Search Results (516)

Background: Tetranectin (TN) is a protein that plays a role in tissue remodeling. In adults with heart failure, TN has a better prognostic value compared to B-type natriuretic peptide (BNP). We aimed to examine changes in TN in neonates following the Norwood operation and explore its prognostic value. Methods: Retrospective observational pilot cohort study in a tertiary pediatric cardiac intensive care unit. Neonates who underwent the Norwood procedure and had stored plasma samples in our biorepository were screened for inclusion. TN and BNP levels were measured by ELISA at five different time points in relation to cardiopulmonary bypass (CPB) in 26 neonates who met the inclusion criteria. The primary outcomes were time to lactate clearance and duration of inotropic support. Results: Univariate analysis showed that higher TN levels at 0 and 4 h were associated with a longer duration of inotropic support. Logistic regression analyses comparing TN levels at different time points with duration of inotropic support showed that TN level at 4 h post-CPB was a significant predictor (p = 0.04) for a longer duration of inotropic support with an AUC of 0.876. Conclusions: In this pilot cohort, higher observed TN concentrations in the early post-operative period were associated with longer duration of inotropic support. TN was not found to be significantly associated with time to lactate clearance. These exploratory findings require validation in larger prospective studies before TN can be considered for clinical prognostication. Full article

Background: Advancing age is incorporated as a strong risk variable in EuroSCORE II and is consistently associated with adverse outcomes after conventional coronary artery bypass grafting (CABG). Whether minimally invasive direct coronary artery bypass (MIDCAB)—which avoids both sternotomy and cardiopulmonary bypass—modifies this age-related risk in patients with single-vessel or LAD-predominant coronary artery disease remains insufficiently characterised. Methods: We retrospectively analysed 350 consecutive patients who underwent MIDCAB at Hannover Medical School between July 1999 and April 2025 (follow-up to April 2025). Elderly patients (age ≥70 years; n = 117) were compared with younger patients (age <70 years; n = 233) before and after 1:1 propensity score matching using greedy nearest-neighbour matching with a caliper of 0.2 × SD of the logit propensity score; age was excluded from the propensity model as it represented the exposure variable. A pre-specified sensitivity propensity model that additionally excluded EuroSCORE II (because EuroSCORE II contains an age component) was also evaluated. The primary endpoint was all-cause long-term mortality; secondary endpoints included perioperative complications and in-hospital outcomes. Long-term survival was assessed by Kaplan–Meier analysis and multivariable Cox proportional hazards regression, with a pre-specified parsimonious Cox model (age, LVEF, renal impairment) and cluster-robust standard errors on matched-pair identifiers. Results: Matching produced 109 pairs with excellent covariate balance (all standardized mean differences < 0.20). MIDCAB was completed without intraoperative conversion in all patients. No 30-day mortality, perioperative stroke, or new postoperative dialysis was observed in either age stratum (Clopper–Pearson 95% CI 0.00–3.33% for each zero-event outcome). Perioperative complications—including new-onset atrial fibrillation, re-exploration for bleeding, and intensive care unit and hospital length of stay—did not differ significantly between elderly and younger patients in the matched cohort (Newcombe 95% CI for risk differences all crossing zero; McNemar’s exact tests non-significant for all matched-pair binary endpoints; Hodges–Lehmann median difference for hospital length of stay +1.0 day, bootstrap 95% CI 0.0–1.0 days). At a median follow-up of 19.0 years (IQR 11.5–24.3; reverse Kaplan–Meier potential median 19.7 years), all-cause mortality was higher in the elderly (20.2% vs. 5.5%, p = 0.002; log-rank p = 0.001; exact McNemar’s p = 0.0025 for the matched-pair mortality endpoint). After multivariable adjustment, elderly age (≥70 years) was independently associated with long-term mortality (adjusted hazard ratio 4.48, 95% CI 1.79–11.20, p = 0.001), as was EuroSCORE II (HR 2.40 per unit, p = 0.034); a pre-specified parsimonious model (age, LVEF, renal impairment) with pair-cluster robust standard errors yielded an essentially identical adjusted HR for elderly age of 4.08 (95% CI 1.65–10.04, p = 0.002), and a sensitivity propensity model without EuroSCORE II yielded HR 3.95 (95% CI 1.68–9.29, p = 0.002). Conclusions: In this propensity-matched analysis with a median follow-up of ~19 years, MIDCAB was associated with excellent observed perioperative outcomes in appropriately selected elderly patients (no 30-day mortality, stroke, or new dialysis observed; upper 95% CI 3.3%) and no evidence of an excess of major in-hospital complications compared with younger patients within the statistical resolution of the cohort. The long-term mortality excess in the elderly is consistent with age-related life-expectancy curves in the source population; cause-specific mortality was not available in this cohort. External benchmarks from large MIDCAB cohorts in which long-term survival approximates that of the age-matched general population support this interpretation indirectly. These findings support MIDCAB as a feasible revascularization strategy associated with favourable observed early outcomes and long-term survival consistent with published MIDCAB literature, in appropriately selected elderly patients with single-vessel or LAD-predominant coronary artery disease treated at experienced centres. Full article

Background: Minimally invasive approaches for combined aortic valve and ascending aortic surgery remain challenging. We report a case of utilizing a transaxillary approach (TAX) in combination with the RAM^® system. Methods: A 65-year-old male presented with exertional angina and palpitations. He reported a one-year history of dizziness. Diagnostics revealed severe aortic regurgitation due to a calcified bicuspid aortic valve and an ascending aortic aneurysm measuring 57 × 54 mm. Left ventricular ejection fraction was reduced to 42%. Coronary artery disease was excluded. Surgery was performed via a right transaxillary mini-thoracotomy (3rd intercostal space) using endoscopic visualization. Cardiopulmonary bypass was established through femoral cannulation. After aortic cross-clamping and cardioplegic arrest, the bicuspid valve was excised and replaced with a bioprosthesis. A supracoronary ascending aortic replacement was performed using a Dacron graft. The RAM^® system was used for annular suturing and proximal anastomosis, with automated fastener fixation. Results: The patient was extubated on postoperative day 1 and transferred to intermediate care on day 2. Postoperative recovery was uneventful, with no neurological deficits, bleeding, or other complications. Discharge occurred on postoperative day 9 in stable condition. Conclusions: This case highlights the feasibility and safety of a minimally invasive transaxillary approach for combined aortic valve and ascending aortic replacement using the RAM^® system. This technique may expand the surgical armamentarium for complex aortic pathology while avoiding sternotomy. Further studies are required to evaluate reproducibility, long-term outcomes, and broader applicability. Full article

Background: Postoperative bleeding remains an important source of morbidity following Bentall procedures despite numerous technical refinements aimed at improving hemostasis. We evaluated whether a modified hybrid cardioplegia strategy incorporating intermittent blood cardioplegia during aortic root reconstruction could reduce bleeding-related complications compared with a conventional double-dose del Nido strategy. Methods: A total of 103 consecutive patients who underwent Bentall procedures were retrospectively analyzed. Patients were divided according to the myocardial protection strategy employed: conventional double-dose del Nido cardioplegia (Group 1, n = 46) and a modified hybrid strategy consisting of initial del Nido cardioplegia followed by intermittent blood cardioplegia during root reconstruction (Group 2, n = 57). The primary endpoint was postoperative re-exploration for bleeding during the index hospitalization. Additional bleeding-related outcomes included 24 h drainage volume and blood product transfusion requirements. Secondary endpoints were intensive care unit (ICU) stay, hospital stay, and in-hospital mortality. Results: Baseline characteristics, cardiopulmonary bypass times, and aortic cross-clamp durations were comparable between groups. Group 2 demonstrated significantly lower 24 h postoperative drainage volumes compared with Group 1 (450 [350–550] mL vs. 550 [400–650] mL, p = 0.005). Postoperative re-exploration for bleeding occurred significantly less frequently in Group 2 than in Group 1 (3.5% vs. 19.6%, p = 0.011). No significant differences were observed in red blood cell transfusion (p = 0.112), fresh frozen plasma transfusion (p = 0.339), or platelet transfusion requirements (p = 0.147). Mechanical ventilation duration (p = 0.423), intensive care unit stay (p = 0.342), and hospital stay (p = 0.103) were similar between groups. In-hospital mortality did not differ significantly between the groups (4.3% vs. 3.5%, p = 1.000); however, the study was not powered to detect differences in mortality because of the low number of events. Conclusions: In patients undergoing Bentall procedures, a modified hybrid cardioplegia strategy incorporating intermittent blood cardioplegia during aortic root reconstruction was associated with lower postoperative drainage volumes and fewer re-explorations for bleeding compared with a conventional double-dose del Nido strategy. These findings suggest that cardioplegia delivery may contribute to intraoperative hemostatic optimization beyond its traditional role in myocardial protection. Larger prospective studies are warranted to validate these observations. Full article

Background: Intraluminal thrombus (ILT) is a recognized complication of aortic arch replacement surgery using a frozen elephant trunk (FET) prosthesis, with a postoperative incidence of around 10%. Risk factors for ILT include aneurysmal aortic disease, central graft positioning, and prothrombotic medical conditions. Perioperative blood product transfusion is frequently required in these patients to correct postoperative coagulopathy following cardiopulmonary bypass (CPB). We hypothesized that there may be an association between (i) intra- and postoperative blood product transfusion volumes and the development of ILT and (ii) whether the use of either aprotinin or tranexamic acid is associated with postoperative ILT formation. Methods: Retrospective analysis was carried out on all non-emergency aortic arch replacement procedures at our institution with FET implantation between January 2017 and June 2025. ILT was defined as the presence of thrombus within the aortic graft identified on postoperative computed tomography (CT). Statistical analysis was performed on transfusion data from anesthesia and intensive care unit records. Secondary analysis compared ILT incidence and blood product transfusion volume between patients receiving aprotinin versus tranexamic acid as antifibrinolytic therapy. Results: Of 162 patients, 10 (6.2%) developed postoperative ILT. All patients received blood product transfusion either intraoperatively or postoperatively. There was no statistically significant difference in the volume of individual blood products (red cells, platelets, fresh frozen plasma, cryoprecipitate, or fibrinogen concentrate) received between the ILT and non-ILT groups. The mean total blood product transfusion was 13.50 units (ILT group) versus 11.10 units (no ILT group), with p = 0.897, indicating no significant association. Among 46 patients receiving aprotinin, only one (2.2%) developed ILT, whereas nine of 114 patients (7.8%) receiving tranexamic acid developed ILT. This difference was not statistically significant (p = 0.232). Conclusions: In this single-centre retrospective cohort study, no statistically significant association was detected between perioperative blood product transfusion volume or choice of antifibrinolytic agent (aprotinin versus tranexamic acid) and intraluminal thrombus formation following non-emergency aortic arch replacement surgery. However, the small number of ILT events (n = 10) limits statistical power, and a clinically meaningful association cannot be excluded. These findings provide preliminary reassurance that correction of intra- and postoperative coagulopathy may not increase ILT risk, though larger multicentre studies with adjustment for confounding variables including postoperative anticoagulation practices are warranted. Full article

Cardiopulmonary bypass (CPB) during heart surgery provokes an inflammatory response that can cause post-operative organ injury, yet how CPB shapes key neutrophil effector programs is unclear. We investigated whether CPB differentially regulates neutrophil degranulation versus neutrophil extracellular trap (NET) formation and whether pre-operative neutrophil phenotypes associate with organ dysfunction. In a prospective cohort (n = 39) of children (1 day–4 years) undergoing CPB, blood samples were obtained before CPB and 24 h post-operatively. Purified neutrophils were analyzed for elastase activity and NET formation, alongside phenotypic markers of activation and neutrophil–platelet aggregation. Findings were correlated with acute kidney injury, respiratory failure, and cardiovascular dysfunction. CPB induced marked neutrophilia (4.5-fold rise; p < 0.0001). Elastase release was robustly enhanced after CPB and showed limited augmentation with secondary stimulation but did not predict organ dysfunction. In contrast, NET formation was significantly reduced after CPB. Importantly, diminished pre-operative responsiveness to low-dose NET priming was observed in patients who developed organ injury. Pediatric CPB uncouples neutrophil effector programs, priming degranulation while suppressing NETosis. Pre-operative NET “reserve” may define a clinically relevant innate immune endotype at risk for post-operative organ dysfunction and supports development of biomarker-driven treatment strategies in patients undergoing CPB. Full article

Existing diagnostic markers of sepsis indicate already developed inflammatory complications, whereas predictors enable preoperative identification of high-risk patients for preventive measures. This study aimed to evaluate the prognostic value of preoperative inflammatory biomarkers for postoperative complications in cardiac surgery patients. Preoperatively, we assessed age, body mass index, EuroSCORE II (European System for Cardiac Operative Risk Evaluation II), complete blood count with hematological indices including neutrophil-to-lymphocyte ratio (NLR), serum cytokines, HIF1A (hypoxia-inducible factor 1-alpha), and EPAS1 (endothelial PAS domain protein 1) expression in peripheral blood leukocytes. During surgery, cardiopulmonary bypass time, myocardial ischemia time, and blood loss were recorded. Postoperatively, complications, intensive care unit (ICU) stay, and total hospitalization were documented. No differences were found in non-modifiable risk factors or perioperative parameters between groups, except for longer ICU stay in the complications group. Preoperatively, absolute neutrophil count and NLR were higher in patients without complications, while eosinophil count, HIF1A expression, and HIF1A/EPAS1 ratio were higher in those with it. The HIF1A/EPAS1 ratio demonstrated the best diagnostic characteristics. Thus, preoperative predictors of postoperative inflammatory complications include low neutrophil count and NLR, as well as high HIF1A expression and HIF1A/EPAS1 ratio. These markers may facilitate early risk stratification and preventive strategies before surgery. Full article

Objective: This study aimed to assess the relationship between excess epicardial fat and the patterns of perioperative myocardial remodeling in patients undergoing surgical correction of mitral valve (MV) disease. Methods: A total of 148 patients with acquired non-infectious MV disease scheduled for surgical correction under cardiopulmonary bypass were screened in this prospective observational non-randomized study. Preoperative computed tomography (CT) of the heart was performed to assess epicardial adipose tissue (EAT) volume. Transthoracic echocardiography (Echo), including evaluation of left ventricular (LV) global longitudinal strain (GLS), right ventricular (RV) free-wall longitudinal strain, and RV systolic function (3D Echo), was conducted preoperatively, as well as postoperatively during one year after surgery. Analysis of postoperative myocardial remodeling and complications within one year after surgery was performed. Patients were divided into groups before surgical correction of MV based on the (1) EAT volume, associated with atrial fibrillation (AF) presence (EAT volume less than or > 115.1 cm³ by CT), and (2) EAT volume, associated with the presence of at least three metabolic factors (EAT volume less than or ≥100.6 cm³). Results: Prior to MV correction, Echo showed that patients with EAT volume > 115.1 cm³ exhibited larger left and right atrial (LA/RA) volumes and more pronounced RV systolic dysfunction. An EAT volume of >115.1 cm³ was associated with a 4.6-fold increase in the odds of detecting a preoperative TAPSE value < 1.7 cm (OR: 4.6 [95% CI: 1.2543; 16.7481]; p = 0.02). In the early postoperative period, patients with EAT volume > 115.1 cm³ exhibited larger RA dimensions and higher RV end-systolic volumes, as well as impaired RV–pulmonary artery coupling. At the one-year follow-up, patients with EAT volume > 115.1 cm³ exhibited larger indexed atrial volumes and basal RV dimensions. By the one-year follow-up, the group with EAT volume ≤ 115.1 cm³ was characterized by dynamic improvements, including a 10.7% increase in LV GLS (p = 0.02), a 33.6% reduction in the indexed LA volume (p = 0.004), a 28% reduction in the LV mass index (p = 0.003), and a 10.3% reduction in the LV end-diastolic dimension (p = 0.01). Furthermore, this group exhibited a 15% increase in LV stroke volume (p = 0.009), a 17.6% increase in TAPSE (p = 0.02), and a 6.5% increase in RV ejection fraction (p = 0.04) (3D Echo), none of which were observed in the group with EAT volume > 115.1 cm³. Patients with EAT volume ≥100.6 cm³ had more pronounced impairment of LV GLS before and one month after surgery compared with those with EAT < 100.6 cm³ (p = 0.046; p = 0.045). One month after surgery, worsening of RV GLS was observed specifically in the group with EAT ≥ 100.6 cm³ (p = 0.031). By the one-year follow-up, significant improvement in RV systolic function was observed only in the group with EAT volume < 100.6 cm³. Conclusions: The presence of excess epicardial fat (verified by cardiac CT) in cardiac surgery patients with acquired MV disease is associated with less favorable preoperative remodeling of both the left and right cardiac chambers and impaired reverse myocardial remodeling within one year post-surgery. Further studies in larger, independent cohorts are needed to confirm the prognostic and clinical relevance of the EAT cut-off in patients with mitral valve disease. Full article

Background and Objectives: Left atrial appendage (LAA) closure is a Class I recommendation in patients with atrial fibrillation to reduce the risk of cardioembolic stroke. Achieving reliable and complete LAA exclusion during minimally invasive mitral valve surgery via right minithoracotomy remains technically challenging. We report here to our knowledge the largest series of a novel technique for LAA exclusion using an epicardial clip device applied via right minithoracotomy during minimally invasive mitral valve surgery. Materials and Methods: Between June 2023 and May 2026, 40 patients with atrial fibrillation underwent minimally invasive mitral valve surgery via right minithoracotomy with concomitant LAA exclusion. Cardiopulmonary bypass was established via percutaneous femoral cannulation. Following completion of the intracardiac procedure and prior to aortic cross-clamp removal, a suture was placed around the LAA base via the transverse sinus and used to guide clip deployment under direct vision. Successful closure was confirmed by intraoperative transesophageal echocardiography. Results: Mean patient age was 66.6 ± 8.0 years; 21 patients (53%) were female. Mitral valve repair was performed in 36 patients (90%) and replacement in 4 (10%). Concomitant cryoablation for AF was performed in 31 patients (78%). Successful LAA clip deployment was achieved in all 40 patients (100%). The 35 mm clip was used in 36 patients (90%), the 40 mm clip in 3 patients (8%), and the 45 mm clip in 1 patient (2%). Mean total operative time was 183 ± 58 min; mean CPB time was 134 ± 42 min; mean aortic cross-clamp time was 70 ± 27 min. In-hospital mortality was 0%. One patient (3%) required re-thoracotomy for bleeding, one developed a postoperative stroke, and two required ECMO support. Median hospital stay was 9 days. At discharge, 18 patients (45%) were in sinus rhythm; among the 31 who underwent concomitant cryoablation, 16 (52%) were discharged in sinus rhythm. Conclusions: Minimally invasive LAA exclusion is feasible and safe when performed via right minithoracotomy during minimally invasive mitral valve surgery. The technique achieves high rates of successful deployment and avoids the need for additional incisions or access sites. This approach represents a valuable addition to the armamentarium of concomitant stroke prevention strategies in patients with AF undergoing minimally invasive valvular surgery. Full article

Background: Neonatal open-heart surgery induces profound oxidative stress, yet its perioperative dynamics remain incompletely characterized. This study quantified urinary 8-hydroxy-2′-deoxyguanosine (8-OHdG) and 8-isoprostane as markers of oxidative damage, and plasma α₁-microglobulin (A1M) as an endogenous antioxidant, while exploring the influence of pre- and intraoperative factors. Methods: In a prospective cohort of 40 term neonates with critical congenital heart defects undergoing open-heart surgery, serial urinary and plasma samples were collected perioperatively. Biomarker concentrations were analyzed using mixed-effects regression models to assess associations with postnatal age, sex, preoperative oxygenation, oxygen surge at bypass initiation, and cell-free hemoglobin in the prime solution. Results: Urinary 8-OHdG and 8-isoprostane increased following bypass separation; 8-OHdG remained elevated through postoperative days 0–2, while 8-isoprostane returned toward baseline by day 1. Plasma A1M declined at bypass initiation, recovered to preoperative levels at separation, and rose thereafter. Females exhibited higher A1M concentrations throughout. Longer time to surgery was associated with greater preoperative oxidative stress, and lower preoperative arterial pO₂ correlated with increased 8-isoprostane at bypass separation. No statistically significant associations were identified between intraoperative variables and biomarker levels, although the study was designed to be a hypothesis generating study and not powered to detect modest intraoperative effects. Conclusions: This exploratory study delineates distinct perioperative trajectories of oxidative stress and antioxidant response in neonates undergoing open-heart surgery, with surgical timing, preoperative hypoxemia, and sex emerging as relevant associations. No statistically significant associations were identified between intraoperative variables and biomarker levels; however, the study was hypothesis-generating in design and not powered to detect modest intraoperative effects. Full article

Background and Objectives: Endoscopic beating-heart tricuspid valve (TV) surgery is increasingly adopted in cardiac surgery due to its association with improved postoperative recovery. Conventional approaches require jugular vein cannulation to establish adequate bicaval venous drainage, and caval snaring is considered mandatory during beating-heart TV procedures to prevent intraoperative air lock. We report our single-center experience with a novel percutaneously placed venous cannula (Smart Cannula) that enables minimally invasive TV surgery without jugular cannulation or caval snaring. Materials and Methods: Between February 2025 and May 2026, 31 consecutive patients underwent endoscopic beating-heart TV surgery using the Smart Cannula system for venous drainage. The device is a stent-like cannula with distributed wall perforations allowing sufficient venous return while preventing air lock. Preoperative atrial fibrillation was present in 21 patients (68%). Six patients (19%) underwent isolated TV procedures; the remainder had concomitant procedures. Mean age was 68.2 ± 10.8 years; 16 patients (52%) were female. Two different cannula lengths were used: 680 mm (n = 15) and 730 mm (n = 16). Six patients (19%) had history of prior cardiac surgery. Results: All procedures were completed without intraoperative air lock. Two patients (6%) required intraoperative conversion to sternotomy. Mean cardiopulmonary bypass time was 163 ± 52 min. Seven patients (23%) underwent beating-heart procedures with no aortic cross-clamping; in 24 patients (77%), aortic cross-clamping was required for concomitant procedures (mean cross-clamp time 79 ± 28 min), with tricuspid repair completed on the reperfused beating heart. Re-exploration for bleeding occurred in two patients (6%). Median ICU stay was 5 days and median hospital stay was 10 days. New permanent pacemaker implantation was required in three patients (10%). Thirty-day mortality was 0%. Postoperative echocardiography at discharge demonstrated TR Grade 0 in 61%, mild TR in 32%, and moderate TR in 3% of patients. Conclusions: In this first and largest published series on endoscopic beating-heart TV surgery without caval snaring or jugular vein cannulation, we have shown that the process is feasible and safe, eliminating the need for jugular vein cannulation and caval snaring while maintaining no occurrence of intraoperative air lock. The device enables a simplified venous drainage strategy without compromising operative safety or early clinical outcomes. Full article

Vasoplegic syndrome is a common and potentially life-threatening complication following cardiac surgery with cardiopulmonary bypass. It is characterized by profound hypotension due to persistently reduced systemic vascular resistance despite preserved or increased cardiac output. The reported incidence ranges from 8% to 44%, and severe, catecholamine-resistant forms are associated with markedly increased mortality. In this retrospective study, 3937 cardiac surgical patients treated at the University Hospital Frankfurt between 2017 and 2021 were analyzed. Postoperative vasoplegic syndrome occurred in 17.5% of the cases and was classified as mild to moderate or severe according to vasopressor requirements. Preoperative, intraoperative, and postoperative variables were assessed using descriptive statistics as well as univariate and multivariable regression analyses to identify independent risk factors. Advanced age, elevated body mass index, EuroSCORE II > 10%, arterial degenerative diseases, preoperative dialysis dependence, atrioventricular valve surgery, emergency procedures, prolonged cardiopulmonary bypass and operative times, blood loss or transfusion and elevated preoperative hematocrit were identified as independent risk factors. Postoperatively, impaired renal function, increased inflammatory markers, and low hemoglobin levels were associated with vasoplegic syndrome. Severe vasoplegic syndrome was associated with increased mortality, prolonged intensive care unit stay, and extended hospitalization. Further research is required to establish standardized definitions and optimize prevention and treatment strategies. Full article

Serotonin (5-hydroxytryptamine, 5-HT) is a vasoactive amine and important regulator of vascular tone. Aberrant serotonergic activity contributes to vascular pathology in multiple cardiovascular disease states, including hypertension, diabetes, metabolic syndrome and chronic myocardial ischemia. Serotonin also plays a vital role in postoperative vascular dysfunction after cardioplegic arrest with cardiopulmonary bypass (CP/CPB). Perioperative microvascular dysfunction following CP/CPB manifests as an increased propensity for vasospasm or vasoplegia, with different effects in different tissue beds (coronary, skeletal muscle, pulmonary and systemic microcirculations). Given the importance of serotonin as a modulator of vasogenic responses, we present a selected narrative survey of the current literature concerning the effects of altered serotonergic activity on vascular dysfunction in the context of CP/CPB and other cardiometabolic diseases. This review begins with a discussion of normal serotonin biology and signaling pathways, then moves into disease-specific discussions covering five major areas of focus: metabolic syndrome, diabetes, hypertension, myocardial ischemia and CP/CPB. Full article

Background/Objectives: Mitral valve surgery is associated with substantial perioperative heterogeneity and risk of postoperative complications. Although established risk scores such as EuroSCORE II provide population-level prognostic estimates, their performance may be limited in specific surgical populations and institutional settings. This pilot study aimed to develop and internally validate an interpretable center-specific machine learning model for perioperative risk stratification following mitral valve surgery and to explore its translational implementation through a prototype clinical application. Methods: A retrospective single-center study was conducted including 211 consecutive patients undergoing mitral valve surgery with ring implantation. Routinely available demographic, laboratory, and perioperative variables were evaluated as candidate predictors. The primary endpoint was a composite of major postoperative complications, including in-hospital mortality, stroke, conversion to sternotomy, and rethoracotomy. Predictive approaches included logistic regression, LASSO regression, and random forest classification. Internal validation was performed using 5-fold cross-validation and bootstrap resampling. Model explainability was assessed using regression coefficients and SHAP (SHapley Additive exPlanations) analysis. Results: The composite endpoint occurred in 34 patients (16.1%). In the complete-case final logistic regression model, apparent discrimination reached an AUC of 0.750 (95% CI 0.643–0.858), with a Brier score of 0.105. In the predefined train-test evaluation, the simplified logistic regression model achieved a test-set AUC of 0.67, while 5-fold cross-validation yielded a mean AUC of 0.75. LASSO regression achieved the highest cross-validated AUC (0.78), although with marked discrepancy between test-set and cross-validation performance, suggesting model instability. Across models, higher age, serum creatinine concentration, cardiopulmonary bypass duration, and cross-clamp time were associated with increased complication risk, whereas higher hemoglobin levels were associated with lower risk. Conclusions: This pilot study demonstrates the feasibility of developing interpretable center-specific machine learning models for perioperative risk stratification following mitral valve surgery. Simplified regression-based approaches provided clinically transparent predictions with moderate discriminatory performance, while penalized models showed potential for improved generalizability. Further multicenter validation is required before clinical implementation. Full article

Background: Totally endoscopic mitral valve surgery has gained increasing interest as an evolution of minimally invasive cardiac surgery. However, concerns remain regarding the implementation of endoscopic techniques and their potential impact on procedural safety and operative efficiency. The present study aimed to evaluate the early experience of transitioning from direct-view minimally invasive mitral surgery to a totally endoscopic approach in an experienced minimally invasive center. Methods: A retrospective analysis of consecutive patients undergoing minimally invasive mitral valve surgery was performed. The study included 209 patients, comprising 36 totally endoscopic and 173 direct-view minimally invasive procedures. Propensity score matching was performed using age, left ventricular ejection fraction, and New York Heart Association functional class, resulting in 36 matched pairs. Continuous variables were compared using Student’s t-test and categorical variables using Fisher’s exact test. Results: After propensity score matching, baseline characteristics were well balanced between groups. The endoscopic cohort demonstrated significantly shorter cardiopulmonary bypass time compared with the direct-view group (120.4 ± 44.3 vs. 153.1 ± 40.1 min; p = 0.001). Aortic cross-clamp time was also significantly shorter in the endoscopic cohort (77.1 ± 23.9 vs. 97.8 ± 32.0 min; p = 0.002). Postoperative outcomes remained comparable between groups. The incidence of de novo atrial fibrillation was similar (11.1% vs. 13.9%; p = 1.0), as were blood transfusion requirements (47.2% vs. 50.0%; p = 1.0). Major postoperative complications occurred infrequently in both cohorts. Procedural success was achieved in 94.4% of direct-view procedures and 100% of endoscopic procedures (p = 0.493). Conclusions: Transition from direct-view minimally invasive mitral surgery to a totally endoscopic approach was associated with significantly shorter cardiopulmonary bypass and aortic cross-clamp times while maintaining comparable early postoperative outcomes. These findings suggest that implementation of totally endoscopic mitral surgery can be achieved safely in experienced minimally invasive centers and may be associated with shorter operative times while maintaining comparable early postoperative outcomes. Further multicenter studies are warranted to better define the impact of endoscopic techniques on operative performance and clinical outcomes. Full article