The Off-pump versus On-pump Coronary Artery Bypass Grafting in Frail Patients (FRAGILE Trial) is a multicenter, randomized controlled trial comparing off-pump and on-pump coronary artery bypass grafting in frail or pre-frail patients undergoing coronary artery bypass grafting. This manuscript presents an update to the FRAGILE Trial study design, detailing protocol modifications made in response to the time gap between the study’s conception and its actual implementation. These changes were implemented early in the trial and were formally approved by the Ethics Committee, ensuring the scientific and ethical integrity of the study and reinforcing its relevance to address a gap in a vulnerable patient population.

Keywords: Coronary Artery Bypass Grafts; CABG; Frailty Syndrome; Outcomes; Coronary Artery Disease

Minimally invasive direct coronary artery bypass grafting (MIDCAB) has considerable benefits over the conventional coronary artery bypass grafting procedure. This case report presents the MIDCAB procedure in a multivessel coronary disease using triple arterial grafts and four arterial anastomoses. The initial anastomosis was made between the left intrathoracic mammary artery (LIMA) and the radial artery (RA), as an end-to-side "T" graft. Next, the RIMA was used to left anterior descending anastomosis. The first obtuse marginal (OM1) branch was grafted to allow LIMA-OM1 side-to-side anastomosis. Then, with the diagonal branch (Dg) opened, the formation of a "jumping" anastomosis was made using LIMA-OM1-Dg. The posterior descending artery (PDA) was used to create a LIMA-RA-PDA.

Keywords: Coronary artery bypass; Coronary Artery Disease; Surgical Anastomosis; Mammary arteries; Radial artery

Post-myocardial infarction ventricular septal defect is an infrequent complication associated with low survival rates in the absence of surgical management. An 80-year-old woman presents to the emergency department with an inferior wall ST-segment elevation myocardial infarction with complete occlusion of the right coronary artery and a rupture of the interventricular septum with rapid deterioration to cardiogenic shock. Advanced age, female sex, and cardiogenic shock are associated with high mortality. The use of intra-aortic balloon pump improves hemodynamic status, allowing stabilization in the preoperative period.

Keywords: Heart Septal Defects. Ventricular. Myocardial infarction. Cardiogenic shock. Hospital Emergency Service. Preoperative Period.

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Introduction: The use of organs from suicide donors in heart transplantation is controversial due to potential concerns about graft function and recipient outcomes. This study investigates the association between heart transplantation using suicide donors related with the incidence of primary graft dysfunction (PGD) and mortality within 30 days after transplant.
Methods: A retrospective analysis was conducted on 97 adult heart transplant recipients at the Instituto do Coração of São Paulo between 2020 and 2021. Data on donor characteristics (age, sex, mechanism of brain death), recipient preoperative status (age, sex, cardiomyopathy etiology, body mass index, comorbidities, use of intra-aortic balloon pump, extracorporeal membrane oxygenation [ECMO]), intraoperative variables (ischemia time, cardiopulmonary bypass time, implantation time), and postoperative outcomes (use of ECMO, mortality) were analyzed.
Results: Of the 97 transplants analyzed, six were from suicide donors (6.2%). Recipients of hearts from suicide donors had a significantly higher need for ECMO (33.3% vs. 4.4%, P = 0.036), increased PGD (66.7% vs. 19.8%, P < 0.05), and higher 30-day mortality (50% vs. 3.3%, P < 0.05) compared to non-suicide donors. No significant intraoperative time differences were found between the groups.
Conclusion: This study is the first to identify a significant association between heart transplantation from suicide donors and adverse outcomes, including higher rates of PGD and early mortality. These findings suggest possible psychological and biological influences on organ quality and transplantation outcomes. Further research is needed to clarify these associations and inform donor selection criteria.

Keywords: Heart transplantation; Donors; Primary Graft Dysfunction; Organ preservation; Inflammatory Markers;

Ventricular assist devices have been widely accepted as an alternative treatment for advanced heart failure, while heart transplantation is a limited procedure because of the shortage of donors. In face of a scarce availability of these devices, many centers around the world have developed their own technologies. We describe historical and general features of the main ventricular assist devices developed at the Instituto Dante Pazzanese de Cardiologia. The auxiliary total artificial heart is an electromechanical pulsatile blood pump with left and right chambers, being originally designed to work as a heterotopic artificial heart. The spiral pump is a disposable device and currently available for clinical use in cardiopulmonary bypass. It works through a combination of centrifugal and axial pumping principles coming from a conically shaped impeller. The implantable centrifugal blood pump was conceived for long-term circulatory assistance with a unique impeller design concept producing a mixed flow. The apico-aortic blood pump consists of a miniaturized centrifugal pump originally conceived for bridge to transplantation strategy. The temporary circulatory support device is a new centrifugal blood pump for temporary ventricular assistance developed with the purpose of bridge-to-decision or recovery strategies. Additionally, the hybrid cardiovascular simulator was developed as a tool to test blood pumps as they minimize the need for animal experiments. Brazil represents an important reference with a few academic groups with a considerable output in ventricular assist devices research and development. Notable devices produced at Instituto Dante Pazzanese de Cardiologia have demonstrated excellent results for clinical application.

Keywords: Engineering; Heart-assist devices; Cardiopulmonary bypass; Animal experimentation; Heart failure; Heart transplantation; Artificial Heart;

This review highlights the pivotal milestones in the development of cardiac transplantation and related techniques. Beginning with Alexis Carrel's pioneering work on vascular anastomosis and organ preservation, the narrative progresses through groundbreaking achievements such as John Gibbon's invention of the heart-lung machine in 1953 and James Hardy's daring chimpanzee-to-human heart transplant in 1964. The story culminates in Christiaan Barnard’s historic human heart transplant in 1967 and Euryclides Zerbini's leadership in bringing this innovation to Brazil in 1968. Key advancements include the development of orthotopic heart transplantation techniques by Richard Lower and Norman Shumway and the resurgence of heart transplants following the introduction of cyclosporine in 1983, which revolutionized organ rejection management. The collaborative Programa Nordeste de Transplante Cardíaco, initiated in 1986, exemplifies regional innovation in overcoming logistical and financial barriers in Brazil. Recent progress, such as the first successful xenotransplantation using a genetically modified pig heart in 2022, underscores ongoing efforts to address donor shortages and improve transplant outcomes. This narrative is a testament to human ingenuity and perseverance in offering life-saving solutions to end-stage heart disease.

Keywords: Surgery; Pioneer; Heart transplantation; Historical Article

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Introduction: Diaphragm elevation is commonly seen after cardiac surgery, mostly due to phrenic nerve injury. However, only historical data is available on the incidence of diaphragm elevation and its consequences during recovery.
Objective: We aim to provide contemporary insights into the incidence of diaphragm dysfunction in patients undergoing cardiac surgery and its effect on postoperative outcomes.
Methods: Records of all patients undergoing cardiac surgery through sternotomy between 2015 and 2016 at the Radboud University MedicalCentre were retrospectively reviewed. Diaphragm position and elevation were evaluated on available chest radiography. Right-sided diaphragm elevation was defined as the right diaphragm being > 3.0 cm above the left diaphragm; left-sided diaphragm elevation was defined as < 0.5 cm below or above the level of the right diaphragm.
Results: A total of 1510 patients have undergone cardiac surgery through sternotomy during the study period, of which 1316 patients were included in the final analysis. Of these 1316 patients, 13% (n = 179) had pre-existing diaphragm elevation, 27% (n = 351) had a new diaphragm elevation postoperative-y, and 60% (n = 786) had no diaphragm elevation. No statistically significant differences were found between the groups in the occurrence of postoperative (pulmonary) complications or mortality. Of patients who developed new diaphragm elevation postoperatively, 65% recovered in the follow-up period.
Conclusion: New postoperative diaphragm elevation occurs in 27% of patients undergoing cardiac surgery. However, new postoperative diaphragm elevation is not associated with a higher incidence of postoperative complications and spontaneous recovery is seen in most patients.

Keywords: Cardiac surgery. Diaphragm Elevation. Phrenic Nerve Injury