Jacob Zeitani

Background: Conventional on-pump cardiopulmonary bypass (CPB) remains widely used in coronary artery bypass grafting (CABG), particularly in limited-resource healthcare systems because of its lower upfront cost and technical simplicity. However, conventional extracorporeal circulation has been associated with systemic inflammation, hemodilution, organ dysfunction, transfusion exposure, and increased postoperative resource utilization. This study evaluated early postoperative outcomes following isolated elective CABG performed using conventional open CPB and explored potentially modifiable determinants of postoperative morbidity. Methods: This retrospective single-center observational study included 122 consecutive adult patients undergoing isolated elective on-pump CABG between January 2024 and March 2025. Emergency procedures, redo surgery, combined procedures, and off-pump CABG were excluded. Primary endpoints were 30-day mortality and acute kidney injury (AKI). Secondary endpoints included postoperative bleeding, postoperative atrial fibrillation (POAF), transfusion requirement, mechanical ventilation time, intensive care unit (ICU) stay, postoperative hospital stay, and re-exploration for bleeding. Results: Thirty-day mortality was 0%. Mean CPB time was 62.6 ± 16 minutes and mean cross-clamp time was 34.9 ± 10.1 minutes. Patients received a mean of 2.99 ± 0.64 grafts, with at least one internal mammary artery used in all cases. AKI occurred in 28.7% of patients, predominantly Kidney Disease: Improving Global Outcomes (KDIGO) stage 1. Significant perioperative hemodilution was observed, with hematocrit decreasing from 43.4% preoperatively to 32.4% on ICU admission. Mean 24-hour chest drainage was 411.8 ± 169.3 mL, while transfusion was required in 9.8% of patients. POAF occurred in 18% of cases and re-exploration for bleeding in 3.3%. Mean ventilation time was 3.4 ± 1.7 hours, ICU stay was 1.15 ± 0.44 days, and postoperative hospital stay was 6.77 ± 1.32 days. CPB duration was not significantly associated with AKI, transfusion, or POAF. However, transfusion exposure was strongly associated with prolonged ventilation and ICU stay. Conclusions: In this exploratory, retrospective single-center analysis without a comparator group, conventional open CPB enabled excellent short-term survival and rapid postoperative recovery when combined with efficient surgical execution and standardized perioperative care. Nevertheless, clinically significant perioperative physiological disturbances remained evident despite favorable early clinical outcomes, particularly in the form of AKI, persistent perioperative hemodilution, and transfusion-associated ICU prolongation. Favorable early clinical outcomes may coexist with measurable postoperative physiological burden, potentially increasing downstream healthcare resource utilization. Progressive implementation of goal-directed perfusion, blood conservation strategies, viscoelastic coagulation monitoring, and more biocompatible extracorporeal circulation technologies may further improve outcomes and healthcare sustainability, particularly in resource-limited settings.

Aortic arch diseases represent one of the most complex domains in cardiovascular surgery due to the need for cerebral protection, anatomical precision, and durable reconstruction. Their management requires highly individualized strategies that balance cerebral protection, systemic organ perfusion, anatomical complexity, and long-term durability. Over recent decades, antegrade cerebral perfusion has significantly reduced neurological morbidity. In parallel, vascular prostheses have progressed from conventional Dacron grafts to hybrid stent graft systems simplifying arch reconstruction and expanded treatment options in high-risk cohorts. Total endovascular arch repair using branched or fenestrated devices has emerged for selected high-risk patients; however, current data remain limited, with early stroke rates of approximately 5–8% and restricted long-term durability evidence. From both clinical and economic perspectives, open and hybrid approaches remain central to durable arch management.

Cardioembolic stroke remains one of the most severe manifestations of cardiovascular disease, with atrial fibrillation (AF) responsible for a large proportion of ischemic cerebrovascular events. Stroke prevention strategies are currently dominated by oral anticoagulation guided by CHA2DS2-VASc scores, which emphasize age and comorbidities and therefore have limited applicability in younger patients with low conventional risk profiles. Although bleeding risk is routinely assessed using tools such as HAS-BLED, lifelong anticoagulation may still confer a substantial cumulative hemorrhagic burden over decades of treatment. The left atrial appendage (LAA) represents the primary anatomical source of thromboembolism in AF, yet current guidelines largely restrict surgical or percutaneous LAA exclusion to patients with AF who have contraindications to anticoagulation, reflecting a predominantly reactive approach. This Perspective advocates reconsideration of prophylactic surgical LAA exclusion at the time of open mitral valve repair in younger patients. Although early mitral repair limits atrial remodeling, it does not abolish lifetime AF risk, and post-operative or late-onset AF remains frequent. Moreover, residual or recurrent mitral regurgitation promotes progressive atrial dilation and fibrosis, increasing long-term thromboembolic risk even in patients initially in sinus rhythm. By integrating atrial remodeling, LAA morphology and function, residual mitral pathology, and the limitations of lifelong anticoagulation, a selective preventive framework emerges. An anatomical brain-heart prevention strategy may reduce lifetime cerebrovascular risk and improve long-term outcomes. While prospective data are needed, existing evidence supports individualized discussion of prophylactic LAA exclusion during mitral valve repair in selected young patients with structural atrial disease.

The left atrial appendage (LAA) is a highly dynamic anatomical structure that plays a key role in left atrial reservoir function, pressure and volume modulation, and endocrine hormone secretion during sinus rhythm. However, its physiological contribution is profoundly altered in atrial fibrillation (AF). Electrical and structural remodeling, impaired contractility, and blood stasis within the LAA collectively transform this functional component into the principal cardiac source of thrombus formation and embolic events in patients with AF. This review focuses on the conceptual continuum from physiological LAA function in sinus rhythm to its pathological transformation in AF and the evolving rationale for progressively more complete (“radical”) anatomical exclusion A variety of strategies, including systemic anticoagulation therapy, percutaneous device-based exclusion, and surgical closure, are currently employed, each with specific indications, limitations, and procedure-related risks. Beyond summarizing available techniques, this review critically synthesizes mechanistic, anatomical, and clinical data to address unresolved controversies regarding patient selection, residual leaks, device-related thrombosis, and post-procedural antithrombotic management. Finally, emerging directions toward minimizing residual foreign material, reducing thrombogenicity, and achieving durable exclusion are discussed, supporting a more personalized and radical approach to stroke prevention in AF.

A 58-year-old man, who has undergone ascending aorta replacement, started to complain of pain in the lower limbs, shortness of breath, and progressive fatigue a few months after surgery. Transthoracic and transesophageal Doppler echocardiographies revealed a diseased bicuspid aortic valve and a subocclusive mass in the ascending aorta. Thoracic computed tomography angiography confirmed the presence of a subocclusive mass, pseudoaneurysm formation, and a distorted shape of the Dacron® graft. The patient underwent urgent surgery to remove the mass, which appeared to be a thrombus, and aortic valve and ascending aorta replacement. Kinking of vascular graft has been reported including surgical techniques to correct the excessive length to avoid gradients and guarantee laminar flow. When kinking is severe, high gradients and hemolysis can be detected. However, thrombus formation in the ascending aorta segment is less likely, due to the high blood velocity flow. Therefore, several concurrent causes should be considered. In this case, the most probable explanation for thrombus formation was kinking of a too long Dacron® graft, combined with extrinsic compression effect of the graft by the pseudoaneurysm at the anastomosis site and anomalous flow directed from the diseased bicuspid aortic valve. Various grades of Dacron® graft kinking might occur following ascending aorta replacement and undiagnosed at follow-up especially if resulting in mild symptoms, thus, careful visual and echocardiography evaluation should be done at the end of surgery. Finally, distorted Dacron® graft might trigger thrombus formation when inflammation and coagulation processes are set off during bacteria or viral infection.

Reentry to the mediastinum when the ascending aorta aneurysm is adherent to the sternum is characterized by high risk of aneurysm rupture during sternum opening. In such cases, often cardiopulmonary bypass via peripheral vessels is instituted, and reentry done in deep hypothermia and circulatory arrest. To reduce both risks of aneurysm rupture during resternotomy and those related to prolonged cardiopulmonary bypass time, we present a surgical approach consisting of a two-stage sternotomy to avoid the risky zone and extra-anatomic epiaortic vessels anastomoses.

Objective: Both the en bloc island technique and the branched graft technique (BGT) present advantages but also limitations in aortic arch surgery. Here is the first presentation of an innovative prosthesis for aortic arch replacement, conceived to overcome the disadvantages of both techniques. Methods: The novel ISLAND graft is a tubular Dacron or hybrid prosthesis with an additional extended Dacron graft (“bubble”) on the superior aspect, for en bloc island graft anastomosis. To verify the technical feasibility, following bench study, 3 prostheses were implanted in human cadavers in which the distal anastomosis was performed either in zone 2 or 3. A flow analysis and a computational simulation were performed in different configurations. The flows of the “full-bubble,” the “cut-bubble,” and the traditional branched grafts were compared. The wall shear stress, time-averaged wall shear stress (TAWSS), oscillatory stress index (OSI), and relative residence time (RRT) were compared in the 3 settings. Results: The novel prosthesis appeared easy to implant with significant technical advantages. The manipulation of epiaortic vessels was reduced with expected lower risk of neurologic events. The fenestration of the external cuff could be tailored to the island segment, thus eliminating most pathological aortic tissue. The flows in the supraortic branches were more favorable in the ISLAND graft, in which the angles of the branches were maintained, and with reduced cuff height (cut-bubble), in which higher values of TAWSS and lower values of OSI and RRT were calculated. Conclusions: The novel ISLAND graft device overcomes the disadvantages of the traditional island technique and benefits from the advantages of the BGT. Given the first results, the next step would represent the in vivo implantation.

Severe functional mitral valve regurgitation should be treated in patients undergoing myocardial revascularization. When replacement is considered the best therapeutic option, preservation of the mitral subvalvular apparatus is crucial, especially in the emergency setting, because of its primary role in preserving geometry and function of left and right ventricles. Here we present a simple and quick technique, where subvalvular apparatus is preserved in toto in patients undergoing mitral valve replacement with a bioprosthesis.