Search Results (24)

Background: Interest in inhalational anesthesia in cardiac surgery has resurged as volatile anesthetics exert biological effects extending beyond hypnosis. Sevoflurane and desflurane activate mitochondrial cytoprotective signaling pathways, modulate inflammatory and endothelial responses and may attenuate ischemia–reperfusion injury during cardiopulmonary bypass, potentially influencing postoperative organ function and recovery. Methods: This narrative review critically examines experimental and clinical evidence on the use of volatile anesthetics in cardiac anesthesia. The current literature was analyzed to elucidate mechanistic foundations of myocardial and extracardiac organ protection, hemodynamic and metabolic effects, and the influence of patient-specific vulnerability profiles on perioperative outcomes. Results: Preclinical studies consistently demonstrate that volatile anesthetics trigger mitochondrial protective pathways, including K-ATP channel activation, controlled reactive oxygen species signaling and inhibition of the mitochondrial permeability transition pore. Clinical studies suggest potential benefits in myocardial protection and modulation of systemic inflammatory and microcirculatory responses. However, translation into consistent clinical outcome improvement remains heterogeneous, influenced by variability in surgical procedures, anesthetic protocols and patient risk stratification. Conclusions: Volatile anesthetics exhibit mechanistic properties supporting a potential role in organ protection during cardiac surgery. Nevertheless, clinical evidence remains inconclusive, underscoring the need for refined patient stratification and precision-based perioperative strategies. Identifying knowledge gaps and research priorities may facilitate rational, individualized integration of inhalational anesthesia into contemporary cardiac surgical practice. Full article

Background: Patients with single-ventricle physiology represent a high-risk group for heart transplantation. Due to complex anatomical and physiological challenges, including multiple prior sternotomies, pulmonary artery abnormalities, and systemic consequences of altered circulation, they represent both a surgical and a clinical challenge. We aimed to analyze perioperative challenges, as well as early and long-term complications, in this specific group of patients. Methods: We performed a retrospective data analysis of a high-volume heart transplant center, focusing on patients with single-ventricle physiology who were scheduled for heart transplantation due to end-stage heart failure. We retrospectively analyzed the period from the beginning of the transplant program in November 1985 to the end of November 2024. Results: Among 1553 transplanted patients (adults and children), 29 were transplanted due to congenital heart disease (congenital valvular disease not included). In this group, nine patients were transplanted due to end-stage heart failure in the course of single-ventricle physiology. Age at transplantation ranged from 7 to 31 years (median, 17 years), and body weight ranged from 15 to 69 kg (median, 47.9 kg). All nine patients referred for heart transplantation presented with single-ventricle physiology. Their underlying congenital heart defects were heterogeneous and included hypoplastic left heart syndrome (HLHS), double-outlet left ventricle (DOLV), transposition of the great arteries (TGA) with associated ventricular septal defects (VSDs), atrial septal defects (ASDs), valvular abnormalities such as tricuspid and or pulmonary valve atresia or stenosis, systemic or atrioventricular valve regurgitation, and vascular abnormalities, including right-sided aortic arch, aortic coarctation, and pulmonary artery hypoplasia, stenosis, or occlusion, as well as associated pulmonary vascular abnormalities such as left pulmonary artery stenosis and MAPCAs. All patients had previously undergone staged palliative procedures, including Norwood, Hemi-Fontan, Fontan, bidirectional Glenn, modified Blalock–Taussig shunts, Bjork–Fontan, or pulmonary artery banding, often with repeated interventions such as balloon angioplasty, stent placement, or MAPCA closure. Extracardiac comorbidities were common and included coagulopathies, protein-losing enteropathy, hepatic dysfunction, and chronic venous insufficiency. Preoperative functional status was markedly impaired in all patients (NYHA III-IV, INTERMACS 3-4), with severely reduced exercise capacity and thrombotic events in several individuals. Perioperative transplant surgical strategies included femoral cannulation in four cases and standard aortic and caval cannulation in five cases. Pulmonary artery reconstruction was required in all patients. Extended donor pulmonary arteries were applied in eight cases, while a bifurcated Dacron prosthesis was utilized in one patient. Perioperative mortality was 33%, with three deaths attributed to bleeding and hemodynamic instability, while overall mortality was 44% including one late death unrelated to transplantation. Protein-losing enteropathy, although persistent in the immediate postoperative period, resolved in all surviving patients, underscoring the transformative impact of transplantation. Conclusions: These findings emphasize the importance of individualized surgical planning, extended donor pulmonary artery harvesting, and careful preoperative coordination. Heart transplantation remains a viable and life-extending option for selected single-ventricle patients, despite the significant technical and clinical challenges involved. Full article

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

Background/Objectives: Obstruction of the Fontan pathway is a severe morbidity after total cavopulmonary connection (TCPC). This study aimed to evaluate the incidence and location of TCPC pathway obstruction and corresponding interventions. Methods: In all patients undergoing TCPC between 1994 and 2023, postoperative interventions for TCPC pathway obstruction were evaluated. Risk factors for TCPC pathway interventions were identified, and the impact of TCPC pathway interventions on late outcomes was analyzed. Results: Among 650 patients, 136 (21%) needed catheter/surgical interventions for TCPC pathway obstructions during the median duration of 0.2 (0.03–6.1) years postoperatively. Interventions comprised 128 catheters and 10 surgeries. Catheter intervention included 107 left pulmonary arteries (PA), 8 right PAs, and 27 extracardiac conduits. Surgery included eight conduit revisions, four PA enlargements, and two SVC enlargements. Freedom from interventions at 1, 3, 5, and 10 years was 87.7, 85.3, 83.6, and 78.5%, respectively. Previous Norwood procedure (HR: 2.228, p = 0.003), previous ductal stent (HR: 2.574, p < 0.001), previous PA interventions (HR: 2.514, p < 0.001), and high PA pressure before TCPC (HR: 1.161, p = 0.004) were risk factors. Patients requiring interventions had a higher incidence of protein-losing enteropathy (16.0 vs. 2.0%, p < 0.001), plastic bronchitis (8.3 vs. 0.8%, p < 0.001), and failing Fontan (28.6 vs. 7.6%, p < 0.001), compared to those who did not. Conclusions: Interventions for Fontan pathway obstruction were needed in 21% of patients. The left-PA stenosis was the main lesion, most cases of which were treated by stent implantation. Norwood procedure, ductal stent, pre-TCPC PA intervention, and high pre-TCPC PA pressure were identified as risks factors. Full article

Objective: The role of calcium in coagulation homeostasis is well established, although the relationship between calcium levels and postoperative bleeding in major cardiac surgery remains largely unexplored. Methods: This retrospective, single-center study investigated the correlations between ionized calcium levels measured at several timepoints: preoperatively (after induction of anesthesia), immediately after cardiopulmonary bypass (CPB) weaning, on the first postoperative day measured three times at 8 h intervals, preoperative vitamin D values, and several significant bleeding outcomes. These outcomes included the volume of blood in the drainage bag (measured in milliliters on days 1 and 2), the need for surgical or medical hemostasis, the requirement for blood transfusion (red blood cells, fresh frozen plasma, or platelets), and the occurrence of extracardiac hemorrhagic complications. A multivariable logistic regression analysis was performed, with a two-sided p-value of <0.00625 considered significant after applying Bonferroni correction. Results: The study included 83 patients with a mean age of 64.9 ± 8.5 years, with 49 (59%) being male. The most common procedures were aortic valve replacement (26 patients, 31%) and coronary artery bypass grafting (26 patients, 31%). The multivariable regression analysis demonstrated a trend toward an association between low levels of preoperative calcium and increased bleeding volume immediately after CBP and on the first day after the intervention (r = 0.30; p = 0.08 for day 1 and r = 0.24; p = 0.03 for day 2). Similar trends were observed for the association between low levels of preoperative calcium, use of medical hemostasis (r = 0.30; p = 0.009), and red blood cell transfusion (r = 0.24; p = 0.03). Additionally, we observed a trend towards a positive correlation between lower serum vitamin D levels and increased postoperative blood loss on both day 1 (r = 0.32; p = 0.07) and day 2 (r = 0.29; p = 0.04). The subgroup analysis of valve procedures vs. coronary procedures showed no statistically difference between preoperative ionized calcium levels, postoperative bleeding (289 27 vs. 283 mL, p = 0.87), the need for surgical hemostasis (p = 0.5), or blood transfusion requirement (p = 0.57). Conclusions: In our study, preoperative calcium levels were consistently associated with increased bleeding after major cardiac surgery. Post-CPB ionized calcium levels did not influence bleeding outcomes. The role of calcium in coagulation homeostasis during major cardiac surgery warrants further research, ideally with more robust data, as our study’s small sample limits robust evidence. Further larger studies will conclude on the importance of calcium levels in cardiac surgery related to hemostasis and bleeding outcomes. Lower preoperative ionized calcium and vitamin D levels showed exploratory associations with increased bleeding-related outcomes following major cardiac surgery. These findings are hypothesis-generating, and larger prospective studies are needed to confirm these potential relationships and clarify their clinical implications. Full article

Background: Patients with single right ventricular morphology (SRV) may exhibit impaired function with increased morbidity, mortality, and need for cardiac transplant due to progressive SRV failure after the Fontan procedure. The aim of the study was to longitudinally characterize the cardiac mechanics and trajectory of disease evolution of SRV failure in Fontan patients. Methods: We performed a case-controlled longitudinal study of 52 patients who underwent extracardiac Fontan palliation for SRV between 1994 and 2015 and compared echocardiographic measures of right ventricular (RV) function, RV-systemic vascular coupling and ventricular remodeling between patients who required heart transplants due to SRV failure (study group, n = 26) and those who did not (control group, n = 26). To define the trajectory, measurements were obtained at four matching time points equivalent in duration from Fontan. Results: RV circumferential shortening function declined in both groups over the time period, but was significantly lower (p < 0.01) in the study group farther from the Fontan. RV-systemic vascular coupling, assessed by systolic time interval measures and RV work, was preserved in the control group, but significantly altered (p < 0.001) in the study group. Relative wall thickness decreased, and the minor/major-axis ratio, as an index of ventricular geometry, increased in the study group, but both remained stable in the control group. Conclusions: This study suggests that positive ventricular remodeling with enhanced circumferential systolic function, and preserved RV-vascular coupling, appear to be adaptive and protective mechanisms against RV failure in Fontan with SRV. These indices of cardiac mechanics may serve as clinically relevant quantifiable markers of disease evolution, and early indicators for therapeutic intervention. Full article

Background: The aim of this study was to evaluate the clinical outcomes of adult patients who underwent repair for delayed isolated coarctation of the aorta (CoA). In addition, we aimed to assess the immediate results of the interventions and long-term follow-up data. Methods: A total of 119 adult patients who were operated on for CoA and remained under follow-up during a 25-year study period were retrospectively analyzed. The pre-, intra-, and postoperative data of the patients were recorded. The surgical methods applied preoperatively and/or postoperatively were classified based on the primary issue as interventions involving the aorta and those not involving the aorta. Results: Of the patients, 81 were males and 28 were females with a mean age of 30.55 ± 10.84 (range: 18 to 67) years. The mean follow-up was 74.79 ± 61.71 (range: 0 to 271) months. A statistically significant difference was found between the presence of pre- and postoperative hypertension and the incidence of postoperative hypertension in patients under the age of 30 (p = 0.021 and p = 0.039, respectively). A total of 13 patients underwent surgery for recoarctation. The overall rate of additional cardiac surgery was 11.80%. The presence of preoperative hypertension and valve morphology (normal vs. bicuspid) were found to be statistically significant for the need for surgery before and after CoA repair. Conclusions: Patients with repaired CoA should be closely monitored due to the lifelong risk of developing complications. In particular, we recommend annual follow-up for patients with BAV. Full article

Aortic valve stenosis (AS) is a valvular heart disease that imposes a high afterload on the left ventricle (LV) due to restricted opening of the aortic valve, resulting in LV hypertrophy. Severe AS can lead to syncope, angina pectoris, and heart failure. The number of patients with AS has been increasing due to aging populations, the growing prevalence of lifestyle-related diseases, and advances in diagnostic technologies. Therefore, accurate diagnosis and appropriate treatment of AS are essential. In recent years, transcatheter aortic valve implantation (TAVI) has become feasible, and the number of procedures has rapidly increased, particularly among elderly patients. As treatment options for AS expand and diversify, detailed pre-procedural evaluation has become increasingly important. In particular, diagnostic imaging modalities such as computed tomography (CT) have advanced significantly, with notable improvements in image quality. With recent advancements in CT technology—such as increased detector rows, faster gantry rotation speeds, new image reconstruction methods, and the introduction of dual-energy imaging—the scope of cardiac assessment has expanded beyond the coronary arteries to include valves, myocardium, and the entire heart. This includes evaluating restricted AV opening and cardiac function using four-dimensional imaging, assessing AV annulus diameter and AS severity via calcium scoring with a novel motion correction algorithm, and detecting myocardial damage through late-phase contrast imaging using new reconstruction techniques. In cases of pre-TAVI evaluation or congenital bicuspid valves, CT is also valuable for assessing extracardiac structures, such as access routes and associated congenital heart anomalies. In addition, recent advancements in CT technology have made it possible to significantly reduce radiation exposure during cardiac imaging. CT has become an extremely useful tool for comprehensive cardiac evaluation in patients with aortic stenosis, especially those being considered for surgical treatment. Full article

Background/Objectives: Cardiac amyloidosis (CA) is associated with amyloid infiltration of the extra-cardiac tissue, which may occur in the early stages of the disease. This study evaluates the diagnostic utility of thoracic fat pad biopsy obtained during a pacemaker or ICD implantation as an alternative to the standard diagnostic criteria for systemic amyloidosis. Methods: This exploratory, retrospective study included 27 patients with suspected or diagnosed CA who underwent pacemaker or defibrillator therapy. Results: Of these, 16 patients were confirmed to have CA (15 with technetium-labeled bisphosphonate bone scintigraphy and 1 with protein electrophoresis and echocardiographic findings) while 11 were confirmed to be CA-negative. The thoracic fat pad biopsy demonstrated a specificity of 100% but a sensitivity of only 31%. Among patients with transthyretin (ATTR)-CA, the sensitivity remained similarly low, at 27%. These results are consistent with prior findings on abdominal fat pad biopsy in ATTR-CA, highlighting the limited diagnostic yield of this method. Conclusions: Thoracic fat pad biopsy cannot be recommended as a standard diagnostic tool for CA, particularly in ATTR-CA, due to its poor sensitivity. However, in AL (amyloid light-chain) amyloidosis, this minimally invasive procedure may aid diagnosis without additional invasive interventions. Full article

Early surgery and improved medical care have led to the increased survival of neonates with congenital heart disease (CHD), who now commonly reach adulthood. Among adults with CHD, a growing subgroup is represented by middle-aged and even elderly patients. In this elderly population, acquired cardiac and extracardiac comorbidities represent the main cause of morbidity and mortality; the control and correction of cardiovascular risk factors or an appropriate check for extracardiac complications (such as malignancies) is therefore of paramount importance. Complications and frailty syndrome appear to occur earlier in ACHD than in the general population due to a frequent discrepancy between chronological and biological age. Multiple stressors throughout life (hemodynamic abnormalities, cardiac operations and interventional procedures, the placement of foreign materials) that result in a chronic inflammatory response are among the leading causes of premature senescence. This review is aimed at assessing the characteristics and special needs of this elderly ACHD population with a view to proposing novel models for the organization of extended care. Full article

Background: Fontan circulation maintains an elevated venous pressure; this promotes venous and lymphatic congestion and may lead to late circuit failure. Our objective was to determine the association between thoracic lymphatic perfusion patterns assessed by magnetic resonance imaging and late Fontan failure. Methodology: A retrospective study was performed. We included patients who underwent the Fontan procedure between January 2005 and December 2019 and who were evaluated with lymphatic mapping using magnetic resonance imaging. Lymphatic abnormalities were classified into four types. The prevalence of late failure was determined, and logistic regression analysis was performed to establish the association between the variables of interest and the outcome. Results: Fifty-four patients were included with a mean age at surgery of 8.8 years ± 3.5 years; 42.6% (n = 23) were men. The most frequent diagnosis was tricuspid atresia (50%, n = 27), and the Fontan procedures were mainly performed using an extracardiac conduit (96.3%, n = 52). The prevalence of late Fontan failure was 35.2%. The lymphatic perfusion patterns observed were Type 1 in 25.9% (n = 14), Type 2 in 46.3% (n = 25), Type 3 in 25.9% (n = 14), and Type 4 in 1.8% (n = 1), with no differences in relation to late failure. (p = 0.42). The age at surgery was found to be a factor associated with the late Fontan failure (OR: 1.23; 95% CI: 1.02–1.48; p = 0.02). Conclusions: One-third of patients with Fontan circulation may experience late failure, not significantly associated with lymphatic changes, but when the total cavopulmonary connection is completed at an older age. Full article

The number of structural aortic valve procedures has increased significantly in recent years. Pre-procedural planning and follow-up with noninvasive testing are essential. Although cardiac magnetic resonance (CMR) is the gold standard for assessing left ventricular mass, volume, and function, it is not performed routinely in patients undergoing structural interventions. CMR can provide useful information for pre- and post-procedural assessment, including quantification of cardiac function, myocardial assessment, grading of the severity of valvular heart disease, and evaluation of extracardiac anatomy while avoiding the limitations of other non-invasive modalities. Here, we review the use cases, future perspectives, and limitations of CMR for patients undergoing structural aortic valve procedures. Full article

Cerebrovascular accident is the most ominous complication observed after cardiac surgery, carrying an increased risk of morbidity and mortality. Analysis of the problem shows its multidimensional nature. In this study, we aimed to identify major determinants among classic variables, either demographic, clinical or type of surgical procedure, based on the analysis of a large dataset of 580,117 patients from the UK National Adult Cardiac Surgical Audit (NACSA). For this purpose, univariate and multivariate logistic regression models were utilized to determine associations between predictors and dependent variable (Stroke after cardiac surgery). Odds ratios (ORs) and 95% confidence intervals (CIs) were constructed for each independent variable. Statistical analysis allows us to confirm with greater certainty the predictive value of some variables such as age, gender, diabetes mellitus (diabetes treated with insulin OR = 1.37, 95%CI = 1.23–1.53), and systemic arterial hypertension (OR = 1.11, 95%CI = 1.05–1.16);, to emphasize the role of preoperative atrial fibrillation (OR = 1.10, 95%CI = 1.03–1.16) extracardiac arteriopathy (OR = 1.70, 95%CI = 1.58–1.82), and previous cerebral vascular accident (OR 1.71, 95%CI = 1.6–1.9), and to reappraise others like smoking status (crude OR = 1.00, 95%CI = 0.93–1.07 for current smokers) or BMI (OR = 0.98, 95%CI = 0.97–0.98). This could allow for better preoperative risk stratification. In addition, identifying those surgical procedures (for example thoracic aortic surgery associated with a crude OR of 3.72 and 95%CI = 3.53–3.93) burdened by a high risk of neurological complications may help broaden the field of preventive and protective techniques. Full article

Right atrial isomerism (RAI) is a complex entity with varying diagnostic and treatment outcomes due to its rarity. Treatment options range from palliative to corrective surgeries, resulting in heterogeneous outcomes. The aim of this study was to analyze the results obtained after cardiac surgery in patients with RAI. A retrospective study was conducted, including patients diagnosed with RAI who underwent cardiac surgery. Their follow-up was from 1 January 2010 to 31 March 2020. Demographic characteristics and perioperative conditions were described. Thirty-eight patients were included, the median age was 4 years (IQR 2–9.2) and 57.9% were men. The main diagnoses were atrioventricular canal (63.2%) and pulmonary stenosis (55.3%). The most common surgical procedures were modified Blalock–Taussig shunt (65.8%) and total cavopulmonary connection with an extracardiac conduit fenestrated without cardiopulmonary bypass (15.9%). We did not find any factors associated with negative outcomes in these patients. The overall survival was 86.8%, with a better outcome in those who did not require reintubation (log rank, p < 0.01). The survival of RAI was similar to other centers. Individuals with RAI should be evaluated rigorously to determine an adequate repair strategy, considering high morbidity and mortality. Full article

Introduction: The aim of this study was to assess clinical outcomes and quality of life after PFO closure in patients with previous stroke/TIA of undetermined cause and in patients with other complex PFO-associated clinical conditions. Methods: Between July 2009 and December 2019 at our University Cardiology Department, 118 consecutive patients underwent a thorough diagnostic work-up including standardized history taking, clinical evaluation, full neurological examination, screening for thrombophilia, brain magnetic resonance imaging (MRI), ultrasound–Doppler sonography of supra-aortic vessels and 24 h ECG Holter monitoring. Anatomo-morphological evaluation using 2D transthoracic/transesophageal echocardiography (TTE/TEE) color Doppler and functional assessment using contrast TTE (cTTE) in the apical four-chamber view and contrast transcranial Doppler (cTCD) using power M-mode modality were performed to verify the presence, location and amount of right-to-left shunting via PFO or other extracardiac source. Completed questionnaires based on the Quality-of-Life Short Form-36 (QoL SF-36) and Migraine Disability Assessment (MIDAS) were obtained from the patients before PFO closure and after 12 months. Contrast TTE/TEE and cTCD were performed at dismission, 1, 6 and 12 months and yearly thereafter. Brain MRI was performed at 1-year follow-up in 54 patients. Results: Transcatheter PFO closure was performed in 106 selected symptomatic patients (mean age 41.7 ± 10.7 years, range 16–63, 65% women) with the following conditions: ischemic stroke (n = 23), transient ischemic attack (n = 22), peripheral and coronary embolism (n = 2), MRI lesions without cerebrovascular clinical events (n = 53), platypnea–orthodeoxia (n = 1), decompression sickness (n = 1) and refractory migraine without ischemic cerebral lesions (n = 4). The implanted devices were Occlutech Figulla Flex I/II PFO (n = 99), Occlutech UNI (n = 3), Amplatzer PFO (n = 3) and CeraFlex PFO occluders (n = 1). Procedures were performed under local anesthesia and rotational intracardiac monitoring (Ultra ICE) alone. The devices were correctly implanted in all patients. The mean fluoroscopy time was 15 ± 5 min (range = 10–45 min) and the mean procedural time was 55 ± 20 min (range = 35–90 min). The total occlusion rate at follow-up (mean 50 months, range 3–100) was 98.1%. No recurrent neurological events were observed in the long-term follow-up. Conclusions: The data collected in this study demonstrate that percutaneous PFO closure is a safe and effective procedure, showing long-term prevention of recurrent cerebrovascular events, significant reduction in migraine symptoms and substantial improvement in quality of life. Full article