001). The ERAS group had faster extubation times, earlier mobilization and pain control with non-opioid analgesics, fewer complications, and shorter hospital stays (9 vs. 12 days, p < 0.001). Logistic regression identified fast-track extubation and absence of complications as strong predictors of reduced opioid use. Conclusions: The implementation of an ERAS protocol in cardiac surgery significantly reduces opioid consumption while enhancing recovery.

Arteria lusoria (AL), an anomaly of the right subclavian artery, occurs in 2% of individuals and can cause symptoms such as dysphagia due to its retroesophageal course. Often associated with Kommerell's diverticulum (KD), a dilation at the artery's origin, this condition poses risks of rupture or dissection. Symptomatic cases and aneurysms necessitate surgical intervention, while asymptomatic cases may warrant observation. We present a case of a 44-year-old woman with dysphagia lusoria due to AL and KD, confirmed by imaging. Given anatomical complexities, a one-stage open surgical repair via sternotomy was performed. This involved resecting the KD and creating a neo-trajectory for the right subclavian artery using a Dacron tube graft. Cardiopulmonary bypass ensured safe manipulation, and post-operative imaging confirmed excellent outcomes, with complete symptom resolution. Surgical approaches for AL and KD vary depending on anatomy and symptomatology, ranging from open repairs to hybrid and endovascular techniques. Open thoracotomy remains the gold standard for young patients without comorbidities. Hybrid approaches are reserved for emergencies or high-risk patients, offering reduced morbidity but potentially higher complication rates. Advances in imaging and surgical techniques, including hybrid methods, have improved outcomes, with mortality rates significantly lower than historical benchmarks. The 2024 EACTS/STS guidelines recommend open surgery for young, fit patients (Class I, Level C) and hybrid approaches for emergencies or patients unfit for open surgery (Class I, Level C). Our case exemplifies the feasibility of sternotomy in providing precise, effective correction for KD with AL in a single operation while minimizing risks associated with other approaches.

Pharmacokinetic drug-drug interactions (DDIs) can compromise the efficacy or safety of oral antithrombotic therapies (defined as oral anticoagulants or antiplatelet agents) due to under- or overexposure. Currently, there is limited published data on DDIs involving direct oral anticoagulants, and there is an alarming lack of clear data on DDIs involving antiplatelet agents. In this paper, we elaborated a comprehensive, up-to-date pocket guide on pharmacokinetic DDIs showing five possible levels of DDI (major, moderate or weak increase and major or moderate/weak decrease in antithrombotic drug exposure). The aim of this tool is to help prescribers, in particular cardiologists, to safely prescribe new antithrombotic therapies based on an individualised assessment of bleeding and thrombotic risk.

The management of large intracardiac masses, such as thrombi, tumors, or endocarditic vegetations, presents significant challenges due to their friable nature and the risks of embolization or hemodynamic compromise. While surgical removal remains the gold standard, it is often contraindicated in high-risk patients. Minimally invasive techniques, particularly thromboaspiration, offer a promising alternative, especially for left-sided cardiac chambers where systemic circulation and delicate anatomy heighten procedural risks. This review analyzes the evolving role of thromboaspiration for left-sided cardiac masses, focusing on 24 cases from 14 studies published between 2014 and 2024. Most cases utilized the AngioVac® system, with others employing devices such as Lasso®, Occlutech®, and Amplatz® systems. Neuroprotection was implemented in 79% of cases, primarily using Sentinel® devices. Access was predominantly transseptal, though transapical, transcaval, and femoral routes were also utilized. Notably, 88% of procedures were performed without ECMO support. The results highlight a high success rate (92%) in mass removal with minimal complications, although potential publication bias must be acknowledged. This success underscores thromboaspiration's viability not only for patients unfit for surgery but also for those with intracavitary or pedunculated thrombi. Thromboaspiration represents a less invasive, effective solution for managing left-sided cardiac masses, expanding its applicability beyond right-sided cases. This review emphasizes the need for further studies to establish standardized protocols and encourage broader adoption of this innovative technique in clinical practice.

Advances in surgical and medical management of congenital heart disease have improved survival rates, leading to a growing population of adult congenital heart disease (ACHD) patients requiring specialized perioperative care. Studies indicate that ACHD patients undergoing non-cardiac surgery (NC surgery) have increased mortality and morbidity risks compared to the general population, with complication rates particularly high in those with complex defects, such as Fontan circulation, Eisenmenger syndrome, or cyanotic congenital heart disease. Key perioperative concerns include hemodynamic instability, arrhythmias, thromboembolic events, and bleeding risks. Additionally, comorbidities, such as frailty, chronic inflammation, or respiratory disease, further complicate perioperative management. Multidisciplinary collaboration is critical, involving cardiologists, anesthesiologists, and surgeons to optimize preoperative preparation and perioperative monitoring. Preoperative risk stratification is essential, integrating congenital heart lesion complexity, functional status, and procedural risk. This review underscores the importance of structured preoperative assessment, appropriate risk evaluation, and individualized perioperative strategies to improve surgical outcomes in ACHD patients undergoing NC surgery. Further research is needed to refine risk prediction models and optimize perioperative protocols tailored to this unique patient population.

Continuous-flow left ventricular assist devices (CF-LVADs) improve quality of life and survival in patients with advanced heart failure but are frequently complicated by gastrointestinal bleeding (GIB). Reduced pulsatile flow may induce mucosal hypoxia, upregulating factors such as hypoxia-inducible factor (HIF)-1α and triggering neo-angiogenesis, leading to the development of gastrointestinal angiodysplasias (GIADs), a common cause of GIB. Digoxin inhibits HIF-1α and may prevent GIAD development, although its impact on the incidence of GIB remains uncertain. This meta-analysis (PROSPERO ID: CRD42024626222) evaluated the association between digoxin use and GIB occurrence (primary outcome) in patients with CF-LVADs. Research articles including adults with CF-LVADs, comparing digoxin users versus nonusers were included. Overall, four studies were included (n = 14,917; age 55 ± 13 years, 21% female) with 2,742 patients in the digoxin group and 12,175 in the no-digoxin group. Continuous-flow left ventricular assist device was axial (HeartMate II) in 78% of cases and centrifugal (HeartMate 3/HeartWare) in 22%. Digoxin use was associated with a nonsignificant lower risk of GIB (hazard ratio [HR]: 0.70; 95% confidence interval [CI]: 0.49-1.01). However, regarding GIAD-related GIB, digoxin was associated with a significantly lower risk (HR: 0.33; 95% CI: 0.13-0.82). Among 14,917 patients with CF-LVADs, digoxin use was associated with a trend toward a lower risk of GIB and a lower risk of GIAD-related GIB.