Search Results (310)

Background: Mitral regurgitation due to Barlow’s disease remains surgically demanding. Despite widespread experience, consensus is lacking on whether the Alfieri repair can serve as a deliberate and durable rather than a rescue strategy in this complex pathology. Methods: We retrospectively analyzed patients undergoing mitral valve repair due to severe mitral regurgitation resulting from Barlow’s disease using either the Alfieri or Neochordae repair techniques. Patients received a uniform semi–rigid annuloplasty ring, while leaflet resection and concomitant coronary or aortic procedures were excluded. Results: Baseline demographics and echocardiography were broadly comparable. Perioperative mortality was 0% in both cohorts, with similarly low rates of major complications. Aortic cross–clamp time was significantly shorter with Alfieri repair (p < 0.001). No relevant postoperative transmitral gradient or systolic anterior motion occurred. At a mean follow–up of 4.2 years, more–than–moderate MR was observed in one patient per group (Alfieri 2.4% vs. Neochordae 1.2%). At 10 years, the cumulative incidence of more–than–moderate mitral regurgitation and redo mitral surgery was similarly low between techniques (p = 0.810 and p = 0.460). Most patients were NYHA class I–II at last follow–up, demonstrating improved functional status. Echocardiography showed left ventricular reverse remodeling without intergroup differences. Conclusions: These data indicate that the Alfieri approach provides durable competence and hemodynamic safety comparable to the Neochordae technique while reducing cross–clamp time, supporting its use as a deliberate strategy rather than a bailout in anatomically suitable valves. Full article

Background: Coronary artery perforation is a potentially life-threatening complication in 0.2–0.6% of all patients undergoing percutaneous coronary intervention. Despite the ongoing development of technical skills and coronary devices, severe recalcitrant calcified coronary lesions remain a challenge for interventional cardiologists and can carry a potential risk for life-threatening complications, including coronary perforation. Discussion and Conclusion: The algorithm for cardiac vessel perforation could be more comprehensive and cover preventive and predictive measures. It is necessary to take into consideration prompt recognition, implement actions to restabilize the hemodynamic status, understand the source and mechanism of bleeding, and classify the cause of bleeding into proximal, distal, coronary artery bypass graft and collateral vessel, pericardial, myocardial extravasation, and vessel-chamber perforation, as each causality would necessitate a different management strategy for a successful outcome. Imaging information about cardiac vessel injury is useful for a better understanding of the spatial orientation of the coronary vessels. It also helps to detect a hematoma that deteriorates the hemodynamic status without effusion “dry tamponade” and could have a particular role in cardiac interventions to predict and prevent this complication. Full article

Post-infarction ventricular septal defect (VSD) represents a rare but frequently fatal mechanical complication of ST-elevation myocardial infarction (STEMI), associated with high morbidity and mortality despite advances in reperfusion strategies. The optimal timing of surgical repair remains a matter of ongoing debate, particularly in patients presenting with hemodynamic instability and evolving right ventricular failure. Two main strategies have been proposed: an early surgical approach aimed at preventing progressive hemodynamic deterioration and right ventricular dysfunction, and a delayed strategy that allows for infarct maturation and fibrotic remodeling of the septal margins, thereby facilitating more secure patch anchoring and reducing the risk of residual shunting. We report the case of a 39-year-old male with multiple cardiovascular risk factors who presented to the emergency department after seven days of persistent chest pain and was diagnosed with an inferior STEMI. Urgent percutaneous coronary intervention was performed, with successful stent implantation in the right coronary artery. Seven days later, transthoracic echocardiography identified an inferior post-infarction ventricular septal defect. In the context of clinical deterioration characterized by progressive right ventricular failure, urgent surgical repair was undertaken. The postoperative course was complicated by severe pulmonary hypertension and refractory cardiogenic shock, necessitating veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support for five days. The patient was subsequently weaned successfully from mechanical circulatory support and discharged on postoperative day 12. At one- and three-month follow-up, he remained asymptomatic, with significant recovery of left ventricular ejection fraction. This case underscores the critical importance of timely surgical intervention in post-infarction VSD, particularly in the setting of right ventricular failure, and highlights the essential role of temporary mechanical circulatory support in the management of severe postoperative cardiogenic shock. Full article

Background: Myocardial ischemia/reperfusion injury (MIRI) remains a major limitation to effective cardioprotection. Chikusetsusaponin IVa (CS-IVa) has shown promising cardioprotective activity; however, its pharmacokinetic behavior and exposure–response relationship under MIRI pathological conditions remain insufficiently characterized. This study aimed to evaluate the disease-state-related pharmacokinetics of CS-IVa in MIRI rats and to explore its concentration–effect relationship using a revised descriptive PK framework. Methods: A rat MIRI model was established by ligation and reperfusion of the left anterior descending coronary artery. The cardioprotective effects of CS-IVa were evaluated using echocardiography, hemodynamic parameters, myocardial infarct size, histopathological examination, and biochemical markers of myocardial injury and oxidative stress. Plasma CS-IVa concentrations were quantified by UHPLC-MS/MS over 0–24 h after administration. Non-compartmental pharmacokinetic parameters were statistically compared between normal and MIRI rats. To address model reliability and parameter identifiability, candidate PK models with different structural assumptions and weighting schemes were systematically re-evaluated. The selected descriptive PK model was further assessed using the leave-one-rat-out robustness analysis. An exploratory exposure–response analysis was performed using CK-MB as the longitudinal PD endpoint, and a Ke0 sensitivity analysis was conducted to evaluate the robustness of the downstream effect-compartment interpretation. Data-driven models were retained only as supplementary exploratory predictive analyses. Results: CS-IVa improved cardiac function; reduced myocardial infarct size; attenuated histopathological injury; decreased serum CK-MB, cTnI, LDH and plasma MDA levels; and restored SOD activity in MIRI rats. In normal rats, systemic exposure to CS-IVa increased with dose escalation. Compared with normal rats at 15 mg/kg, MIRI rats showed markedly altered pharmacokinetic behavior, including reduced C_max and AUC, delayed T_max, shortened apparent half-life, and increased apparent volume of distribution. After systematic model re-evaluation, a one-compartment model with first-order absorption, no lag time, and unweighted fitting was selected as the revised working descriptive PK model, providing a better balance between model fit, parameter stability, and parsimony. The leave-one-rat-out analysis supported the robustness of this revised model. The exploratory concentration–effect analysis revealed a temporal dissociation between plasma CS-IVa exposure and CK-MB response, suggesting a delayed pharmacodynamic response. Ke0 sensitivity analysis indicated that effect-compartment-based PD fitting was sensitive to Ke0 selection; accordingly, the exposure–response analysis is interpreted as exploratory rather than as a definitive mechanistic PK/PD model. Conclusions: CS-IVa exerted cardioprotective effects in MIRI rats, while MIRI markedly altered its overall pharmacokinetic behavior. The revised analysis supports disease-state-related PK changes and an exploratory exposure–response delay between plasma CS-IVa exposure and CK-MB response. These findings provide a pharmacokinetic basis for understanding CS-IVa under MIRI pathological conditions; however, further studies incorporating individual-level PD endpoints, tissue distribution data, and clinically relevant formulations are needed before translational dosing recommendations can be made. Full article

Acute coronary syndrome (ACS) remains a leading cause of death and morbidity worldwide. The pathophysiology of ACS has been largely interpreted through abnormalities of the coronary arteries and the microvascular bed. However, the coronary circulation is fundamentally a closed-loop system, in which the venous component represents the final link in myocardial blood return. In contrast to the extensive literature on arterial and microvascular disease, there are relatively few studies on the coronary venous system (CVS) in the context of ACS. The CVS is important in relation to ACS from two complementary perspectives. First, structural or functional abnormalities of the CVS can contribute to myocardial ischemia; second, coronary venous flow can reflect the hemodynamic outcomes of acute ischemia and reperfusion. The ‘vascular waterfall’ phenomenon is considered one of the primary mechanisms governing coronary venous return, linking myocardial compression and venous pressure to the flow from the coronary sinus (CS) into the right atrium. Experimental and clinical evidence has shown that CS thrombosis is associated with myocardial infarction and may also complicate ACS. Furthermore, studies evaluating CS blood flow generally show a decrease in the acute phase of ischemia and an increase after reperfusion. However, the existing evidence is limited and largely based on small observational studies. Therefore, this review aimed to examine the pathophysiological mechanisms and hemodynamic behavior of the CVS in ACS, starting from embryological development. Full article

Fractional flow reserve derived from coronary computed tomography angiography (FFR-CT) has emerged as a non-invasive modality for the functional assessment of coronary artery disease. By using computational fluid dynamics, particularly in its most extensively validated off-site implementation, FFR-CT enables lesion-specific estimation of pressure gradients across coronary stenoses without the need for invasive catheterization. This narrative review summarizes the technical foundations of FFR-CT as well as the evidence demonstrating that FFR-CT enhances the diagnostic accuracy of coronary CT angiography alone by improving specificity for hemodynamically significant stenoses when compared with invasive fractional flow reserve. Beyond diagnosis, FFR-CT provides incremental prognostic information, supporting risk stratification and guiding revascularization decisions. Suggestions for clinical implementation of FFR-CT and guidance on interpreting results within the appropriate clinical context are provided. Despite these advantages, limitations remain, including dependence on image quality, reduced performance in heavily calcified vessels, assumptions regarding hyperemic flow conditions, and limited validation in certain populations. While computational fluid dynamics-based FFR-CT remains the most commonly adopted approach in clinical settings, machine learning-based on-site FFR-CT is rapidly evolving and is expected to become a reliable alternative. As technical refinements continue, FFR-CT is poised to play an expanding role in precision-guided management of coronary artery disease. Full article

Computational fluid dynamics (CFD)-based simulation of coronary blood flow provides valuable hemodynamic markers, such as pressure gradients, for diagnosing coronary artery disease (CAD). However, CFD is computationally expensive, time-consuming, and difficult to integrate into large-scale clinical workflows. These limitations restrict the availability of labeled hemodynamic data for training AI models and hinder the broad adoption of non-invasive, physiology-based CAD assessment. To address these challenges, we develop an end-to-end pipeline that automates coronary geometry extraction from coronary computed tomography angiography (CCTA), streamlines simulation data generation, and enables efficient learning of coronary blood pressure distributions. The pipeline reduces the manual burden associated with traditional CFD workflows while producing consistent training data. Furthermore, we introduce a diffusion-based regression model. Specifically, the inverted conditional diffusion (ICD) model is designed to predict coronary blood pressure directly from CCTA-derived features, thereby bypassing the need for computationally intensive CFD during inference. The proposed model is trained and validated on two CCTA datasets using the Adam optimizer with a weight decay of $1\times {10}^{-3}$, a learning rate of $1\times {10}^{-5}$, a batch size of 100, and Huber loss. It is then evaluated on a test set of ten simulated coronary hemodynamic cases. Experimental results demonstrate state-of-the-art performance. Compared with Long Short-Term Memory (LSTM), the proposed model improves the $R^2$ score by 19.78%, reduces the root mean squared error (RMSE) by 19.44%, and lowers the normalized root mean squared error (NRMSE) by 18%. Compared with a multilayer perceptron (MLP), it improves the $R^2$ score by 8.38%, reduces RMSE by 4.3%, and reduces NRMSE by 5.4%. This work represents a first step toward a scalable and accessible framework for rapid, non-invasive, CFD-based blood pressure prediction, with the potential to support CAD diagnosis. Full article

Spontaneous coronary artery dissection (SCAD) is an important non-atherosclerotic cause of acute coronary syndrome, predominantly affecting younger women without traditional cardiovascular risk factors. In hemodynamically stable patients, accumulating evidence supports a conservative management strategy owing to the high rate of spontaneous vessel healing, while technically challenging invasive interventions should be reserved for selected high-risk cases. Despite growing evidence regarding acute management, recurrent SCAD and other adverse cardiovascular events have been reported during follow-up, underscoring the need for surveillance. However, optimal strategies for post-acute follow-up and for assessing the appropriateness of treatment decisions remain insufficiently established. This review focuses on clinical decision-making in the management of SCAD, with particular emphasis on follow-up assessment. We summarize the existing evidence regarding indications for conservative versus invasive treatment and discuss the clinical rationale for longitudinal imaging surveillance. Special attention is given to the role of non-invasive follow-up using coronary computed tomography angiography, including confirmation of vessel healing, evaluation of residual intramural hematoma, and assessment of distal coronary flow. Given the heterogeneity of SCAD and the risk of recurrence, individualized treatment decisions and structured follow-up strategies are essential to optimize management, avoid unnecessary invasive procedures, and support care and risk stratification in patients with SCAD. Full article

Kounis syndrome (KS) describes the occurrence of acute coronary syndromes precipitated by allergic, hypersensitivity, or anaphylactic reactions and represents a unique intersection between immunologic activation and cardiovascular disease. The epidemiology of KS is likely underestimated due to diagnostic overlap with other cardiac and allergic conditions and limited awareness across medical specialties. This narrative review focuses on the distinctive features of KS in special populations, emphasizing how patients’ age, comorbidities, immune status, and vascular substrate modify presentation, diagnosis, and outcomes. In elderly patients, polypharmacy, increased plaque vulnerability, and endothelial dysfunction favor Type II and III KS. Pediatric cases, although rare, are predominantly Type I and strongly associated with food allergies, insect stings, vaccines, and antibiotics, with under-recognition driven by diagnostic bias and ethical concerns surrounding invasive testing. Patients with coronary stents, cardiac devices, chronic kidney disease, and those receiving dialysis exhibit heightened susceptibility due to chronic inflammation, foreign-body hypersensitivity, and prothrombotic states. Pregnancy and the peripartum period represent a unique immuno-hemodynamic milieu in which Th2 immune shift, increased coronary vasoreactivity, and obstetric triggers can compromise both maternal and fetal perfusion. Additional risk modulation is observed in atopic individuals, asthmatics, patients with autoimmune, inflammatory, oncologic, psychiatric, and neurodevelopmental conditions, as well as in COVID-19 and post-infectious states. We propose a host-modified framework for KS that complements traditional classification by integrating immune phenotype and vascular substrate, enabling improved risk stratification and personalized preventive strategies. Full article

Background: Acute type A aortic dissection (ATAAD) is a life-threatening condition that may be complicated by malperfusion, particularly in patients with prior aortic interventions such as Thoracic Endovascular Aortic Repair (TEVAR). Management becomes increasingly complex when the dissection involves supra-aortic branches and compromises previously placed stents. Methods: We report the case of a 58-year-old male presenting with ATAAD and left lower limb paralysis, with a history of prior TEVAR. Imaging demonstrated an entry tear in the ascending aorta with extension into the distal left main and supra-aortic branches, resulting in a dissection flap obstructing the proximal end of the TEVAR stent. The patient underwent emergency surgical intervention including a Bentall procedure, coronary artery bypass grafting (CABG), and deployment of a small Ascyrus Medical Dissection Stent (AMDS) distally within the TEVAR stent. Pre-operatively, the patient had severe lower limb ischemia due to near-complete obstruction of distal flow. Results: Following surgical intervention, there was restoration of true lumen perfusion with resolution of malperfusion. The patient was successfully weaned from cardiopulmonary bypass, extubated on post-operative day 4, and discharged on day 7 with stable hemodynamics and intact bilateral lower limb perfusion. Post-operative computed tomography (CT) demonstrated a well-seated AMDS with no evidence of ongoing false lumen perfusion. At 30-day follow-up, there was no clinical or biochemical evidence of organ malperfusion. Conclusions: The use of an AMDS deployed within a pre-existing TEVAR stent may represent an effective strategy for managing complex ATAAD with malperfusion, particularly in cases requiring combined surgical interventions. Full article

Background: Patients with coronary artery disease (CAD) and severely reduced left ventricular ejection fraction (LVEF) ≤ 30% represent a high-risk group for coronary artery bypass grafting (CABG). Outcomes are of significant concern; therefore, real-world outcome data and predictors of early mortality remain important for perioperative decision-making. Aim: This study aims to evaluate early and mid-term outcomes in patients with severe ischemic cardiomyopathy (LVEF ≤ 30%) undergoing isolated CABG and to identify independent predictors of in-hospital mortality. Methods: We conducted a retrospective single-centre cohort analysis including patients with preoperative LVEF ≤ 30% undergoing isolated CABG (2017–2021). Early outcomes included in-hospital and 30-day mortality. The mid-term outcome was all-cause mortality up to 36 months. Multivariable logistic regression was used to identify independent predictors of in-hospital mortality. A predefined subgroup comparison was performed for LVEF ≤ 20% versus LVEF 20–30%. Results: The study comprised 147 patients with LVEF ≤ 30% undergoing isolated CABG. Overall, in-hospital mortality was 21.1%, and 30-day mortality was 23.8%. Cumulative all-cause mortality was 31.3%, 37.4%, and 42.9% at 12, 24 and 36 months respectively. Patients with LVEF ≤ 20% showed significantly higher early mortality (in-hospital 37.2% vs. 14.4%; 30-day 41.9% vs. 16.3%) and 36-month mortality (58.1% vs. 36.5%) compared with those with LVEF at 20–30%. Independent predictors of in-hospital mortality included preoperative hemodynamic instability, elevated operative risk scores, emergency status, prolonged cardiopulmonary bypass time, and major postoperative complications (all p < 0.05). Conclusions: CABG in patients with LVEF ≤ 30% is associated with substantial early mortality, while mid-term survival remains acceptable. Severely reduced LVEF identifies a particularly high-risk subgroup requiring careful perioperative risk stratification. Full article

Electrocardiographic changes resembling myocardial ischemia are rare in gastrointestinal emergencies. In particular, gastric perforation has been reported in association with ST-segment elevation, but not with ST-segment depression mimicking non-ST-segment elevation myocardial infarction (NSTEMI). We report the case of a 60-year-old woman presenting with sudden-onset epigastric pain radiating to the chest. She remained hemodynamically stable throughout her emergency department stay. On admission, the ECG showed diffuse ST-segment depression with ST-segment elevation in aVR. High-sensitivity troponin and inflammatory markers were within normal limits. Coronary angiography revealed no significant coronary stenosis, and left ventriculography demonstrated preserved left ventricular systolic function. Abdominal computed tomography showed abundant pneumoperitoneum, diffuse anterior gastric wall thickening, and moderate intraperitoneal fluid, findings highly suggestive of gastric perforation. The patient underwent laparoscopic gastric repair and abdominal lavage, with an uneventful postoperative recovery. A repeat ECG 24 h after surgery showed complete resolution of the ST-segment abnormalities. To our knowledge, this is the first reported case of gastric perforation presenting with diffuse ST-segment depression and aVR ST-segment elevation. Awareness of this presentation helps to broaden the spectrum of diagnostic possibilities and to plan appropriate diagnostic–therapeutic procedures. Full article

Background: Kounis syndrome is an allergic acute coronary syndrome precipitated by coronary vasospasm, plaque destabilization, stent thrombosis, or bypass occlusion. Cardiac surgery represents a uniquely high-risk setting due to cardiopulmonary bypass–associated inflammation and exposure to multiple pharmaceutical agents. Importantly, Kounis syndrome remains underrecognized in this context, as classical signs of anaphylaxis may be masked under general anesthesia and cardiopulmonary bypass, while ischemic manifestations may be misattributed to other perioperative conditions. Methods: A narrative review of PubMed-indexed literature was conducted to synthesize current evidence on the pathophysiology, perioperative triggers, clinical presentation, diagnostic strategies, and management of Kounis syndrome in cardiac surgery, with emphasis on intraoperative recognition and surgical decision-making. Published cases were retrieved involving perioperative cardiac surgery patients with a definite diagnosis of Kounis syndrome. Additionally, cases presenting with severe perioperative anaphylaxis and life-threatening cardiovascular involvement (grade III with cardiovascular collapse and grade IV with cardiac arrest) were included as possible Kounis syndrome, reflecting real-world diagnostic uncertainty in the intraoperative setting. Results: The literature review identified five cases of definite Kounis syndrome and ten cases of possible Kounis syndrome, including three cases with cardiovascular collapse and seven cases with cardiac arrest. Recurrent episodes were reported in several patients, particularly due to re-exposure to the triggering agent. In the context of cardiac surgery, Kounis syndrome is most frequently triggered by chlorhexidine, protamine, antibiotic prophylaxis, and anesthetic agents. The clinical presentation is often subtle during cardiopulmonary bypass. Vasoplegia, pulmonary hypertension, ventricular dysfunction, new regional wall-motion abnormalities, and hyperdynamic ventricles on transesophageal echocardiography commonly precede overt electrocardiographic changes. Diagnosis is primarily clinical and relies on intraoperative ultrasound, hemodynamic monitoring, serum tryptase, serum troponin, and, when indicated, coronary angiography. A dual-pathway approach addressing both anaphylaxis and myocardial ischemia is essential; however, one component may predominate, particularly in perioperative patients with limited clinical information, potentially leading to misdiagnosis. A multidisciplinary approach is therefore required for rapid diagnosis and individualized management. In refractory cases, cardiopulmonary bypass or ventricular assist devices may provide lifesaving support. Conclusions: Kounis syndrome remains underrecognized in cardiac surgery but carries significant morbidity. Increased clinical awareness, multidisciplinary collaboration, structured diagnostic approaches, and preventive strategies are essential to improve outcomes and reduce the risk of recurrence during future procedures. Full article

Introduction: Hypertrophic cardiomyopathy (HCM) is a common myocardial disease worldwide and is associated with heart failure symptoms and sudden cardiac death. In a subset of patients, it may produce dynamic left ventricular outflow tract obstruction (LVOTO) and systolic anterior motion (SAM)-related mitral valve dysfunction through drag forces and altered mitral–septal geometry. In contrast, subaortic stenosis caused by a subaortic membrane is an uncommon congenital lesion that may lead to fixed subvalvular LVOTO in adulthood. The coexistence of these entities is rare and can substantially complicate diagnosis and management. Case presentation: A 51-year-old woman with HCM, paroxysmal atrial fibrillation, and heart failure presented with acute decompensation and cardiogenic shock. After initial hemodynamic stabilization and cardioversion for atrial fibrillation with rapid ventricular response, multimodality imaging with transthoracic and transesophageal echocardiography, coronary computed tomography angiography, and cardiac magnetic resonance demonstrated dual LVOTO, with a dynamic component related to HCM/SAM physiology and a fixed component caused by an elongated subaortic membrane, accompanied by severe SAM-related mitral regurgitation. Echocardiography showed a resting peak LVOT gradient of 49 mmHg, increasing to 85 mmHg with the Valsalva maneuver. After exclusion of obstructive coronary artery disease and evaluation for selected phenocopies, the patient underwent septal myectomy, subaortic membrane resection, and adjunctive mitral valve plication. Early postoperative echocardiography showed reduction in the maximum provoked LVOT gradient to 38 mmHg and improvement of mitral regurgitation from severe to mild. At 3-month follow-up, she remained in sinus rhythm, improved to New York Heart Association functional class II, and had no documented readmissions for heart failure. Conclusions: Combined fixed and dynamic LVOTO due to concomitant subaortic membrane and HCM is exceedingly rare. Accurate diagnosis requires a high index of suspicion and a multimodality imaging strategy to define the obstructive mechanisms and support mechanism-based surgical management and avoid incomplete treatment when a coexisting fixed lesion is present. Full article

Background: Coronary artery bypass grafting is the optimal revascularization strategy for patients with complex multivessel coronary artery disease. However, saphenous vein grafts are associated with high failure rates and donor site morbidity. Off-the-shelf tissue-engineered vascular grafts offer a potential solution for patients lacking suitable autologous vessels. Here, we report the first successful clinical implant of an acellular Tissue-Engineered Vessel (TEV) for coronary artery bypass grafting in Europe. Methods: A 73-year-old male with two-vessel disease and no suitable autologous vein underwent on-pump coronary artery bypass grafting using the left internal mammary artery to the left anterior descending artery and a 4 mm TEV to the right coronary artery. Results: Implant procedure followed standard surgical techniques, sutures and duration. The conduit handling was comparable to native vessels. Intraoperative flow measurements demonstrated excellent graft performance (TEV: 110 mL/min, Pulsatility Index 1.0). Postoperative recovery was uneventful. One-month computed tomography coronary angiography confirmed graft patency. Discussion: This case demonstrates the feasibility of using a bioengineered conduit for coronary revascularization in patients without suitable autologous grafts. If these findings are confirmed in larger trials, bioengineered vessels could expand surgical revascularization to patients without suitable autologous conduits and fundamentally alter conduit selection strategy in CABG. Conclusions: This first-in-Europe clinical implant demonstrates that an off-the-shelf acellular tissue-engineered vessel can meet the procedural, hemodynamics, and patency requirements of coronary artery bypass. These proof-of-concept results support progression to prospective multi-center evaluation. Full article