Search Results (50)

Systolic anterior motion (SAM) of the mitral valve remains a clinically relevant complication after mitral valve repair and may result in dynamic left ventricular outflow tract (LVOT) obstruction, SAM-associated mitral regurgitation, and hemodynamic instability. Despite advances in surgical techniques and perioperative imaging, SAM remains an important cause of difficult separation from cardiopulmonary bypass and postoperative circulatory compromise. The development of SAM is multifactorial and results from the interaction between mitral valve anatomy, ventricular geometry, surgical repair characteristics, and perioperative hemodynamic conditions. Contemporary evidence has identified several echocardiographic predictors, including excessive posterior leaflet height, elongated anterior leaflets, reduced coaptation–septal distance, a narrow mitro–aortic angle, basal septal hypertrophy, and small hyperdynamic left ventricles. Recognition of these risk factors facilitates perioperative risk assessment and pre-repair surgical planning. Transesophageal echocardiography plays a pivotal role throughout the perioperative period, enabling risk assessment before repair, early diagnosis after cardiopulmonary bypass, and guidance of therapeutic interventions. Initial treatment is based on preload optimization, afterload augmentation, withdrawal of inotropic stimulation, and heart rate control, whereas refractory cases may require surgical revision. This narrative review summarizes the current understanding of SAM after mitral valve repair, focusing on pathophysiological mechanisms, echocardiographic predictors, surgical prevention and perioperative management, with particular emphasis on the practical role of cardiac anesthesiologists and mitral valve surgeons. Full article

Background: Minimally invasive cardiac valve surgery (MIVS) provides distinct clinical advantages, yet annular suturing remains a technically demanding step. Automated annular suturing devices (RAM^®) have been developed to standardize suture placement during valve replacement. This study evaluates the initial clinical feasibility, technical safety, and operational integration of automated suturing during its institutional adoption phase. Methods: We retrospectively evaluated 43 consecutive patients undergoing MIVS supported by the RAM^® system (2021–2025), stratified into mitral valve replacements (RAM-MVR, n = 26) and aortic valve replacements (RAM-AVR, n = 17). Technical parameters, procedural safety metrics, and perioperative outcomes were descriptively analyzed and contextualized against our broader institutional MIVS platform using percutaneous femoral cannulation (n = 182). Results: Automated annular suturing achieved a 100% technical feasibility rate (43/43, 95% CI: 91.8–100.0%) with zero mechanical device failures or intraoperative suture-line disruptions (0%, 95% CI: 0.0–8.2%). In the RAM-MVR cohort, median cross-clamp and cardiopulmonary bypass (CPB) times were 73.0 min (IQR 64.0–91.0) and 114.5 min (IQR 94.8–129.5), respectively. In RAM-AVR, median cross-clamp time was 75.0 min (IQR 71.0–83.0). Thirty-day mortality was 4.7% (2/43, 95% CI: 0.6–15.8%), secondary to non-device-related medical complications in high-risk baseline patients. Postoperative echocardiography demonstrated no paravalvular regurgitation (0%, 95% CI: 0.0–8.2%). Conclusions: Initial institutional experience demonstrates that automated annular suturing is technically feasible and safe in minimally invasive mitral and aortic valve replacement. The system enables consistent procedural execution across valve positions. These observational data support automated suturing as a feasible alternative to manual suturing in MIVS workflows. Full article

Background/Objectives: Single atrium is a rare congenital heart defect typically repaired in infancy. Unrepaired adults with pregnancy face high risk, and postpartum repair with delayed sternal closure (DSC) has rarely been reported. Methods: We present a 33-year-old multiparous woman who presented at 30 weeks + 1 day of gestation with progressive dyspnea. Transthoracic echocardiography (TTE) revealed a single atrium with a common atrioventricular valve and an estimated pulmonary artery systolic pressure (PASP) of 47 mmHg. The multidisciplinary team advised early cesarean section, which was performed at 30 weeks + 3 days of gestation, but postpartum symptoms persisted. Six months later, the patient underwent surgical correction. The procedure was converted from right subaxillary mini-thoracotomy to median sternotomy due to intraoperative aortic dissection, which was repaired. The single atrium was partitioned using a bovine pericardial patch. Due to myocardial edema and hemodynamic instability, the sternum was left open and closed on postoperative day 4. She required 8 days of mechanical ventilation and 13 days of intensive care, and was discharged on day 27. Results: Surgical repair was successful, and at the 6-month postoperative follow-up, she had achieved NYHA class I functional status, with an estimated PASP of 40 mmHg and a well-positioned baffle with no residual shunt. Conclusions: This case demonstrates that multidisciplinary collaboration is essential for pregnant patients with unrepaired congenital heart disease, postpartum surgical correction is feasible with careful perioperative planning, and DSC is a safe strategy for managing hemodynamic instability in complex cardiac cases. Full article

Myocardial strain imaging, derived from speckle-tracking echocardiography (STE), has evolved from a research tool into a reproducible technique for detecting subclinical myocardial dysfunction. Recent advances in automated contouring and artificial intelligence have improved feasibility, reproducibility, and analysis speed, making multichamber strain assessment increasingly accessible in perioperative practice. Perioperative cardiovascular complications, including myocardial injury after non-cardiac surgery (MINS), postoperative atrial fibrillation (POAF), and heart failure, are associated with substantial postoperative morbidity and mortality. Conventional echocardiographic parameters, particularly left ventricular ejection fraction (LVEF), lack sensitivity for detecting early myocardial dysfunction. By quantifying myocardial deformation, strain imaging identifies subtle abnormalities in ventricular and atrial mechanics before conventional echocardiographic abnormalities become evident. Among available parameters, left ventricular global longitudinal strain (LV-GLS) and left atrial reservoir strain (LASr) provide the strongest evidence for perioperative risk stratification, with impaired values independently associated with MINS and POAF, respectively. Right ventricular strain (RV-GLS, RV-FWLS) and right atrial reservoir strain (RASr) remain promising but less standardized parameters supported mainly by observational data. Despite these advances, several barriers continue to limit widespread implementation, including vendor variability, the lack of standardized thresholds, and the absence of validated transesophageal echocardiography (TEE)-specific reference values. Importantly, current evidence supports myocardial strain primarily as a tool for risk stratification rather than for guiding therapy. No randomized trial has demonstrated that strain-guided perioperative management improves clinical outcomes, and its incremental value beyond established perioperative tools, including clinical risk scores, biomarkers, and conventional echocardiography, remains to be established. This review aims to provide a practical framework for the perioperative use of myocardial strain by summarizing the current evidence, clarifying its methodological limitations, simplifying its acquisition and interpretation for non-expert users, distinguishing established clinical applications from future research directions, and identifying the key evidence gaps that must be addressed before strain-guided strategies can be incorporated into routine perioperative care. 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/Objectives: The Ross procedure is recognized for its excellent long-term outcomes in aortic valve surgery, providing superior hemodynamic performance, freedom from anticoagulation, and a low risk of valve thrombosis. The aim of this study was to evaluate the technical feasibility and early clinical outcomes of performing the Ross procedure through a minimally invasive V-shaped (arrow-shaped) partial sternotomy in adult patients. Methods: Eleven consecutive adult patients underwent a Ross procedure through a 7 cm upper midline skin incision and a V-shaped (arrow-shaped) ministernotomy sternotomy extending to the third intercostal space. Cardiopulmonary bypass was established through central cannulation. The pulmonary autograft was implanted in the aortic position using the miniroot technique, followed by implantation of a pulmonary homograft in the pulmonary position. Operative, perioperative, and early echocardiographic outcomes were prospectively evaluated. Results: All procedures were completed successfully without conversion to full sternotomy or major intraoperative complications. The cardiopulmonary bypass and aortic cross-clamp times were consistent across the series, averaging 144 and 86 min, respectively. Intraoperative transesophageal echocardiography confirmed satisfactory function of both the autograft and homograft in all patients. Postoperative recovery was uneventful, with mechanical ventilation times ranging from 4 to 8 h and intensive care unit stays of 24–48 h. No cases of stroke, renal failure, permanent pacemaker implantation, atrial fibrillation, wound infection, sternal instability, reoperation for bleeding, readmission, or mortality occurred. Patients were discharged between postoperative days 7 and 10. At 3-month follow-up, transthoracic echocardiography demonstrated preserved left ventricular function, absence of aortic regurgitation, and low transvalvular gradients in all patients. Conclusions: This initial single-center case series demonstrates the technical feasibility of performing the Ross procedure through a V-shaped (arrow-shaped) partial sternotomy in carefully selected adult patients. The approach provides satisfactory operative exposure for all components of the procedure while maintaining the advantages of minimally invasive surgery. Larger studies with longer follow-up are required to further evaluate clinical outcomes and long-term durability. Full article

Background: Older adults undergoing non-cardiac surgery are vulnerable to perioperative complications, but the prognostic value of routine echocardiographic markers in high-acuity cohorts remains incompletely defined. Methods: This secondary analysis of a prospective cohort included 503 consecutive adults with known cardiovascular disease undergoing non-cardiac surgery, characterized by a high proportion of urgent presentations. Patients were stratified by age (geriatric, ≥65 years; non-geriatric, <65 years). The primary endpoint was major in-hospital adverse events (MIAEs), defined as a composite of in-hospital death, surgical reintervention, and postoperative acute kidney injury (AKI). Postoperative creatinine was not routinely measured in stable patients discharged early; therefore, renal outcomes were interpreted strictly as available-case analyses (n = 364). Results: MIAEs occurred more frequently in geriatric than in younger patients (45.5% vs. 30.8%). Within the geriatric cohort, patients with reduced LVEF (<50%) had lower MAPSE values and higher crude rates of AKI, death, and MIAE than those with LVEF ≥ 50%. In multivariable analyses, reduced LVEF was associated with MIAE, although this small subgroup was susceptible to statistical overfitting. MAPSE reflected longitudinal systolic dysfunction but did not retain independent prognostic value after adjustment. Conclusions: In this pilot subgroup analysis of high-acuity patients, reduced preoperative LVEF (<50%) served as a clinical flag identifying a high-risk geriatric phenotype with increased cardiorenal vulnerability. Given the event-enriched available-case denominator, these findings should be considered hypothesis-generating observations intended to increase clinical awareness. Full article

Transient myocardial thickening (TMT) is considered a reversible feline cardiac disease that initially mimics hypertrophic cardiomyopathy. The exact etiopathogenesis remains unknown and is likely multifactorial. General anesthesia and surgery may contribute to the development of TMT in predisposed patients due to systemic inflammation, perioperative stress, surgery itself, anesthetic management, and individual susceptibility. Additionally, inadequate analgesia could result in pain, which triggers a stress response. This stress response could stimulate endogenous catecholamine release and facilitate the development of TMT. In this retrospective study, anesthetic and analgesic protocols were compared between cats with and without TMT following gonadectomy. The study group consisted of 15 cats that presented with congestive heart failure after recent anesthesia and were later suspected of or diagnosed with TMT. The control group consisted of 300 cats without TMT after gonadectomy. All cats were considered healthy prior to gonadectomy based on physical examination; no echocardiography was performed prior to anesthesia. All cats in the TMT group were anesthetized with ketamine and an alpha-2 agonist, which was medetomidine in 14/15 (93.3%) and dexmedetomidine in 1/15 (6.7%) of the cats. In the control group, all cats were anesthetized with ketamine and dexmedetomidine. The ketamine dose was significantly higher (p < 0.001) in the TMT group compared to the control group, with a median dose of 6.78 mg/kg (4.52–10.34) and 4.29 mg/kg (2.08–6.45), respectively. The doses of the alpha-2 agonist and atipamezole were not significantly different. The most commonly administered non-steroidal anti-inflammatory drug was meloxicam in 83.3% of the study group cats and 98.7% of the control group cats. The dose of meloxicam was significantly lower (p < 0.001) in the study group compared to the control group, with median doses of 0.2 mg/kg (0–0.3) and 0.29 mg/kg (0–0.38), respectively. In the control group, 93.0% of the cats received buprenorphine, and 75.0% of males received intratesticular lidocaine. None of the cats in the study group received buprenorphine or intratesticular lidocaine during the procedure. Additionally, oxygen supplementation was significantly different (p < 0.017), and lack of oxygen was associated with the development of TMT. Anesthetic protocols between the two groups were significantly different. However, it is important to note that not all observed complications can solely be attributed to anesthetic or analgesic differences; effects might also be due to different perioperative circumstances. Full article

Background/Objectives: Minimally invasive valve surgery via right minithoracotomy is well established for isolated aortic and mitral procedures, but its application to multivalve operations remains uncommon and clinical data are scarce. We report our initial single-center experience with minimally invasive multivalve surgery—defined as a small skin incision without rib spreading or internal mammary artery dissection—in patients with combined aortic and mitral disease. Methods: We retrospectively analyzed 10 consecutive patients who underwent minimally invasive multivalve cardiac surgery at our institution. All operations were performed through a 5–7 cm right minithoracotomy in the third or fourth intercostal space, with femoral cannulation for cardiopulmonary bypass (CPB). Nine patients underwent a double-valve procedure (aortic and mitral) and one a triple-valve procedure (aortic, mitral, and tricuspid). Operative variables, perioperative complications, and early echocardiographic outcomes were assessed. Results: The mean age of patients was 69.8 ± 5.2 years and 60% were female. Mean CPB and aortic cross-clamp times were 197.6 ± 48.3 min and 148.1 ± 34.7 min, respectively. All procedures were completed via the minimally invasive approach, with no conversion to sternotomy and no in-hospital deaths. No rethoracotomies, wound infections, or peripheral vascular complications occurred. Postoperative atrial fibrillation, observed in five patients (50%), was the most common complication. Early echocardiography showed good valve function in nine patients (90%); one had a moderate aortic paravalvular leak managed conservatively. Conclusions: In a center with established experience in single-valve minimally invasive surgery, multivalve procedures can be safely extended to a right minithoracotomy approach, with low perioperative morbidity and no early mortality despite operative times reflecting the early learning curve. Full article

Perioperative anaphylaxis, though rare, is a potentially life-threatening complication. While antibiotics and neuromuscular blocking agents are common triggers, benzodiazepine-induced reactions have been considered uncommon. Remimazolam, a novel benzodiazepine sedative, has gained widespread use in Korea due to its rapid onset, short recovery, hemodynamic stability, and availability of flumazenil. However, increasing utilization has coincided with rising reports of hypersensitivity. We report the case of a 62-year-old female undergoing contralateral total knee replacement under spinal anesthesia. Continuous remimazolam infusion was initiated, but within ten minutes the patient developed chest discomfort followed by abrupt hypotension and oxygen desaturation, requiring urgent conversion to general anesthesia. Following a remimazolam bolus and rocuronium administration, sudden cardiac arrest occurred. Return of spontaneous circulation (ROSC) was achieved after approximately 28 min of cardiopulmonary resuscitation with a cumulative intravenous epinephrine dose of approximately 17 mg, and veno-arterial extracorporeal membrane oxygenation (ECMO) was required. Post-ROSC transesophageal echocardiography demonstrated a transient anteroseptal regional wall motion abnormality; subsequent coronary angiography demonstrated no significant coronary disease, and computed tomography pulmonary angiography was negative for embolism, leaving acute hypersensitivity as the most plausible mechanism. Acute serum tryptase was elevated at 11.6 µg/L and normalized to 3.4 µg/L (the patient’s individual baseline) prior to discharge, satisfying the World Allergy Organization (WAO) criterion. A skin prick test performed four weeks later was positive for remimazolam and negative for rocuronium and the other coadministered agents. An expanded multi-database literature review identified 16 prior cases of remimazolam-induced anaphylaxis. Most described cardiovascular collapse as the predominant manifestation. To our knowledge, based on available literature, this is among the first reports of remimazolam-induced anaphylaxis occurring in the setting of high spinal anesthesia with sympathetic blockade. Vigilance and adherence to established anaphylaxis management guidelines are essential. Full article

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

The progressive aging of the atrial fibrillation (AF) population, frequently characterized by high ischemic and bleeding risks, has led to a substantial increase in referrals for left atrial appendage occlusion (LAAO). The expansion of indications and the high procedural success rate of LAAO have further contributed to rising procedural volumes. However, this growth introduces important challenges: LAAO candidates are often elderly and frail, with increased anesthesia-related risks, and high-volume catheterization laboratories may face logistical constraints, particularly in centers without dedicated anesthesiology support. The current gold standard approach, transesophageal echocardiography (TEE) under general anesthesia (GA), ensures optimal imaging and procedural control but may increase procedural complexity and perioperative risks. In response, minimalist strategies are increasingly explored, targeting either the anesthetic protocol or the imaging modality. Conscious sedation (CS) protocols have been adopted to reduce anesthesia-related burden while maintaining TEE guidance. Alternatively, imaging-based strategies aim to replace TEE with less invasive modalities, including intracardiac echocardiography (ICE), transesophageal–intracardiac echocardiography (TE-ICE), and MicroTEE. Each approach presents specific advantages and limitations regarding safety, feasibility, operator expertise, and institutional resources. Taken together, these findings support a patient-centered approach to LAAO, whether traditional or minimalist, in which the choice of anesthetic strategy and echocardiographic guidance is driven by institutional resources, operator expertise, and individual patient characteristics rather than by expected differences in procedural or clinical efficacy. This review summarizes current evidence on minimalist LAAO pathways and discusses their role in achieving a tailored, resource-conscious procedural model. 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

Background: Perioperative cardiovascular risk assessment remains challenging in non-cardiac surgery, particularly in older patients and those with multiple comorbidities. Traditional models rely largely on clinical history and may not fully reflect current cardiovascular functional status. This study aimed to derive and assess the apparent performance of a new composite score, PERFORM-CV, integrating clinical, laboratory, and echocardiographic data. Methods: We conducted a prospective two-center cohort study including 503 non-cardiac surgical patients with cardiovascular comorbidity. The Revised Cardiac Risk Index (Lee/RCRI) and the AUB-HAS2 index were calculated according to their original published definitions as raw point totals ranging from 0 to 6; without additional normalization. The PERFORM-CV score was derived from univariable and multivariable analyses, with continuous predictors dichotomized using ROC-derived thresholds. Results: Emergency admission, chronic heart failure, and elevated serum creatinine remained independently associated with in-hospital mortality. Lower left ventricular ejection fraction, lower mitral annular plane systolic excursion (MAPSE), lower hemoglobin, and atrial fibrillation also contributed to the final composite score. ROC analysis showed good discrimination for PERFORM-CV (AUC 0.852; 95% CI 0.806–0.897; p < 0.001), comparable to Lee/RCRI (AUC 0.860; 95% CI 0.818–0.901; p < 0.001) and higher than AUB-HAS2 (AUC 0.779; 95% CI 0.731–0.826; p < 0.001). Conclusions: PERFORM-CV showed good apparent discrimination in the derivation cohort and may complement established bedside risk tools by incorporating echocardiographic and laboratory data. The ROC-derived thresholds should be interpreted as data-driven derivation cut-offs; resampling-based internal validation and external validation are required before broader clinical use. Full article

Background/Objectives: Totally endoscopic mitral valve repair reduces surgical trauma and accelerates recovery but can be technically challenging, particularly for precise annuloplasty suturing. The VirtuoSEW^® (LSI Solutions, Victor, NY 14564m, USA) automated annular suturing system was developed to standardize and simplify suture placement. This study was an early evaluation of this technology’s safety, efficacy, and feasibility in totally endoscopic microInvasive mitral valve repair (µMVr). Methods: We conducted a retrospective observational study of 20 patients with severe mitral valve disease of various etiologies. All patients underwent mitral valve repair using the VirtuoSEW^® system for automated placement of annuloplasty sutures, combined with leaflet resection or chordal management as appropriate. Postoperative outcomes were assessed at one month using echocardiography and clinical evaluation. Perioperative and postoperative complications and early mortality were systematically recorded. Results: VirtuoSEW^®-assisted mitral valve repair was safe and effective, achieving complete elimination of severe mitral regurgitation in all patients (N = 20, 100%). Annuloplasty rings included Physio-ring (N = 12, 60%), Memo 3D (N = 4, 20%), and Memo 4D (N = 4, 20%), combined with leaflet repair techniques: leaflet plication (N = 5, 25%), neochordae implantation (N = 7, 35%), sliding plasty (N = 2, 10%), commissural repair (N = 1, 5%), and hemibutterfly repair (N = 1, 5%). Concomitant procedures included: tricuspid valve repair (N = 1, 5%) and atrial septal defect closure (N = 1, 5%). Mitral annulus diameter decreased from 42.0 ± 5.3 mm to 34.2 ± 2.2 mm (p = 0.001). Mean total surgery, cardiopulmonary bypass, and aortic cross-clamp times were 170.3 ± 21.3, 143.4 ± 21.5, and 80.4 ± 7.9 min, respectively. ICU stay was 1.0 ± 0.2 days, with a hospital stay of 8.0 ± 1.9 days. No perioperative complications—including bleeding (N = 0, 0%), stroke (N = 0, 0%), infections (N = 0, 0%), or 30-day mortality (N = 0, 0%)—occurred. Conclusions: µMVR invasive mitral valve repair using the VirtuoSEW^® system is safe, effective, and reproducible, as well as compatible with almost all repair techniques, providing complete restoration of valve competence with no early device-related complications. To our knowledge, this is the first clinical study reporting outcomes with this device, supporting its potential to streamline mitral repair and improve procedural efficiency. Full article