In this review, the authors discuss the perioperative management of patients who undergo thoracoabdominal aortic aneurysm or descending thoracic aortic aneurysm repair. All major organ systems are potentially vulnerable to complications from these repairs; meticulous preoperative attention to optimizing relevant comorbidities, diligent performance of intraoperative anesthetic and surgical techniques, and careful postoperative management are necessary to maximize the likelihood of successful outcomes. Specific attention should be given to reducing the risk for spinal cord ischemia and for paraplegia. Of note, renal and respiratory systems are especially vulnerable to major complications and require a thoughtful multidisciplinary approach. Because preventing complications is the primary goal of perioperative management, deviations from the normal course must be recognized promptly and addressed aggressively to reduce the likelihood of major morbidity and death.

Cerebral complications, especially intracranial hemorrhage (ICH), are critical determinants of the early outcomes of cardiac surgery for active infective endocarditis (AIE). Relevant society guidelines still recommend delaying cardiac surgery for AIE complicated by ICH for 4 weeks. Some early studies indicated that the mortality decreases when cardiac surgery for ICH is delayed. In contrast, some reported that surgical intervention should not be delayed if an early operation is indicated, even in patients with ICH. The current literature on early versus late surgery for AIE with ICH is conflicting. ICH is classified by its mechanism which includes primary intraparenchymal hemorrhage, hemorrhagic transformation of ischemic infarcts, and rupture of intracranial infectious aneurysms. Some reported that for AIE with a mycotic cerebral aneurysm, early cardiac surgery should be done after repair of the aneurysm, either surgically or endovascularly. Except for the rupture of mycotic aneurysm, primary intraparenchymal hemorrhage and hemorrhagic transformation of ischemic infarcts remain a critical and challenging dilemma. Modifying the cardiopulmonary bypass (CPB) strategy might be necessary to improve the surgical outcomes of AIE with ICH. Some studies reported that cardiac surgery using nafamostat mesylate as an alternative anticoagulant during CPB (NM-CPB) was performed successfully. The NM-CPB can be a useful option as an anticoagulant in critical situations of cardiac surgery with ICH. The timing of surgery should be decided on a case-by-case basis with multidisciplinary specialties including cardiac and neurological teams.

Atherosclerosis plays a significant role in the development of cardiovascular diseases, the leading cause of death worldwide. Modification of low-density lipoproteins (LDLs) is a critical event in atherogenesis. Native LDL undergoes several modifications that can lead to the formation of atherogenic modified LDLs. LDL modifications change their physicochemical and biological properties. Possible modifications include changes in the lipoprotein particle’s structure, size, charge, and composition. Uptake and utilization of modified LDLs are impaired in cells. Macrophages take up modified LDLs that promote forming of foam cells, one of the critical cellular components of atherosclerotic lesions. Nevertheless, the direct role of each atherogenic LDL modification in atherogenesis remains uncertain. This review highlights LDL's most critical atherogenic modifications, including oxidized, enzyme-modified, non-oxidative, desialylated, glycated and carbamylated LDLs. Studying the role of each type of LDL modification will clarify the unknown elements of atherosclerosis progression and facilitate the development of effective methods for its diagnosis, treatment, and prevention.

Immune-inflammatory rheumatological diseases are a large group of pathological conditions that lead to chronic inflammation and organ damage. Many autoimmune diseases are associated with a high risk of cardiovascular complications, including atherosclerosis. Inflammation plays a significant role in the development and accelerated course of atherosclerotic lesions. Disorders of lipid metabolism are closely associated with the functions of cells of the immune system and can contribute to the development of these diseases. Cholesterol and lipids are involved in various cellular processes, including intercellular recognition, signal transmission and energy supply. The effect of cholesterol metabolism on the immune response is of great importance and is being actively investigated. Further study of the mechanism of cholesterol efflux from cells may be the key to understanding the relationship between immune-inflammatory and cardiovascular diseases. In this review, we have summarized data on cholesterol metabolism and its effect on the development of pathological conditions.

Open total arch replacement (TAR) remains the mainstay management strategy for thoracic aortic diseases involving the aortic arch. TAR evolved from the 2-stage conventional elephant trunk (CET) technique to the hybrid frozen elephant trunk (FET) which combined open surgical repair (OSR) with thoracic endovascular aortic repair (TEVAR) into a 1-stage procedure. Although FET has been able to achieve superior results to CET, including excellent survival, it still carries a risk of certain complications that may even require secondary reintervention. The era of elephant trunk is being overtaken by the new generation of TEVAR devices being used for total endovascular aortic arch (or endoarch) repair. Total endoarch repair (TER) is currently indicated in patients deemed high-risk for open surgery; however, it has shown strong potential for becoming the gold stand treatment for aortic arch pathologies. Despite the minimally-invasive nature of TER providing an obvious advantage over OSR in certain cases, TER remains associated with comparable mortality rates and key complications such as technical failure, neurological injury, need for reintervention, and loss of or failure to achieve target vessel patency. Upon comprehensively searching the literature, the technical success of TER ranged from 91%-100%, mortality 0%-19%, stroke 0%-16.7% and reintervention 0%-30.3%, using different commercially available endografts. Given its novelty, further studies with larger cohorts and longer follow-up periods are necessary to solidify the evidence on TER, taking into account the significant learning curve associated with TEVAR. In addition, studies directly comparing arch OSR to TER are warranted to determine superiority. This review aimed to highlight the evolution of aortic arch repair, focusing on TER device development, intervention criteria and clinical outcomes.

Total arch replacement via frozen elephant trunk (FET) is a strategy for managing complex thoracic aortic pathologies involving the arch and descending thoracic aorta (DTA). The FET procedure involves the distal anastomosis of the FET hybrid prosthesis at a chosen aortic arch zone. Though distal anastomosis has been traditionally performed at Zone 3 (Z-3-FET) of the aortic arch, recent practice has seen a significant increase in Zone 2 FET (Z-2-FET). The literature concerning independent Zone 2 and 3 studies and head-to-head comparative studies suggest that Z-2-FET is the superior approach, yielding more favourable results overall, except for aortic remodelling. The improved clinical outcomes achieved with Z-2-FET can be attributed to the shorter operative times, including cardiopulmonary bypass duration, due to the ease and increased surgical site exposure at the aortic arch using this technique. The slightly inferior aortic remodelling observed in Z-2-FET can be explained by the decreased coverage of the DTA distally by the FET stent graft. However, this difference in results can also be attributed to the complexity and severity of the underlying pathology and the surgical approach adopted. The prospect of utilising Zone 0 FET (Z-0-FET) is highly promising, with some studies hinting at its superiority over Z-2-FET. Nevertheless, studies are needed to determine the efficacy of Z-0-FET and directly compare it to Z-2-FET to reach a definitive consensus on the most optimal FET technique. The present literature review aims to provide an overview of major intraoperative and postoperative outcomes achieved with Z-2-FET and Z-3-FET and summarise evidence from studies directly comparing them. Another aim of this narrative review is to explore current literature trends on Z-0-FET uptake.

Aim: Evaluate the diagnostic and prognostic performance of the ESC 0/1H Algorithm and its utility in safely discharging patients with suspected Acute Coronary Syndrome (ACS) in the Emergency Department.

Methods: This analysis is a retrospective cohort study of 3,156 patients presenting to an academic medical center emergency department (ED) between May 20, 2019 and May 31, 2020. After completing the Beckman Coulter Access High Sensitivity Troponin I (hs-TnI) assay per current institution protocol (T0, T1H, T3H), patients identified to have symptoms concerning ACS were retrospectively analyzed using the ESC 0/1H Algorithm to assess the safety and efficacy of a rule-out algorithm for early discharge.

Results: The negative predictive value (NPV) of the protocol (T₀ < 6 pg/mL; or females with T₀ ≤ 15 pg/mL and T₁ ≤ 15 pg/mL; or males with T₀ ≤ 20 pg/mL and T₁ ≤ 20 pg/mL) was 99.4% (95%CI: 99.0-99.7%) for acute myocardial injury at the initial ED visit (index ED visit) and/or 30-day cardiac-related death. The negative likelihood ratio was 0.08 (95%CI: 0.05%-0.13%), and the specificity was 86.3% (95%CI: 85.0-87.5%).

Conclusion: The protocol was found to have a NPV greater than 99% and a negative likelihood ratio of 0.08, suggesting it is safe to use for patients presenting to the ED with ACS symptoms no matter the time of symptom onset.

Aim: Endovascular treatment of cerebral bifurcation wide-neck aneurysms remains a therapeutic challenge in terms of safety profile and timely treatment efficacy. The aim of this study is to investigate the very long-term efficacy and safety of Y stenting-assisted coiling with Neuroform Atlas in the treatment of wide-neck bifurcation aneurysms.

Methods: Clinical, procedural and follow-up data were analyzed to evaluate the safety and effectiveness of the treatment with Y-stenting assisted coil strategy (with Neuroform Atlas) in wide-neck bifurcation aneurysms. Endovascular technical aspects were also investigated. Morbidity and mortality were recorded. Digital subtraction angiography (DSA) for mid-term follow-up (12-15 months) and MR-angiography (MRA) for long-term follow-up (24-36 months) and very long-term follow-up (48-60 months) were evaluated in order to assess the efficacy.

Results: The study included 21 Patients (12 Females, 9 Males) aged between 41 and 78 years, with a median age of 60 years. Of the aneurysms treated, 6 belonged to the middle cerebral artery bifurcation (MCA) (28.6%), 10 to the anterior communicating artery (AComA) (47.6%) and 5 to the basilar artery tip (BA) (23.8%). The median aneurysm size and dome/neck ratio were 5 and 1.2 mm, respectively. Technical success was achieved in all 21 cases (100%). No complication related to stent placement was observed. The morbidity rate was 9.5% (2/21) procedure-related; 1 case of intra-procedural SAH and 1 post-procedural stroke were observed. No death was observed. Mid-term DSA, according to the modified Raymond-Roy Occlusion Classification (RROC), showed 16 Class I (76.2%), 4 II (19%), and 1 IIIa (4.8%). Long-term MRA follow-up (24-36 months) showed aneurysm complete occlusion (CO) in 17 cases (80.9%) and residual neck (NR) in 4 cases (19.1%). Very long-term MRA follow-up (48-60 months) confirmed the same rate of occlusion (CO 80.9%; NR 19.1%). Long-term and very long-term MRA follow-up showed vessels’ patency in all cases (100%).

Conclusion: Y-stenting-assisted coil embolization represents a safe and effective technique demonstrating an adequate rate of aneurysm occlusion at long-term follow-up and very long-term follow-up.

Objective: To assess follow-up mortality and reoperation rate in patients undergoing Bentall-De Bono operation according to the type of composite valve graft used.

Methods: All consecutive adult patients operated on between May 1997 and December 2019 at our institution were included in the analysis and classified according to the use of a biological or a mechanical composite valve graft (bCVG or mCVG). The primary outcomes were follow-up mortality and reoperation rate. Secondary outcomes were operative mortality and major adverse events (MAEs) including operative mortality, myocardial infarction, cerebrovascular accident, dialysis, tracheostomy, and re-exploration for bleeding. Kaplan-Meier and competing risk analyses were used. Propensity matching analysis was used to balance differences in baseline characteristics between procedures.

Results: Of 1,210 included patients, 798 received a bCVG and 412 a mCVG. The mean follow-up was 6.64 ± 0.21 years. The ten-year mortality rate was higher in the mCVG group (25.3% vs. 16.4%, P = 0.023). The ten-year reoperation rate was higher in the bCVG group (7.4% vs. 1.1%, P < 0.001). Overall operative mortality was 0.7%, and MAEs occurred in 6.2% of patients, with no significant differences between groups. Older age (hazard ratio [HR] 1.06, 95% confidence interval [CI: 1.04-1.08], P < 0.01), chronic obstructive pulmonary disease (HR 1.63, 95%CI: [1.01-2.64], P = 0.04), preoperative renal dysfunction (HR 3.08, 95%CI: [1.98-4.78], P < 0.001), New York Heart Association Class III/IV (HR 1.48, 95%CI: [1.04-2.10], P = 0.031), and mCVG (HR 2.15, 95%CI: [1.42-3.26], P < 0.001) were associated with higher risk of follow-up mortality. After propensity matching, the differences in mortality and reoperation remained significant.

Conclusions: The Bentall-De Bono operation can be performed with consistently good results in experienced centers. Early outcomes are excellent regardless of the valve choice. In our study, the Bentall-De Bono operation with bCVG was associated with lower 10-year mortality but carried a higher risk of aortic reoperation. While the risk of reoperation is largely tied to valve choice, follow-up mortality is more likely to be influenced by patient comorbidities and risk factors.

Infective endocarditis (IE) is a complex disease whose prognosis depends on the causative microorganism, among other factors. The latter can be difficult to identify and/or treat. In this narrative review, we identify knowledge gaps in the diagnosis and antimicrobial treatment of IE, and attempt to shed light on current questions. Specifically, we: (1) analyze the factors that may hinder the microbiological diagnosis of blood culture-negative IE, as well as the role of new imaging techniques, such as ¹⁸F-fluorodeoxyglucose ([¹⁸F]FDG PET/CT), in the diagnostic capacity of this disease, understanding their advantages and assuming their limitations; (2) discuss the therapeutic approach to various difficult-to-treat microorganisms. In particular, we focus on the treatment of staphylococcal IE since, at present, staphylococci are the most frequent cause of IE in developed countries and staphylococcal IE is one of those with the highest short- and long-term mortality. We critically evaluate the current evidence on combination therapy and address the occurrence of serious side effects, an aspect that is often overlooked owing to the severity of the infection; and (3) emphasize the need for home antimicrobial treatment of patients with IE, as these are fragile people who benefit from an early return to their environment. This poses undoubted logistical challenges and requires robust evidence to ensure the best short- and long-term outcomes.

Aim: The mental illness (MEI) impact upon risk-adjusted first-time aortic valve replacement (AVR) or repeat AVR (r-AVR) outcomes is unknown. Comparing patients with and without new-onset postoperative atrial fibrillation or atrial flutter (POAF/AFL), this retrospective cohort investigation evaluated if MEI impacted patients’ risk-adjusted AVR/r-AVR outcomes.

Methods: Using de-identified New York Statewide Planning and Research Cooperative System (administrative) database reports, multivariable logistic regression models compared post-procedural POAF/AFL, 30-day readmission, and composite (i.e., 30-day operative mortality or morbidity) endpoints between MEI and non-MEI patients.

Results: From 2005-2018, there were 36,947 first-time AVR patients and 242 r-AVR patients; of these, 13.18% AVR (n = 4,868) and 16.94% r-AVR (n = 41) patients had preprocedural MEI diagnoses. Compared to non-MEI patients, MEI patients had increased rates of transcatheter vs. surgical procedures and higher pre-procedural risks including alcoholism, illegal drug use, tobacco product use, suicidal ideation, or other comorbidities (e.g., valvular disease, atherosclerotic disease, hypertension obesity, and anemia); they were younger, female, and non-Black/non-Hispanic, and had non-commercial (e.g., government or self-pay) insurance. Contrasted to non-MEI patients, MEI patients had no different risk-adjusted new onset of POAF (AVR P = 0.575; r-AVR P = 0.497), 30-day readmission (AVR P = 0.163; r-AVR P = 0.486), and mortality/morbidity composite (AVR P = 0.848; r-AVR P = 0.295) rates.

Conclusions: Despite MEI patients’ inherent higher pre-procedural AVR/r-AVR risk, no differences in the MEI vs. non-MEI risk-adjusted POAF/AFL, 30-day readmission, or composite rates were found; however, MEI patients more frequently were selected to receive transcatheter rather than open surgical procedures.

Drug-coated balloons (DCB) have emerged as a valid alternative for drug-eluting stents in the treatment of in-stent restenosis and de-novo lesions in small vessels. In the past years, a significant effort has been made to investigate the role of this strategy in larger vessel disease, with promising preliminary results being reported for several clinical scenarios, including complex lesions, such as bifurcations, chronic total occlusions and diffuse, long lesions. A DCB strategy appears to be of significant interest in diffuse coronary disease, as the total stent length represents an independent predictor for target-vessel failure and a surgical approach does not seem to improve mid- and long-term results compared to optimal medical treatment. Several studies have investigated the safety and efficacy of a non-stent-based approach in this complex setting, and as promising results have been reported, it is fair to assume that reducing the amount of implanted metal in diffusely affected vessels could become the standard of care for these patients if a full or blended therapy with DCB is adopted. However, long-term results from large-scale studies are awaited to confirm these preliminary and intriguing results.

Descending thoracic and thoracoabdominal aortic replacement is a complex and high-risk surgery. Deep hypothermic circulatory arrest (DHCA) is a surgical technique that is useful in large distal aortic arch aneurysms or chronic dissections that require fenestration where proximal cross clamping would be difficult. It can also be used as part of a multimodal strategy for end-organ protection. However, DHCA has potential adverse effects on the myocardial, cerebral, pulmonary, and coagulation systems. The use of DHCA is guided by the experience and preferences of the surgical team as well as the technical demands of the proposed surgery.

Severe coronary artery calcifications remain a challenge for the contemporary interventional cardiologist in the light of the growing demand for diagnostic procedures and interventions in elderly patients; in addition, the general prognostic improvement after percutaneous coronary intervention (PCI) is expanding the indications to PCI to increasingly complex anatomies. In the last decade, a renewed interest in the treatment of calcific lesions has been observed, with the aim to optimize the mechanic effects of balloon angioplasty and the expansion and apposition of DES to the vessel wall. However, patients with calcific coronary artery disease represent a subset with a high risk of adverse outcomes, both intra-procedural and in the long-term. The need to guarantee a targeted and tailored treatment based on the coronary anatomy of any individual patient is a current priority of the interventional community. The efficacy of rotational atherectomy in improving procedural success for the treatment of calcified lesions has been widely demonstrated. The advent of new technologies -especially of intravascular lithotripsy (IVL)-, the application of techniques and materials initially developed for as complex procedures as chronic total occlusions (CTO), the increasing experience of contemporary operators and the introduction of latest generation drug-eluting stents (DES) with excellent technical and structural properties, are further contributing to improving outcomes of current PCI for calcific lesions.

Thoracic endovascular aortic repair (TEVAR) today represents the first option for the treatment of most pathologies involving the descending thoracic aorta. Proximal endograft failure, which includes endograft migration or type IA endoleak, represents the most frequent complication during the mid-term and long-term period. Proximal sealing length is the single most important factor affecting the technical success and durability of TEVAR. Other factors related to aortic arch anatomy, fluid dynamics, type of endograft, or type of pathology, may influence the risk of proximal endograft failure, and should be considered during the endovascular planning of the proximal sealing length. This review summarizes the evidence on the factors affecting the risk of proximal endograft failure, and provides the rationale for the choice of the proximal sealing length during TEVAR, based on specific patients’ characteristics.

This review article discusses the utilisation of nanotechnology in the treatment of pulmonary diseases, including asthma, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, pneumonia, lung infections, and lung cancer. It highlights the importance of early diagnosis and novel drug delivery systems for successful disease management. Specifically, nanoformulations administered via the pulmonary route have shown effectiveness in managing asthma and COPD, while targeted drug delivery is crucial for improving therapeutic outcomes and minimising systemic side effects in lung infections and cancer. The article also explores the role of nanotechnology in gene therapy for cystic fibrosis, showcasing the development of nonviral vectors. Overall, this review provides a comprehensive overview of the causes of pulmonary diseases and the advancements in nanoscience and nanotechnology for their treatment.

The introduction of deep hypothermic circulatory arrest (CA) was the factor that contributed to the diffusion of aortic arch surgery in the surgical world. The progressive quest to improve the outcome of such a complex surgery included the introduction of different tools to better protect the brain, such as retrograde or antegrade cerebral perfusion. The increased experience not only resulted in a continuous improvement of the results, but also facilitated the widespread adoption of arch surgery across most of the cardiac Centers. The trend moved towards a gradual rise in the temperature (from ≤ 20 to 30 °C), coupled with a preference for selective/unilateral antegrade cerebral perfusion for brain protection. Nevertheless, results are not perfect and neurologic dysfunctions, temporary or permanent, remain a frequent complication. The spinal cord is not completely protected by cerebral perfusion and ischemia of the lower body can cause organ malfunctions with severe consequences. After decades, the field is still open for new strategies to minimize the damages intrinsic to the procedure. This review will briefly describe the energetics of the brain, the mechanisms of neurologic dysfunctions, and the advantages and disadvantages of the strategies of cerebral protection commonly used during CA for aortic arch surgery.

Since the first balloon angioplasty 40 years ago, percutaneous coronary interventions (PCI) applicability continues to expand, even in the context of complex coronary anatomies, previously considered unsuitable for PCI. A very challenging scenario for PCI is the treatment of heavily calcified coronary stenosis that is associated with early complications and late adverse events. Countless tools and techniques have been introduced to treat calcified coronary stenosis, and among these, a new and promising technique obtained from lithotripsy technology employed for the treatment of uretero-renal calculi has been introduced: the intravascular lithotripsy (IVL). IVL utilizes acoustic shockwaves in a balloon-based delivery system that induces calcium fractures, facilitating stent advancement and expansion. This review aims to describe the device used for IVL, the results of clinical studies published, and the possible clinical use.

Carotid atherosclerotic disease is a widely acknowledged risk factor for ischemic stroke, making it a major concern on a global scale. To alleviate the socio-economic impact of carotid atherosclerotic disease, crucial objectives include prioritizing prevention efforts and early detection. So far, the degree of carotid stenosis has been regarded as the primary parameter for risk assessment and determining appropriate therapeutic interventions. Histopathological and imaging-based studies demonstrated important differences in the risk of cardiovascular events given a similar degree of luminal stenosis, identifying plaque structure and composition as key determinants of either plaque vulnerability or stability. The application of Artificial Intelligence (AI)-based techniques to carotid imaging can offer several solutions for tissue characterization and classification. This review aims to present a comprehensive overview of the main concepts related to AI. Additionally, we review the existing literature on AI-based models in ultrasound (US), computed tomography (CT), and Magnetic Resonance Imaging (MRI) for vulnerable plaque detection, and we finally examine the advantages and limitations of these AI approaches.

Aim: Continuous blood pressure (BP) monitoring can provide invaluable information for cardiovascular disease (CVD) diagnosis. The purpose of this study is to develop a deep recurrent neural network (RNN) model with an optimal feature set of photoplethysmogram (PPG) and electrocardiogram (ECG) signals for continuous BP estimation.

Methods: This paper presents a novel deep recurrent neural network (RNN), which consists of 2-layered bidirectional Long Short-term Memory (Bi-LSTM) and 6-layered LSTM networks. It is used to estimate BP based on the optimal feature set of PPG and ECG signals. In this work, the optimal feature set is determined using five different feature selection methods.

Results: The proposed method is evaluated based on 660 subjects from the University of California Irvine (UCI) machine learning repository. The RNN model with optimal feature set achieved root mean square error (RMSE) of 3.223 and 1.781 mmHg for systolic BP (SBP) and diastolic BP (DBP), respectively. It also showed mean absolute error (MAE) of 2.514 and 1.383 mmHg for SBP and DBP, respectively. Regarding the British Hypertension Society (BHS) standard, the results attained grade A for the estimation of SBP and DBP.

Conclusion: The experimental results suggest that the proposed deep RNN model with an optimal feature set can improve the performance of BP prediction. Thus, it is possible to further apply our proposed method to develop a wearable device for real-time BP monitoring.

The clinical spectrum of cryoglobulinemic-associated diseases is broad and heterogeneous, with manifestations ranging from mild symptoms (e.g., isolated palpable purpura) to organ- and life-threatening involvement (e.g., membranoproliferative glomerulonephritis). Cryoglobulins are classified into three types. Type I cryoglobulinemia consists of one monoclonal immunoglobulin (Ig) and is practically always associated with B-cell lymphoproliferative disorders. In contrast, type II/III (mixed) cryoglobulinemia is composed of mono- or polyclonal IgM with rheumatoid factor activity bound to polyclonal IgG. Since the introduction of more efficient therapies for chronic hepatitis C virus (HCV), other diseases such as systemic autoimmune disorders and lymphoproliferative neoplasms have been established as the main causes of mixed cryoglobulinemic vasculitis. The pathogenesis of cryoglobulinemic vasculitis is a complex multifactorial process that involves B-cell aberrant lymphoproliferation and autoantibody production. Therefore, treatment of these patients may involve not only measures aimed to mitigate the severity of clinical manifestation but also those that address the associated underlying disease responsible for Ig production. The treatment of patients with type I cryoglobulinemia is primarily focused on controlling B lymphocyte clones responsible for cryoglobulin production, mostly with chemotherapy drugs. Treatment of mixed cryoglobulinemia syndrome is based on rituximab plus glucocorticoids, which induces remission in the vast majority of cases. In the rare patients that do not respond to rituximab administration, potential rescue approaches include alkylating agents, biologic therapies, conventional immunosuppression, and plasma exchange, although with partial efficacy. This narrative review explores the etiology, pathophysiology, clinical manifestations, treatment, and prognosis of nonviral cryoglobulinemic disease. A special focus is placed on the treatment of type I cryoglobulinemia and rituximab-resistant non-HCV cryoglobulinemic vasculitis.

Thoraco-abdominal aortic aneurysm (TAAA) open repair is a high-risk surgery further burdened with both mortality and morbidity. Despite numerous experimental endeavors and technical advancements, spinal cord ischemia (SCI) is still the most formidable morbidity to be resolved, irrespective of the open or endovascular surgical approach. It presents a spectrum of severity, ranging from temporary or permanent paraparesis to paraplegia with or without autonomic dysfunction. The timing of SCI occurrence is a crucial factor, with approximately 15% of cases manifesting intraoperatively, 50% within 48 h post-surgery, and the remaining 35% classified as late SCI, occurring more than 48 h after the procedure. The mechanism responsible for SCI is complex and multifactorial; hence, understanding its underlying pathophysiology is essential for its effective management. Over the last decade, strategies to enhance spinal cord perfusion and minimize the risk of SCI during TAAA open repair have been implemented. These include optimization of hemodynamics, hemoglobin levels, cardiac function, and cerebrospinal fluid pressure, ensuring collateral vascular network stability and distal aortic perfusion and intrathecal administration of drugs. A multimodal approach involving anesthesiologists and surgeons can lead to improved neurological recovery and a reduced incidence and severity of SCI.

Spinal cord ischemia (SCI) is undoubtedly the most devastating adverse event that occurs after either a thoracic aortic aneurysm (TAA) or thoracoabdominal aortic aneurysm (TAAA) repair. While open surgery techniques and minimally invasive endovascular options are now available for treating complex anatomy aortic aneurysms, spinal cord ischemia still occurs to a greater extent than desirable. Multiple risk factors have been associated with this adverse event, such as advanced age, perioperative hypotension, extent of the repair, and ligation of multiple intercostal and lumbar arteries during the surgical repair. The present literature review aims to analyze the contributing risk factors for SCI in the context of aortic surgery, explore the most relevant strategies for preventing postoperative SCI, and discuss the current management strategy when this complication occurs.

Introduction: Research has shown epigenetic change via alternation of the methylation profile of human skeletal muscle DNA after Cardio-Pulmonary Bypass (CPB). In this study, we investigated the change in epigenome-wide DNA methylation profiles of porcine myocardium after ischemic insult in the setting of treatment with extracellular vesicle (EV) therapy in normal vs. high-fat diet (HFD) pigs.

Methods: Four groups of three pigs underwent ameroid constrictor placement to the left circumflex artery (LCx) and were assigned to the following groups: (1) normal diet saline injection; (2) normal diet EV injection; (3) HFD saline injection; and (4) HFD EV injection. DNA methylation was profiled via reduced-representation bisulfite sequencing (RRBS) and compared using a custom bioinformatic pipeline.

Results: After initial analysis, 441 loci had a nominal P value < 0.05 when examining the effect of ischemia vs. normal heart tissue on a normal diet in the absence of treatment. 426 loci at P value threshold < 0.05 were identified when comparing the ischemic vs. normal tissue from high-fat diet animals. When examining the effect of EV treatment in ischemic tissue in subjects on a normal diet, there were 574 loci with nominal P value < 0.05 with two loci Fructosamine 3 kinase related protein [(FN3KRP) (P < 0.001)] and SNTG1 (P = 0.03) significant after Bonferroni correction. When examining the effect of EV treatment in ischemic tissue in HFD, there were 511 loci with nominal P values < 0.05. After Bonferroni correction, two loci had P values less than 0.05, betacellulin [(BTC) (P = 0.008)] and [proprotein convertase subtilisin/kexin type 7 (PCSK7) (P = 0.01)].

Conclusions: Alterations in DNA methylation were identified in pig myocardium after ischemic insult, change in diet, and treatment with EVs. Hundreds of differentially methylated loci were detected, but the magnitude of the effects was low. These changes represent significant alterations in DNA methylation and merit further investigation.

Aim: To analyze the feasibility and procedural outcome of percutaneous coronary intervention (PCI) using rotational atherectomy (RA), performed via transradial sheathless guiding catheter, as compared to a standard radial and femoral vascular approach.

Methods: All consecutive patients undergoing RA at two high-volume PCI centers from May 2011 to May 2023 were included. Comparisons were made between the two transradial approaches and between the three types of vascular access.

Results: Two hundred twenty-three patients were enrolled. Baseline characteristics were similar, with the exception of gender. We observed, in percentages, fewer cases of failure for sheathless than standard transradial attempts (7.5% vs. 11.5%, respectively), whereas all trans-femoral attempts were successful. Transfemoral procedures were longer and more frequently performed under mechanical circulatory support. There was no difference in procedural success between the three vascular approaches. A trend towards a higher rate of vascular and bleeding complications was found in the femoral group.

Conclusion: Sheathless transradial vascular access is a viable option when performing RA during complex PCI procedures, tending to result in fewer failures than the standard transradial approach and reduced bleeding and vascular complications compared to the femoral method.

MicroRNAs (miRNAs) are small non-coding RNA molecules that regulate translation and are involved in many pathological processes. They have emerged as promising biomarkers for diagnosis of conditions such as aortic aneurysm disease. Quantifying miRNAs in plasma is uniquely challenging because of the lack of standardized reproducible protocols. To facilitate the independent verification of conclusions, it is necessary to provide a thorough disclosure of all pertinent experimental details. In this technical note, we present a comprehensive protocol for quantifying plasma miRNAs using droplet digital PCR. We detail the entire workflow, including blood collection, plasma processing, cryo-storage, miRNA isolation, reverse transcription, droplet generation, PCR amplification, fluorescence reading, and data analysis. We offer comprehensive guidance regarding optimization, assay conditions, expected results, and insight into the troubleshooting of common issues. The stepwise normalization and detailed methodological guide enhance reproducibility. Moreover, multiple portions of this protocol may be automated. The data provided in this technical note is demonstrative of the values typically obtained when following its steps. To facilitate standardization in data reporting, we include a table of expected aortic aneurysm-related miRNA levels in healthy human plasma. This versatile protocol can be easily adapted to quantify most circulating miRNAs in plasma, making it a valuable resource for diagnostic development.

Despite advancements in operative techniques and perioperative management, early mortality and morbidity from open thoracoabdominal aortic aneurysm (TAAA) repair remain significant. Endovascular aortic repair (EVAR), with visceral parallel grafts or branched/fenestrated stent grafts, is the less invasive treatment option. However, off-the-shelf, branched/fenestrated stent grafts are currently not readily available on the market. The anatomical complexities of TAAAs, which make open repair difficult, such as the involvement of visceral branches and spinal cord blood supplies, are also challenges to endovascular repair. Open surgical TAAA repair should be considered in patients with connective tissue disorders, younger age (less than 50 years old), and ruptured hemodynamically unstable TAAA. Endovascular TAAA repair should be considered in patients with sarcopenia, advanced age, renal dysfunction, and lung dysfunction, if patients have suitable anatomy. The two approaches should remain complementary. Overall, few data exist on which TAAA patient population would benefit from open vs. endovascular approaches. Therefore, this manuscript discusses patient selection for open and endovascular repair of TAAA from a literature review and our institutional experience.

Revascularization through percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is used to manage left ventricular systolic dysfunction (LVSD) due to coronary artery disease (CAD). This review provides an overview of coronary revascularization for CAD with reduced left ventricular ejection fraction (LVEF), focusing on disparities in management. CABG provides more complete revascularization, and lower long-term all-cause mortality and reintervention and MI rates compared to PCI in patients with LVSD and CAD. Consequently, CABG is recommended as the primary revascularization therapy for CAD with reduced LVEF, with PCI being reserved for patients who are high-risk or have unfavorable coronary anatomy. Although LVSD increases revascularization risk, differential outcomes can be attributed to patients’ biological, behavioral, and socioeconomic factors as well as health system deficiencies. Women and racially and/or ethnically minoritized patients often present with progressive disease and greater comorbidity, experience delays in diagnosis and treatment, and have higher morbidity and mortality rates post-revascularization. These disparities may be explained by biological differences compounded by social determinants of health. Patients with CAD with LVSD pose unique medical challenges, which may be further complicated by disparities in care. Increased representation of minoritized patients in cardiovascular trials is needed to elucidate these differences and their long-term impact.

The choice of graft used to bypass stenoses in the coronary circulation is crucial to coronary artery bypass grafting (CABG) surgery and its success. Herein is a review of the existing literature on CABG grafts, including the discussion of utilization of different CABG grafts, patency of different grafts, and technical and other considerations pertinent to the use of each graft. Lastly, we present special considerations for graft selection in women.

Saphenous vein grafts (SVGs) are the most widely used conduit in coronary artery bypass grafting (CABG) surgery; however, SVG failures due to neointimal hyperplasia present a significant long-term limitation to the effectiveness of myocardial revascularization. This review will provide a comprehensive overview of the biological mechanisms of vein graft failure, including compensatory endothelial proliferation, extracellular matrix deposition, and adventitial disruption. We will discuss historical and emerging strategies for vein graft failure prevention with a focus on the role of mechanical vein graft support using external stenting. Finally, we will highlight the results of preclinical and human trials and discuss future directions for investigation.

Acute myocardial infarction (AMI) is the leading cause of cardiovascular mortality in developed countries. While primary percutaneous coronary intervention is the gold-standard first-line therapy for initial revascularization of a culprit vessel, coronary artery bypass grafting (CABG) surgery can allow for subsequent complete revascularization when additional high-risk coronary stenoses remain. The optimal timing of CABG after AMI remains controversial. Early surgery during the acute period can lead to a detrimental systemic inflammatory response and may be associated with a higher bleeding risk due to the use of antiplatelet and fibrinolytic agents. On the other hand, later surgery increases the risk of ischemic recurrence while waiting, with the potential for an irreversible decrease in myocardial function or death. This narrative review summarizes the evidence supporting decision-making for optimal timing of surgical revascularization in patients with AMI.

Aim: To determine the differences in improvement in cardiac function by intramyocardial (IM) vs. intravenous (IV) injection of human bone mesenchymal stem cell-derived extracellular vesicles (HBMSC-EV) after acute MI.

Methods: FVB mice underwent acute MI via left anterior descending coronary artery ligation and subsequent injection of: (1) IM saline control; (2) IM HBMSC-EV; (3) IV saline control; and (4) IV HBMSC-EV. Cardiac function was evaluated with weekly postoperative echocardiography. On postoperative day 28, the mice were euthanized, and the heart, lungs, liver, spleen, and kidneys were harvested. Given previous studies showing HBMSC-EV hepatic uptake after IV injection, the liver was evaluated for changes in inflammation, fibrosis, and proliferation.

Results: On postoperative day 28, there were no significant differences in left ventricular ejection fraction (P = 0.6151), fractional shortening (P = 0.1135), or anterior border zone fibrosis (P = 0.6333) in any of the experimental groups. Interestingly, there was a strong trend demonstrating improvement in infarct size on fibrosis staining, which did not reach significance (P = 0.05620). There were no differences in hepatic inflammation, fibrosis, and proliferation.

Conclusions: Although there was a trend in the improvement in infarct size, a single-dose administration of neither IM nor IV injection of HBMSC-EV resulted in significant improvement in post-MI cardiac function. A major limitation of this study is the lack of trials determining the optimal dose of HBMSC-EV needed in this model. However, the current study demonstrates that future studies are required to either optimize administration or bioengineer HBMSC-EV with cardiac-homing properties.

Thoracic aortic surgery poses significant challenges due to the complex anatomy and potential for life-threatening complications. Transesophageal echocardiography (TEE) has emerged as a crucial imaging tool in the management of patients undergoing these operations. TEE offers real-time, high-resolution imaging of the heart and aorta, enabling accurate assessment of aortic pathology, evaluation of cardiac function, and monitoring of intraoperative hemodynamics. Its semi-invasive nature, immediate availability, and ability to provide dynamic information make TEE an indispensable adjunct during these intricate procedures. One of the primary indications for TEE during thoracic aortic surgery is the assessment of aortic pathology, including aneurysms, dissections, and aortic valve diseases. TEE allows precise visualization of the extent, location, and severity of aortic lesions, facilitating decision-making regarding repair strategies, graft sizing, and intraoperative guidance. Furthermore, TEE aids in identifying associated cardiac abnormalities such as valvular or ventricular dysfunction, which may impact surgical planning and outcomes. This review aims to summarize the current evidence supporting the use of TEE during thoracic aortic surgical interventions and highlight its invaluable contributions to perioperative patient care.

The many ways in which ATP-sensitive potassium (K_ATP) channels can be exploited for human benefit have expanded over recent decades. Especially since the early 2000s, research has improved our understanding of the components and mechanisms of K_ATP channels. They have the potential to have a prominent role in cardiac surgery. Pharmacologic and non-pharmacologic activation of K_ATP channels has been shown to be both cardioprotective and neuroprotective in early basic science and clinical studies. However, many questions remain unanswered and require further study, necessitating further basic science work and large human clinical trials. This review discusses the history and recent progress in the research relating to the use of K_ATP channels for cardiac surgery.