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Management of malignant hemispheric stroke (MHS) after cardiothoracic surgery (CTS) remains difficult as decision-making needs to consider severe cardiovascular comorbidities and complex coagulation management. The results of previous randomized controlled trials on decompressive surgery for MHS cannot be generally translated to this patient population and the expected outcome might be substantially worse. Here, we analyzed mortality and functional outcome in patients undergoing decompressive hemicraniectomy (DC) for MHS following CTS and assessed the impact of perioperative coagulation management on postoperative hemorrhagic and cardiovascular complications. All patients that underwent DC for MHS resulting as a complication of CTS between June 2012 and November 2021 were included in this observational cohort study. Outcome was determined according to the modified Rankin Scale (mRS) score at 1 and 3–6 months. Clinical and demographic data, anticoagulation management and postoperative hemorrhagic and thromboembolic complications were assessed. In order to evaluate a predictive association between clinical and radiological parameters and the outcome, we used a multivariate logistic regression analysis. Twenty-nine patients undergoing DC for MHS after CTS with a female-to-male ratio of 1:1.9 and a median age of 60 (IQR 49–64) years were identified out of 123 patients undergoing DC for MHS. Twenty-four patients (83%) received pre- or intraoperative substitution. At 30 days, the in-hospital mortality rate and neurological outcome corresponded to 31% and a median mRS of 5 (5–6), which remained stable at 3–6 months [Mortality: 42%, median mRS: 5 (4–6)]. Postoperatively, 15/29 patients (52%) experienced new hemorrhagic lesions and Bayesian logistic regression predicting mortality (mRS = 6) after imputing missing data demonstrated a significantly increased risk for mortality with longer aPPT (OR = 13.94, p = .038) and new or progressive hemorrhagic lesions after DC (OR = 3.03, p = .19). Notably, all but one hemorrhagic lesion occurred before discontinued anticoagulation and/or platelet inhibition was re-initiated. Despite perioperative discontinuation of anticoagulation and/or platelet inhibition, no coagulation-associated cardiovascular complications were noted. In conclusion, Cardiothoracic surgery patients suffering MHS will likely experience severe neurological disability after DC, which should remain a central aspect during counselling and decision-making. The complex coagulation situation after CTS, however, should not per se rule out the option of performing life-saving surgical decompression.

Background and Objectives: Minimally invasive valve surgery (MIVS), integrated within enhanced recovery after surgery (ERAS) programs, is a pivotal advancement in modern cardiac surgery, aiming to reduce perioperative morbidity and accelerate recovery. This systematic review analyzes the integration of ERAS components into MIVS programs and evaluates their impact on perioperative outcomes and patient recovery. Materials and Methods: A systematic search of PubMed/Medline, conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, identified studies on ERAS in MIVS patients. Coronary and robotic surgery were excluded to prioritize widely adopted minimally invasive valve methods. Studies were included if they applied ERAS protocols primarily to MIVS patients, with at least five participants per study. Data on study characteristics, ERAS components, and patient outcomes were extracted for analysis. Results: Eight studies met the inclusion criteria, encompassing 1287 MIVS patients (842 ERAS, 445 non-ERAS). ERAS protocols in MIVS were heterogeneous, with studies implementing 9 to 18 of 24 ERAS measures recommended by the ERAS consensus guideline, reflecting local hospital practices and resource availability. Common elements include patient education and multidisciplinary teams, early extubation followed by mobilization, multimodal opioid-sparing pain management, and timely removal of invasive lines. Despite protocol variability, these programs were associated with reduced morbidity, shorter hospital stays (intensive care unit-stay reductions of 4–20 h to complete omission, and total length of stay by ≥1 day), and cost savings of up to EUR 1909.8 per patient without compromising safety. Conclusions: ERAS protocols and MIVS synergistically enhance recovery and reduce the length of hospital stay. Standardizing ERAS protocols for MVS could amplify these benefits and broaden adoption.

Minimally invasive mitral valve repair (MI-MVr) is the preferred treatment approach in experienced centers for mitral valve disease (MVD), offering reduced surgical trauma and fast recovery. However, limited operative exposure and increased procedural complexity can represent a challenge in complex MVD. This narrative review provides an overview of current literature on clinical outcomes of MI-MVr in challenging MVD scenarios, such as mitral valve (MV) endocarditis, annulus calcification, and mitral annular disjunction, in the context of myxomatous MVD. Despite the complex anatomy and MVD, MI-MVr is non-inferior in long-term outcomes in treating MV endocarditis, MV calcification, and myxomatous MVD with mitral annular disjunction. Nonetheless, careful patient selection and referral to high-volume centers, where surgeons with expertise in MI-MVr operate, are key elements for achieving a durable, patient-tailored repair with an optimal long-term outcome in treating complex MVD.

Objectives Cardiogenic shock (CS) can occur in patients with Takotsubo syndrome (TTS). As TTS has received increasing attention and has been more closely researched, several aspects of the pathogenesis have been identified, particularly that an excessive release of catecholamines plays an important role. Nevertheless, evidence on specific therapy concepts is still lacking. As a result, TTS with severe hemodynamic instability and low cardiac output creates unique challenges, and mechanical circulatory support is needed with as few inotropic drugs as possible. Methods We present a 77-year-old female patient who underwent minimally invasive surgical mitral valve replacement. After an uneventful course, the patient developed acute heart failure eleven days after surgery. Transthoracic echocardiography (TTE) revealed a new onset of TTS. The patient needed left ventricular venting and full haemodynamic flow. We successfully implanted a microaxial left ventricular assist device (Impella 5.5) using the transaxillary approach. The haemodynamic situation stabilised immediately. The patient was weaned and the Impella 5.5 was explanted after five days. Conclusion We present the first-in-man implantation of a transaxillary Impella 5.5 in a patient with TTS. The patient benefitted from Impella 5.5 therapy with full haemodynamic support and venting of the left ventricle.

We sought to outline perioperative patient data to analyse surgical, clinical and echocardiographic outcomes and mortality of patients undergoing minimally invasive mitral valve surgery. Systematic literature research was performed in MEDLINE/PubMed according to PRISMA guidelines. Our research considered original works published until January 31, 2025. A pooled meta-analysis of studies reports early and late follow-up data of mitral valve repair for complex mitral valve regurgitation. In order to outline possible adverse events and comorbidities, we compared patients' mortality by differentiating preoperative, intraoperative and postoperative data. This review analysed publications involving 222,947 patients, of which 43.4% were female and 56.6% were male, who underwent minimally invasive mitral valve surgery (MIMVS). The patients had a median age of 63.40 years (IQR: 60.42, 68.00), an average BMI of 25.1 kg/m (±7.9) and BSA of 1.7 m (±0.2). Severe mitral insufficiency was present in 86.4% of patients, 10% showed mild to moderate mitral insufficiency and 3.8% had mitral stenosis. The average EuroSCORE II showed a median value of 1.75% (IQR: 1.20, 2.95) and NYHA class III was most frequent. Comorbidities such as pulmonary hypertension were present in 35.37% of patients, diabetes mellitus in 8.57% (IQR: 4.76, 19.41), arterial hypertension was seen in 57.58% (IQR: 40.66, 68.79) with a significantly increased risk of mortality (  = 0.018). Coronary artery disease exhibited a prevalence of 17.41% (IQR: 10.78, 34.04), hypercholesterolaemia of 29.13% (IQR: 23.12, 49.74) and chronic kidney disease of 8.93% (IQR: 1.90, 20.00). New-onset atrial fibrillation occurred in 19.2% of patients. Besides this, 4% of patients required postoperative pacemaker implantation. Left atrial (LA) diameter decreased significantly from 50.37 mm preoperatively to 40.41%mm postoperatively (p < 0.001), LVDD was significantly reduced after MIMVS (  < 0.001). Mitral valve repair (75.83%) was considerably more common than replacement (21.09%). Applied techniques included annuloplasty (67.87%) and neochordal reconstruction (42.71%). Average mechanical ventilation was 540.8 min (±439.8), with a significant positive correlation between 30-day mortality and ventilation duration. In-hospital death occurred in 8 patients (±25), the average length of stay was 8.6 days (±3.9) and the mean postoperative ICU stay was 35.1 h (±15.9). Revision surgery was necessary in 4.1% of patients due to postprocedural bleeding. Postoperatively, 92% of patients showed no signs of MR, whereas 8% exhibited residual MR. Of those with residual MR, 78% continued to have mild MR, 14.9% had moderate MR and 7.1% showed severe mitral regurgitation after MIMVS. Postoperative mortality was associated with comorbidities like chronic kidney disease, diabetes mellitus and hypercholesterolaemia. Patients with a history of smoking, arterial hypertension or coronary artery disease showed variable risks, indicating that these factors may be associated with elevated in-hospital death or death within the first postoperative month. MIMVS shows favourable outcomes concerning echocardiographic measurements and haemodynamics such as LVEF, as well as length of hospital stay, ICU stay, postprocedural bleeding and complications such as wound infection or the need for blood transfusions.

Background Hybrid coronary revascularisation benefits patients with multivessel disease, as it amalgamates the minimally invasive direct coronary artery bypass (MIDCAB) procedure and percutaneous coronary intervention (PCI). Case summary We present a 63-year-old female with triple-vessel coronary artery disease including marked ostial stenosis of the left main coronary artery, as well as moderate stenosis of the right coronary artery. The risk of death following heart surgery (EuroSCORE II) is 4.27%. The patient exhibited multiple morbidities including chronic obstructive pulmonary disease, renal impairment, extracardiac arteriopathy, and multiple prior gastrointestinal surgeries, as well as a recent episode of paroxysmal atrial fibrillation. A MIDCAB procedure without electrocoagulation was stipulated by the ENT specialist due to the patient’s cochlear implant. Conclusion A successful MIDCAB procedure omitting electrocoagulation was performed for the first time for multivessel coronary disease in a multimorbid patient as part of a hybrid approach.

Background The “UFO procedure” was initially developed as a surgical option to enlarge the aortic annulus in patients requiring valve replacement. This technique can be employed to treat extensive endocarditis located in the intervalvular fibrous body (IVFB). One of the indications for a \"UFO procedure\" is massive aortic and mitral valve calcification. It is a challenging surgical procedure with a high risk of intraoperative complications. Case summary We present a 76-year-old male patient with massive aortic and mitral valve calcification involving the left atrium, the left ventricle and the left ventricular outflow tract. Both valves exhibited severe stenosis and moderate to severe regurgitation. The left ventricle was hypertrophic and the left ventricular ejection fraction was > 55%. The patient was prediagnosed with persistent atrial fibrillation. The risk of death following heart surgery (EuroSCORE II) was calculated as 9.21%. We successfully performed a so-called “UFO procedure” including replacement of both valves without annular decalcification to avoid atrioventricular dehiscence. We enlarged the IVFB and replaced the non-coronary sinus of Valsalva with doubled bovine pericardium. The left ventricular outflow tract was decalcified. The patient was transferred to a local hospital on the 13th postoperative day. Conclusion Successful surgical treatment to this extent was demonstrated for the first time. Due to the high perioperative mortality, the surgical treatment of patients with this constellation would be refused in most cases. In our patient, the preoperative imaging showed extreme calcification of both valves and the surrounding myocardium. Excellent preoperative planning and a highly experienced surgical team is necessary.

Hybrid coronary revascularization (HCR), a revascularization strategy that amalgamates the minimally invasive direct coronary artery bypass (MIDCAB) procedure and percutaneous coronary intervention (PCI), represents a significant advancement in coronary artery disease treatment. This study compares conventional and robotic approaches in HCR. A systematic literature review and individual patient data analysis was conducted via PubMed following PRISMA guidelines, including original works published until 28 February 2025. 32 publications met the inclusion criteria, providing individual data from 2,048 patients. All patients underwent MIDCAB for LAD lesions and perioperative PCI for non-LAD lesions. 903 patients (670 male, 233 female; mean age 51.69 ± 7.77 years; BMI 34.66 ± 13.13) were treated with robot-assisted HCR, whilst 1,145 patients (890 male, 255 female; mean age 69.62 ± 8.42 years; BMI 26.62 ± 1.30) underwent conventional HCR. The robot-assisted group showed significantly higher rates of right coronary artery (RCA) stenosis (18.60% vs. 16.07%,  = 0.004) and drug-eluting stent use (62.68% vs. 5.42%,  = 0.027), along with significantly shorter hospital stays (4.27 ± 1.34 vs. 10.27 ± 7.34 days,  = 0.001). Although not statistically significant, wound complications were more frequent in the robot-assisted cohort (0.66% vs. 0.09%), whereas pleural effusion (10.74% vs. 0.00%), pericardial effusion (0.61% vs. 0.11%), and pneumothorax (1.83% vs. 0.11%) were more frequent in the conventional group. Mortality was low in both cohorts (robotic vs. conventional): intra-operative (0% vs. 0.09%,  = 0.73), 30-day (0.44% vs. 0.70%,  = 0.82), follow-up (2.66% vs. 4.72%,  = 0.41). Hybrid coronary revascularization offers a less invasive alternative with potential benefits. Robotic assistance may enhance outcomes, but limited adoption and heterogeneous data underscore the need for further investigation and validation.

We aimed to investigate the safety and medium-term durability of an adjustable mitral annuloplasty ring in patients undergoing surgery for mitral valve regurgitation. Forty-five patients requiring mitral valve repair were enrolled into this prospective, multicentre study between May 2012 and May 2013 in six hospitals in Europe and Israel. Study endpoints evaluated the performance and safety of the device assessed using inter-individual comparisons. Implantation was performed through a sternotomy in ten patients and mini-thoracotomy in 35 patients. The ring was adjusted after declamping and weaning from cardio-pulmonary bypass under echocardiographic guidance if the coaptation surface was not optimal, or in cases of residual mitral regurgitation. Follow-up was performed up to 2 years post-procedure. Mean age was 61 ± 12 years. Ring adjustment was performed in 71% of patients to optimise the results of mitral valve repair. Following the procedure, 11/45 patients (24%) who had had mild residual mitral regurgitation had no mitral regurgitation following ring adjustment. Two patients with severe mitral regurgitation post-procedure had mild regurgitation following ring adjustment. Coaptation length increased significantly after adjustment. One patient died before hospital discharge due to complications unrelated to the adjustable ring. One patient had to undergo re-operation at 39 days post-procedure due to endocarditis. At 2 years of follow-up, 78% of patients had no residual mitral regurgitation and 22% had mild residual mitral regurgitation. Adjustable mitral annuloplasty ring implantation was safe in all patients. Mitral valve repair with the adjustable ring was durable in all patients who reached 2 years follow-up. Clinical Trial Registration NCT01617720.