Ioannis Zoupas

Introduction: Deep hypothermia (DH) has been widely adopted for cerebral and visceral protection during pediatric cardiac surgery, but concerns about perioperative complications remain. This meta-analysis aims to evaluate the impact of DH compared to moderate hypothermia (MH) on outcomes in pediatric cardiac surgery patients. Methods: Following a PRISMA-compliant systematic search in PubMed, Cochrane, and Embase, eligible studies comparing DH (p = 0.02), and circulatory arrest was more frequently used in DH patients ( p = 0.01). No significant differences were found in overall postoperative complication rates, acute kidney injury, 24-h chest drainage volume, or in-hospital mortality. However, the incidence of early postoperative neurological complications was significantly higher in the DH group ( p < 0.001). Conclusions: Moderate hypothermia may be associated with a significantly lower incidence of postoperative neurological complications compared to deep hypothermia, while overall in-hospital mortality and morbidity rates remained similar between the two groups. Taken together, these findings support moderate hypothermia with regional perfusion as a clinically feasible and well-tolerated alternative to deep hypothermia in pediatric cardiac surgery.

Background/Objectives: Minimally invasive (MIS) mitral valve surgery has been proven to be a safe and effective alternative to median sternotomy (ST), with advantages in postoperative recovery and morbidity. However, its role in the setting of infective endocarditis (IE) remains uncertain. This meta-analysis aims to evaluate the outcomes of MIS in mitral valve surgery for infective endocarditis. Methods: A PRISMA-compliant search for studies including patients undergoing MIS for mitral valve IE was performed through 14 January 2026, in PubMed, Scopus and Cochrane. Time-to-event data were reconstructed from published Kaplan–Meier curves. A secondary comparative analysis focusing on MIS versus ST techniques was conducted. Results: Fourteen retrospective studies comprising 949 patients were analyzed. In the MIS cohort, early mortality was 4.2% (95%CI: 1.8%, 7.4%). Overall survival was 86.7% at 1 year, 75.2% at 5 years and 56.2% at 10 years. Freedom from IE-related reoperation remained high at 97.5%, 95.9%, and 90.7% at 1, 5, and 10 years, respectively. Mitral valve repair was performed in 52.5% of patients. In secondary comparative analyses, overall survival at 4-year follow-up was not different between MIS and ST [HR: 0.82 (95%CI: 0.43, 1.57), p = 0.55]. MIS was associated with a significantly shorter intensive care unit (ICU) stay [MD: −1.52 days (95%CI: −2.08, −0.97), p < 0.01]. Conclusions: MIS for mitral valve IE is associated with favorable early and long-term outcomes, comparable survival with sternotomy, and reduced ICU stay. These findings suggest that MIS may be considered as a feasible and potentially effective alternative for the management of mitral valve IE in carefully selected patients. Further prospective comparative studies are warranted.

Objective: Minimally invasive techniques represent a safe alternative to full sternotomy in proximal aortic surgery. This meta-analysis evaluates their efficacy in aortic root, ascending aortic, and aortic arch procedures compared with the conventional approach. Methods: A PRISMA-compliant systematic review and meta-analysis of matched cohorts was conducted, comparing minimally invasive surgery with full sternotomy. MEDLINE was searched for eligible studies. Continuous variables were analyzed using standardized mean differences and categorical data with odds ratios. Kaplan–Meier-derived individual patient data were used to assess survival. Subgroup analysis for elective cases was performed. Results: Seventeen studies with 3113 matched patients were included. Mean age was 58.1 ± 13.3 years for minimally invasive group versus 58.1 ± 12.8 years in full-sternotomy group (p = 0.29). Postoperative blood loss (612.5 versus 883.2 mL, p < 0.01), number of red blood cell units transfused (1.0 versus 2.2, p < 0.01) and postoperative ventilation time (15.3 versus 19.2 h, p < 0.01) were significantly lower in the minimally invasive group. Similarly, overall hospital (8.4 versus 9.4 days, p < 0.01) and intensive care unit stay (1.5 versus 1.8 days, p < 0.01) were decreased in minimally invasive group. Overall survival was significantly improved in minimally invasive patients (Hazard Ratio: 0.54, p = 0.045), which was not confirmed by two-stage meta-analysis (Hazard Ratio: 0.72, p = 0.29). Bypass and cross-clamp times, reinterventions, bleeding events and wound infections were comparable between the two groups. Conclusion: Minimally invasive proximal aortic surgery reduces perioperative morbidity, hospitalization and transfusion requirements compared with full sternotomy. While a survival benefit requires further confirmation, these findings support minimally invasive approaches as an effective and safe alternative in selected patients.

Purpose of Review: Pulmonary autograft autotransplantation represents a popular surgical approach for pediatric patients requiring aortic valve replacement due to the potential for autograft enlargement to accommodate somatic growth. Nevertheless, autograft dilatation and the subsequent need for reintervention are quite common. Published data suggest that autograft enlargement may result from pathological passive remodeling rather than active somatic growth and vice versa. The present review serves to comprehensively evaluate available evidence related to the fate of the pulmonary autograft after the Ross procedure as it relates to the etiology, risk factors and patterns of autograft failure. Results: Studies present conflicting results supporting both pathological dilation and active somatic growth. Primary factors impacting the successful remodeling of the autograft include native aortic and pulmonary valve anatomy, medical history, concomitant procedures, perioperative management, age at the time of surgery, and the surgical technique used for the Ross procedure. Conclusion: Autograft enlargement after the pediatric Ross operation may result from either somatic growth or passive dilation or a combination of both factors. Distinguishing between the two primary etiologies of autograft enlargement depends upon meticulous patient selection and a surgical strategy precisely tailored to individual anatomy and risk.

Background: Neonatal management of congenital heart defects (CHD) among heterotaxy patients remains challenging due to significant heterogeneity in cardiac and visceral phenotypes. This study evaluated contemporary surgical outcomes and identified high-risk anatomic substrates. Methods: A total of 41 heterotaxy CHD patients who underwent neonatal surgical repair and/or palliation over a 10-year period were evaluated at a single institution. Heterotaxy anatomy was characterized according to right atrial isomerism (RAI) or left atrial isomerism (LAI), and other cardiac defects. Multivariate Cox regression and Kaplan-Meier analyses evaluated operative and intermediate-term outcomes. Results: Median age at initial operation was 7.0 days, and median operative weight was 3.1 kg. Median follow-up was 2.3 years. Of the total 41 patients, 27 (66%) had RAI, and 14 (34%) had LAI. Functional single ventricle anatomy was present in 30/41 patients (73%); 28/30 (93.3%) patients achieved stage II bidirectional Glenn and 14/30 (46.7%) achieved stage III Fontan completion; 1/30 (2%) patient underwent biventricular conversion. Operative mortality was 9.8% (4/41) after the initial operation. Permanent pacemaker placement was more common in patients with LAI. Interstage death rate was 10%, with no deaths after Fontan. Obstructed total anomalous pulmonary venous connection (TAPVC) was a risk factor for overall mortality (hazard ratio [6.0]; 95% confidence interval, 1.2-31.2; P = .033). Kaplan-Meier survival analysis demonstrated decreased five-year survival in RAI patients, LAI patients with single ventricle physiology, and RAI patients with obstructed TAPVC. Conclusions: Cardiac surgical outcomes for neonates with heterotaxy syndrome have significantly improved. Right atrial isomerism anatomy, single ventricle LAI patients, and RAI patients with obstructed TAPVC are associated with increased operative risk.

Objective: There is little evidence regarding the most beneficial choice between a mechanical and a bioprosthetic valve in the aortic position in dialysis patients. This meta-analysis compares the survival and freedom from reintervention rates between mechanical and bioprosthetic valves in patients on dialysis undergoing aortic valve replacement surgery.Methods: Two databases were searched, and the systematic review was performed in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. We conducted one-stage and two-stage meta-analysis with Kaplan–Meier-derived individual patient data and meta-analysis with random-effects model.Results: Eight studies were included, providing data about 1215 dialysis patients receiving mechanical valves and 1851 patients receiving bioprosthetic valves. During a mean follow-up of 43.1 months, overall survival rates were significantly improved in the mechanical valve group in comparison to the bioprosthetic one (hazard ratio [HR]: 0.76, 95% confidence interval [CI]: 0.69–0.84, p < 0.001). This was confirmed by the two-stage meta-analysis (HR: 0.72, 95% CI: 0.62–0.83, p = 0.00, I²= 17.79%). Regarding freedom from reintervention, no arm offered a statistically significant advantage, according to the two-stage generated analysis (HR: 1.025, 95% CI: 0.65–1.61, p = 0.914). Similarly, there was no evident superiority of a valve type for perioperative outcomes.Conclusions: Mechanical valves are likely to be associated with a better survival outcome compared to bioprosthetic valves for patients on dialysis undergoing aortic valve replacement. However, freedom from reoperation rates and perioperative outcomes were comparable between the two valve types, with no arm exhibiting a statistically significant advantage.