Volume 40 - Issue 6

Introduction: This study assessed the impact of a quality and safety (Q&S) improvement program on outcomes in pediatric and congenital heart surgery (PCHS) through an international non-governmental collaboration in a low-and-middle-income country (LMIC).
Methods: Surgical data from two distinct periods, PRE (January 2016 – December 2019) and POST (January 2020 – May 2024) Q&S implementation, were analyzed. Outcomes included 30-day mortality, urgency status, patient age, and procedure complexity using the Risk Adjustment for Congenital Heart Surgery (RACHS) 1 classification.
Results: A total of 4,297 surgeries were performed: 2,429 in the PRE and 1,868 in the POST era. Overall, 30-day mortality decreased significantly from 7.5% to 5.1% (P = 0.002), reaching 3.1% in 2024. Urgent surgeries increased from 28% to 44% (P < 0.0001), while mortality in elective and urgent cases dropped from 3.9% to 1.7% (P = 0.0007) and from 16.5% to 9.6% (P < 0.0001), respectively. A shift toward more neonatal and infant cases was observed, with significant reductions in mortality in both groups (P = 0.01). Case mix complexity also increased (RACHS categories 3–6), yet mortality declined across all RACHS strata.
Conclusion: The introduction of Q&S initiatives led to marked improvements in PCHS outcomes, even amid growing case complexity and acuity. These findings highlight the value of structured protocols and sustained Q&S efforts and underscore the transformative role of international partnerships in strengthening surgical care in LMICs.

Introduction: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a popular and severe complication after cardiac surgery. We aimed to set up a quick and accurate predictive model for rapid identification of CSA-AKI and to evaluate its predictive value.
Methods: In this retrospective study, we included a total of 120 patients who underwent heart surgery and divided them into 55 patients who developed kidney injury following heart surgery (CSA-AKI group) and 65 patients who did not experience kidney injury after the same surgical procedure (non-CSA-AKI group). The predictive capacity of various laboratory indicators for CSA-AKI were assessed, including tumor necrosis factor-α (TNF-α), interleukin 2, interleukin 6, and neutrophil gelatinase-associated lipocalin (NGAL). Additionally, receiver operating characteristic curve analysis was employed to evaluate the performance of the model in predicting CSA-AKI.
Results: After cardiac surgery, patients who developed CSA-AKI exhibited significantly higher levels of TNF-α, interleukin 2, interleukin 6, and NGAL compared to the control group. Receiver operating characteristic curve analysis revealed that TNF-α, interleukin 2, interleukin 6, and NGAL showed good diagnostic performance, with area under the curve values of 0.66, 0.78, 0.66, and 0.80, respectively. Further analysis demonstrated that the combination of TNF-α, interleukin 2, interleukin 6, and NGAL had the highest predictive value for acute kidney injury (area under the curve = 0.93).
Conclusion: TNF-α, interleukin 2, interleukin 6, and NGAL exhibited a promising predictive capability for CSA-AKI, while a combined diagnostic model was established to enhance the diagnostic value further.

Objective: We herein probed the effects of ozone autohemotherapy (O3-AHT) on inflammatory response and postoperative cognitive function in patients undergoing valve replacement with cardiopulmonary bypass (CPB).
Methods: Totally, 130 patients undergoing valve replacement with CPB were included in the study (O3-AHT) and control (banked blood transfusion) groups. Blood samples were taken for blood gas analysis, with arterial oxygen saturation, jugular venous oxygen saturation, partial pressure of arterial oxygen and jugular venous PO₂, hemoglobin, and cerebral oxygen extraction rate documented. Interleukin (IL)-6, tumor necrosis factor alpha (TNF-α), and IL-1β levels and serum S100β and neuron-specific enolase (NSE) concentrations were measured by enzyme-linked immunosorbent assay, followed by cognitive function assessment by Mini-Mental State Examination and Montreal Cognitive Assessment scales.
Results: The research group exhibited elevated thrombin time, activated partial thromboplastin time, and prothrombin time and decreased fibrinogen level immediately after surgery; it also presented reduced 24-hour postoperative serum IL-6, TNF-α, IL-1β, S100β, and NSE levels. Intraoperative cerebral oxygen metabolism was improved, and cognitive dysfunction was alleviated in the research group. The comparison of transfusion complication incidence between the two groups showed no significant difference.
Conclusion: The application of O3-AHT in patients undergoing valve replacement with CPB enhanced intraoperative brain oxygen metabolism and reduced postoperative 24-hour inflammatory response and cognitive dysfunction.

Introduction: Postoperative atrial fibrillation (POAF), the pathophysiology that includes inflammation and oxidative stress, is associated with increased hospital length of stay, mortality, and complications. The uric acid-to-albumin ratio reflects the inflammatory status of the body. We sought to evaluate whether there is an association between POAF and uric acid-to-albumin ratio in patients undergoing cardiac surgery.
Methods: Five hundred forty-three patients who developed POAF and 166 patients who did not formed our control and study groups, respectively. Patients who had an episode of atrial fibrillation lasting > 30 seconds were considered to have POAF. The uric acid-to-albumin ratio was calculated for each patient.
Results: Patients who developed POAF were older; had higher rates of hypertension, carotid artery disease, left atrial diameter, urea, creatinine, uric acid, and C-reactive protein levels; and had lower hemoglobin and albumin levels. The uric acid-to-albumin ratio of patients with and without POAF was 1.65 ± 0.63 and 1.26 ± 0.39, respectively (P < 0.001). Compared with uric acid and albumin, uric acid-to-albumin ratio had the highest area under the curve for predicting POAF (0.681, 0.449, and 0.702, respectively). Age and hemoglobin concentration were predictors of POAF. Although uric acid and albumin did not reach statistical significance for predicting POAF, the uric acid-to-albumin ratio had predictive value for the development of POAF.
Conclusion: The ability of the uric acid-to-albumin ratio to predict POAF in cardiac surgery patients and its nonnegligible benefits justify its use in clinical practice.

INTRODUCTION: The advantages of beating heart tricuspid surgery without aortic cross-clamping remain underexplored, particularly in the context of concomitant procedures. This study aimed to compare the short- and long-term outcomes of tricuspid valve surgery performed with and without aortic cross-clamping.
METHODS: This retrospective cohort study included 1,154 patients who underwent isolated or concomitant tricuspid valve surgery between 2009 and 2021. Patients were divided into two groups, those who underwent surgery without aortic cross-clamping (beating heart, n = 170) and those with cross-clamping (arrested heart, n = 984). Propensity score matching identified 139 matched pairs.
RESULTS: The mean age was 56 years (25^th-75^th percentiles: 47, 65), with 61.27% female patients and 95% undergoing concomitant procedures. In the unmatched cohort, patients who underwent beating heart surgery had higher preoperative creatinine clearance (93.53 vs. 81.33 ml/min, P = 0.036) and shorter intensive care unit stays (3 [1 – 5] vs. 3 [1 - 6] days, P = 0.037). However, after propensity score matching, there were no significant differences in postoperative heart block (P > 0.99), creatinine levels (P = 0.780), or tricuspid regurgitation grade (P = 0.082) between the two groups. Long-term outcomes, including 10-year freedom from reintervention (95% vs. 98%, log-rank P = 0.087), survival (77% vs. 82%, P = 0.964), and heart failure rehospitalization (76% vs. 77%, P = 0.444), were also comparable between the matched cohorts.
CONCLUSION: Concomitant tricuspid surgery without aortic cross-clamping is a viable alternative to traditional arrested heart surgery, with no significant differences in short- or long-term outcomes.

INTRODUCTION: Perfusion accidents still threaten the safety of perfusion during open-heart surgery. To prevent these accidents and increase perfusion safety, it is important to first determine the profile of perfusionists. The aims of this study were to determine the current status of perfusion safety during open-heart surgeries in Turkiye and to investigate the knowledge, attitudes, and experiences of perfusionists about cardiopulmonary perfusion safety.
METHODS: First, 148 perfusionists answered the Perfusionists' Attitudes on Perfusion Safety survey, and second, 109 perfusionists answered the Perfusion Safety and Accidents survey. In the first survey, perfusionists' attitudes and opinions help us understand the profile of Turkish perfusionists. In the second survey, we tried to obtain experiences and data about perfusion accidents, experienced by the participant perfusionists, to make a detailed analysis.
RESULTS: Turkish perfusionists are willing to ensure perfusion safety and prevent accidents. In this study, however, we found that educational institutions and clinics have not transmitted enough knowledge to perfusionists related to perfusion safety issues. There is some lack in the perfusionists knowledge about perfusion safety and preventing or reducing perfusion accidents.
CONCLUSION: Perfusionists need more training to ensure perfusion safety and to prevent perfusion accidents. It would be very beneficial to include a course on perfusion safety in academic settings that focuses on this subject in the curricula. Further comprehensive studies on this subject will make very important contributions to the practical perfusion applications in increasing perfusion safety and reducing perfusion accidents.

INTRODUCTION: Orthotopic heart transplantation (OHT) has become the standard of care for children with end-stage heart failure refractory to medical or surgical therapy. Despite the improvement in perioperative survival in the last decades, the long-term complications and mortality remain significant. This report examines the experience of a single center in Brazil with pediatric OHT, focusing on long-term results and mortality.
METHODS: This is a retrospective study from January 2002 to December 2022. Data collection consisted of demographic data, indication for heart transplantation, immunosuppression, main complications, and mortality.
RESULTS: There were 77 OHT in 74 patients. The median age at the time of OHT was 11.5 years (interquartile range 0.25 – 22 years). The indications for OHT were congenital heart disease in 46.8%, cardiomyopathy in 45.5%, and retransplantation in 3.9% of the patients. There was an average of 2.2 rejection episodes/patient and 1.3 infection episodes/patient during the first year of follow-up. The most common long-term complications were acute kidney injury (51%), systemic arterial hypertension (40.5%), and post-transplantation diabetes mellitus (10.4%). Overall survival after one year of OHT was 89.6% and five- and 10-year survivals were 80% and 59%, respectively.
CONCLUSION: Heart transplant is an acceptable therapeutic option for children and young adults in middle-upper income countries, with outcomes and long-term follow-up close to those of high-resource countries.

INTRODUCTION: The aims of this study are to compare sternal closure techniques (single, figure-of-8, and combined use) in patients undergoing cardiac surgery and to investigate their relationship with postoperative sternal complications.
METHOD: Between 2023 and 2024, 645 patients (470 males; mean age 58.5 ± 11.1 years) who underwent cardiac surgery were evaluated. The patients were divided into three groups: Group 1, simple wire (n = 141); Group 2, figure-of-8 (n = 224); and Group 3, combination of these two techniques (n = 280). Preoperative and perioperative data, postoperative complications, and sternal complications were compared between these groups.
RESULT: The distribution ratio of the groups is 141 (22%), 224 (35%), and 280 (43%) in Groups 1, 2, and 3, respectively. There was no significant difference between the groups regarding basic demographic characteristics, comorbidities, and operative data. There was no difference between the groups in terms of postoperative exploration, delayed chest closure, subxiphoid decompression, superficial sternal wound infection (SSWI), deep sternal wound infection (DSWI), vacuum-assisted closure usage, intubation time, intensive care unit stay, and mortality. The hospital stay was found to be shorter in Group 3 compared to the other groups (median 8 days - 7 days, P = 0.02).
CONCLUSION: In patients undergoing cardiac surgery, we found no difference in sternal complications (DSWI, SSWI) between the three most commonly used closure techniques (simple wire, figure-of-8, and their combination). We found that the length of hospital stay was shorter in patients with the combined technique than in the other two techniques.

INTRODUCTION: Choosing a surgical technique in patients with acute type A aortic dissection is still a debatable issue. In patients with massive aortic root destruction, the Bentall procedure is a gold standard. Aortic valve reimplantation is a reliable alternative, especially in patients with the preserved anatomy of aortic valve leaflets.
OBJECTIVE: To compare the results of modified valve sparing procedure and composite root replacement in patients with acute type A aortic dissection.
METHODS: In total, 62 patients were included in this study. Of those, 27 patients underwent aortic valve reimplantation, and 35 had the Bentall procedure with the Kouchoukos modification.
RESULTS: Preoperative demographics and clinical characteristics were analyzed in both groups. Similar indicators of preoperative malperfusion were observed in both. Cardiopulmonary bypass time (P = 0.125) and aortic clamping time (P = 0.001) were longer (≈ 30 minutes) in the reimplantation group while the time of circulatory arrest was longer in the Bentall group (P = 0.290). Hospital mortality rates were 8.3% in the reimplantation group and 22.9% in the Bentall group. During the long-term follow-up period, there were six (25%) deaths in the reimplantation group and 10 (28.6%) deaths in the Bentall group. The aortic regurgitation degree was stable in all cases up to the moment of last contact with the patients.
CONCLUSION: Modified aortic valve reimplantation shows good immediate and long-term outcomes in patients with acute type A aortic dissection.

INTRODUCTION: Reoperative cardiac surgery is associated with a higher risk of complications due to technical difficulties compared to the first-time surgery. This study aims to compare the early outcomes of median sternotomy (MS) and lateral thoracotomy (LT) procedures in patients with a history of previous open-heart surgery who underwent left ventricular assist device (LVAD) implantation with cardiopulmonary bypass (CPB).
METHODS: A retrospective analysis was conducted on 36 patients who received LVAD implants for end-stage heart failure between November 2012 and June 2015. The patients were divided into Group 1 (MS, n = 18) and Group 2 (LT, n = 18).
RESULTS: The mean age of the patients was 57.2 ± 9.4 years (range: 24 – 70 years), and only 8.3% were female. Demographic data, preoperative characteristics, use of blood products, anesthetic drugs, and complications were similar in both groups (P > 0.05). The MS group had significantly longer operation duration (101 ± 46 minutes vs. 70 ± 20 minutes, P = 0.038) and CPB time (328 ± 79 minutes vs. 265 ± 47 minutes, P = 0.048) compared to the LT group. Postoperative analgesic consumption and pain scores were similar between the two groups (P > 0.05).
CONCLUSION: In patients with a history of previous cardiac surgery, LVAD implantation with LT through CPB demonstrated favorable outcomes regarding reduced operation duration and CPB time. However, it did not positively impact the duration of stay in the intensive care unit, hospital stay, use of blood products, and complications.

INTRODUCTION: Frailty syndrome is a significant risk factor for elderly patients undergoing cardiovascular surgery. However, there is no consensus on which criteria are most effective for assessing frailty in this context.
OBJECTIVE: This study aimed to evaluate the relationship between different widely cited frailty syndrome criteria and postoperative morbidity and mortality.
METHODS: Patients aged ≥ 60 years scheduled for coronary artery bypass graft, valve, and/or ascending aortic surgery were assessed for frailty preoperatively. Frailty was defined by Clinical Frailty Scale (CFS) ≥ 4, Katz Index ≥ 1, Short Physical Performance Battery (SPPB) ≤ 6, Fried Frailty Phenotype (FFP) ≥ 3 or abnormal values in 15-feet gait speed (GS) test, or hand grip strength. Clinical outcomes, including mortality and major adverse cardiovascular and cerebral events (MACCE), were assessed 30 days post-surgery.
RESULTS: Among 137 patients (70.1% male, mean age 69.43 ± 5.98 years), frailty prevalence ranged from 13.1% to 43.1%, depending on criterion, with no significant differences by age strata or surgery type. At 30-day follow-up, mortality was 5.1% (n = 7), and a total of 29 MACCE (21.1%) were recorded. Patients identified as frail by the FFP, CFS, SPPB, and GS criteria showed a significant association with mortality and MACCE. Multivariate analysis indicated FFP and CFS as independent risk factors for MACCE with equivalent prognostic prediction.
CONCLUSION: Frailty is a prevalent condition among elderly patients undergoing cardiovascular surgery and is associated with mortality and morbidity. Frailty defined by FFP and CFS criteria was independently associated with higher MACCE rates.

OBJECTIVE: This study aimed to investigate the frequency of persistent left superior vena cava (PLSVC) and its impact on outcomes in children undergoing congenital heart surgery.
METHODS: The study was conducted retrospectively in cases diagnosed with congenital heart disease who were operated on under the age of 16 years between October 1st, 2021, and October 1st, 2024, at two major tertiary centers. The frequency of PLSVC and its possible impact on surgical outcomes were evaluated in these cases. The results were analyzed statistically.
RESULTS: There were 4,000 cases during the study period, with 52% being male. The median weight was 5.2 kg (interquartile range 4.5 - 6 kg). PLSVC was detected in a total of 260 cases (6.5%). Of these cases, 92.3% (240/260) drained into the coronary sinus, while 7.7% (20/260) drained directly into the left atrium. In 251 (96.5%) of the patients with PLSVC, there was a right SVC, while nine (3.5%) did not have a right SVC. Of the 251 patients with double SVC, 105 (42%) had a normal innominate vein. PLSVC was primarily associated with heterotaxy syndrome, atrioventricular septal defect, and vascular ring defects.
CONCLUSION: There is an increased frequency of PLSVC among certain congenital heart disease groups, and raising awareness during echocardiographic examination can facilitate the diagnosis of PLSVC. Preoperative diagnosis of PLSVC can help in managing complications more effectively

Introduction: Mechanical circulatory support (MCS) devices have evolved significantly over the past decades and play a vital role in managing end-stage heart failure, especially as a bridge to heart transplantation. From the pioneering heart-lung machines to third-generation ventricular assist devices (VADs), MCS technology has advanced to provide more durable, efficient, and safer options for both short- and long-term support. This review outlines the historical development of mechanical assist devices, the types of available supports – ranging from intra-aortic balloon pumps and extracorporeal membrane oxygenation to implantable devices like HeartMate 3 – and their clinical indications and complications. Special attention is given to right ventricular dysfunction, thromboembolic and hemorrhagic complications, and infections, which remain major challenges in the management of patients with MCS devices.
In Brazil, despite the growing evidence supporting MCS in critically ill patients, access remains limited due to financial and systemic constraints. The review explores the current landscape of device availability in the country, national guidelines, cost-effectiveness data, and the impact of recent changes in transplant allocation criteria that prioritize patients receiving mechanical support. Notably, the approval of long-term VADs for destination therapy in the public health system in 2024 marks a significant milestone.
This review offers a comprehensive perspective on MCS utilization, highlighting both global advances and Brazil-specific challenges. By identifying gaps in access and proposing future directions, it advocates for expanded use of these life-saving technologies to improve survival and quality of life in advanced heart failure patients.

Three-dimensional (3D) printing is an innovative technology with increasing and emerging potential in cardiothoracic surgery. This technology has significantly impacted translational research, education, and clinical practice. In high-income countries, 3D printing has vastly broadened the understanding of the cardiovascular system and helped in surgical planning by facilitating the nuanced creation of patient-specific cardiac models with exact precision to allow the development of personalized devices and surgical tools to facilitate improved patient outcomes. However, in low-income countries, such as those in Africa, there is limited access to 3D printing technology. The growing burden of complex cardiovascular diseases in Africa warrants the need for this technology to improve the standard of care for cardiac surgical patients. This review discusses the fundamentals of 3D printing, its relevance to current disease burdens in the context of the African population, its current state and future prospects in African cardiac care, its unmet needs, challenges, and how to implement it in the continent.

In this article, the authors present the indication for surgical ablation of atrial fibrillation and of left atrial appendage occlusion. They also present technical aspects of Cox-Maze IV operation and of left atrial appendage clip occlusion. They discuss the result of those techniques and what the guidelines recommend for their use.

We present a case of left atrial thrombus mimicking myxoma after orthotopic heart transplantation. Multimodality imaging established the diagnosis of atrial myxoma, and the patient was treated accordingly, but the definite diagnosis after surgical excision and histology showed left atrial thrombus. This report demonstrates the limitations of multimodality diagnosis in tumors with features highly suggestive of an atrial myxoma.

We report the case of a surgical treatment after transcatheter edge-to-edge mitral valve repair failure in a 79-year-old patient who had undergone cardiac surgery 30 years earlier. The transcatheter procedure of mitral valve got complicated by single leaflet device attachment leading to recurrent severe regurgitation. Despite the extremely high surgical risk and a porcelain aorta, we deemed the patient operable thanks to his performant physical and cognitive status. He underwent mitral valve replacement with a bioprosthesis in deep hypothermic circulatory arrest and retrograde cerebral perfusion. The postoperative course was regular, and he is in good functional class at one-year follow-up.

Implanting sutureless aortic valves enables a reduction in surgical times and related complications. Nonetheless, their application has been limited in cases involving aortic aneurysms due to anchor system concerns. We present a case of aortic valve replacement using a Perceval^TM sutureless aortic valve in a patient with stage IV chronic kidney disease, an ascending aortic aneurysm, and a porcelain aorta. The procedure was performed concomitantly with coronary artery bypass grafting involving two grafts, as well as ascending aorta and hemiarch replacement. This case underscores the critical importance of time efficiency, technical modifications for valve implantation, and strategic surgical planning to mitigate potential intraoperative and postoperative complications.

Left ventricular aneurysm is an important mechanical complication of myocardial infarction, and its reported incidence after myocardial infarction varies between 10 and 35%. Left ventricular aneurysms in patients with angina pectoris, congestive heart failure, malignant ventricular arrhythmias, and systemic embolization should be surgically repaired. In this paper, we present a novel modified off-pump linear closure technique performed by using a simple Foley catheter for hemostasis on beating heart without cardiopulmonary bypass for the surgical treatment of left ventricular aneurysm. To the best of our knowledge, this is the first reported case of such an approach in the literature.

Cardiopulmonary bypass (CPB) in children presents challenges related to blood volume and surface area of the circuit. Conventional ultrafiltration (CUF) is used to minimize complications, but modified ultrafiltration (MUF) can optimize clinical outcomes. We propose a modification to the CPB circuit, incorporating three luer connectors and a 12 Fr extension tube, allowing for simple and safe MUF implementation. Since 2014, this technique has been applied to approximately 3,500 children weighing < 20 kg, proving to be effective and low-cost. The new configuration does not require additional pumps, facilitates volume replacement, and maintains blood temperature, thereby improving procedural safety. Results indicate that this circuit modification for MUF offers safe and efficient management strategy for pediatric patients, with low risk of complications and potential easy implementation in various cardiovascular surgery centers.