Background/Objectives: In recent decades, the advantages of minimizing surgical trauma have led to the development of minimally invasive surgical procedures. While the benefits often outweigh the risks, several challenges are encountered that are not present in conventional surgical approaches. Unilateral pulmonary edema (UPE) after mitral interventions performed through a right-sided approach is a rare but potentially life-threatening event. Methods: We present the case of a 49-year-old patient who underwent endoscopic mitral valve repair. Immediately following ICU admission, the patient’s oxygen saturation suddenly dropped, and serous discharge was exteriorized from the endotracheal tube, with a thoracic X-ray revealing right-sided unilateral pulmonary edema. Results: The therapeutical course was complex. The patient developed hemodynamic instability, leading to cardiac arrest, which required cardiopulmonary resuscitation and the initiation of peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The endotracheal cannula was replaced with a right-sided double-lumen cannula, and the patient was placed on two ventilators operating independently. The patient was weaned off extracorporeal membrane oxygenation (ECMO) on the fifth day and extubated on the sixth postoperative day. Conclusions: We successfully treated this patient using ECMO and independent lung ventilation. Several cases have been described in the literature, but the pathogenesis and risk factors of UPE remain unclear. Management depends on the severity of UPE, but a deeper understanding of its underlying mechanisms could provide cardiac surgeons with enhanced strategies for preventing UPE and implementing timely interventions.

Background: Totally endoscopic techniques have become increasingly popular in cardiac surgery, with minimally invasive mitral valve repair emerging as an effective alternative to median sternotomy. This approach could be particularly advantageous for patients with Noonan syndrome, who often present with structural thoracic anomalies and other comorbidities like bleeding disorders. Endoscopic mitral valve surgery is rapidly establishing itself as the new standard of care for mitral valve operations, demonstrating both safety and efficacy. Noonan syndrome is an autosomal-dominant multisystem disorder with variable expression and is the second most common syndromic cause of congenital heart disease, surpassed only by Down syndrome. A wide spectrum of cardiovascular phenotypes is associated with Noonan syndrome, including pulmonary valve stenosis (often with dysplastic valves), hypertrophic cardiomyopathy, secundum atrial septal defect and mitral valve abnormalities. Methods: Given the limited data in the literature regarding the experience of other centers with endoscopic mitral surgery in patients with this condition, we aim to present the case of a 46-year-old male with a known diagnosis of Noonan syndrome who presented to a cardiologist with a 6-month history of dyspnea and fatigue. Transthoracic echocardiography revealed severe mitral regurgitation. Following multidisciplinary discussions within the Heart Team and after obtaining informed consent from the patient and his family, the decision was made to proceed with totally endoscopic mitral valve repair. Results: The patient experienced an uneventful postoperative course and was discharged 8 days after the procedure. In this case, endoscopic surgery was essential for successfully repairing the mitral valve. Structural abnormalities, such as chest wall deformities causing heart malrotation and atypical positioning, significantly impaired visualization. Conclusions: The endoscopic approach provided superior access to the mitral valve, enabling precise and effective repair. Additionally, it offered benefits such as improved esthetic outcomes, faster recovery, and a reduced risk of exacerbating thoracic deformities due to improper sternal bone healing.

Background and Clinical Significance: Primary cardiac tumors are among the rarest types of tumor, and until the mid-20th century, they were diagnosed only post-mortem or during other surgical interventions. With the rapid evolution of cardiovascular imaging and the widespread use of echocardiography, the incidence of cardiac fibroelastoma has increased, though it remains one of the rarest primary cardiac tumors. Papillary fibroelastoma is a benign primary cardiac tumor that develops from endocardial tissue, is usually solitary, and can have multiple locations, with the pulmonary valve being one of the rarest sites. The symptoms and complications depend on the tumor’s location, ranging from asymptomatic patients to cerebral ischemic embolism or pulmonary embolism. We analyzed the electronic databases PubMed, Web of Science, and Cochrane and conducted a systematic review of pulmonary valve papillary fibroelastoma (PVPF). Additionally, we included a case from the Adult and Pediatric Cardiovascular Surgery Clinic in Targu Mures. Case Presentation: We present the case of a 58-year-old patient who complained of exertional dyspnea. A transthoracic echocardiography (TTE) revealed a tumor mass attached to the pulmonary valve and coronary angiography identified severe coronary lesions. Following discussions within the Heart Team, surgical myocardial revascularization and tumor excision were decided upon due to the thromboembolic risk. Histopathological examination confirmed the diagnosis of papillary fibroelastoma. The postoperative course was uneventful, with an improvement in dyspnea. The mean age of the patients was 60 years, with half being men (n = 26, 50%). Regarding symptoms, 34% (n = 18) of cases were incidentally identified, while over 30% (n = 17) presented with dyspnea. Pulmonary embolism (PE) was reported in only two patients, and the most common associated comorbidities included high blood pressure (HBP) in 33% (n = 16) and dyslipidemia in 18%. Tumor size ranged from 0.7 cm to 3 cm with the initial benign cardiac tumor; its occurrence in the pulmonary valve remains exceedingly rare. Due to its frequent overlap with other cardiac pathologies, the clinical presentation is often a nonspecific diagnosis or suspicion of a tumor predominantly established via transthoracic echocardiography in 62% of patients. From a surgical perspective, 63% (n = 33) underwent tumor resection with valve sparing, 25% (n = 12) required pulmonary valve repair, and three patients necessitated pulmonary valve replacement. Conclusions: Although the incidence of papillary fibroelastoma is increasing, making it the most common, there is a need to highlight the indispensable role of echocardiography in diagnosis. Although papillary fibroelastoma is benign, surgical intervention is recommended, particularly in symptomatic patients, or if the tumor exceeds 1 cm in size, exhibits increased mobility, or is present alongside other cardiac surgical procedures.

This study aimed to investigate the impact of long-term survival on cardiac serum biomarkers such as natriuretic peptides (mid-regional pro-atrial natriuretic peptide [MR-proANP], B-type natriuretic peptide [BNP], N-terminal prohormone BNP [NT-proBNP]), soluble ST2 (sST2), galectin-3 and mid-regional pro-adrenomedullin (MR-proAMD). Consecutive patients hospitalized in a tertiary center, undergoing echocardiographic and invasive left cardiac catheterization for diastolic dysfunction assessment were prospectively included in this study. Cardiac biomarkers were determined from pre-procedural peripheral venous blood samples. A total of 110 patients were included, with a median follow-up of 1.66 (1.23–2.16) years during which 16 (14.5%) patients died. A total of 45.4% (50) of patients had diastolic dysfunction. In the univariate Cox regression, long-term survival was predicted by BNP (p < 0.0001, HR = 0.39 [0.20–0.53]), NT-proBNP (p < 0.0001, HR = 0.40 [0.22–0.55]), MR-proANP (p = 0.001, HR = 0.30 [0.11–0.46]), sST2 (p < 0.0001, HR = 0.47 [0.30–0.60]), but not with MR-proAMD (p = 0.77) or galectin-3 (p = 0.76). In the final stepwise multivariable Cox regression non-invasive and invasive models, NT-proBNP and sST2 remained independent predictors of survival. Natriuretic peptides (BNP and NT-proBNP) and sST2 were predictors of long-term survival, while MR-proANP, MR-proADM and galectin-3 did not have predictive values. NT-proBNP and sST2 improved survival prediction in both a non-invasive scenario (including clinical, serum and echocardiographic parameters) and an invasive clinical scenario (including left heart catheterization parameters). The sST2 pathway could provide a target for therapeutic intervention.

Background: The term ‘left atrial appendage aneurysm’ (LAAA) has been recognized since 1962, when it was first described. It is an exceedingly rare pathology that can affect both adults and children. Often asymptomatic, it may be discovered incidentally. The anomaly consists of an exaggerated dilation of the primitive portion of the left atrium, resulting from pectinate muscle dysplasia or as a consequence of an obstructive lesion between the left atrium and the mitral valve. Surgical intervention represents a reliable strategy for preventing catastrophic complications such as stroke, thromboembolism, and rupture. This is a very rare condition, which is why we aimed to present a case report along with a review of the literature. Case presentation: We report the case of a 6-year-old asymptomatic girl in whom a giant left atrial appendage aneurysm was incidentally detected during a routine transthoracic echocardiogram, associated with a small atrial septal defect and a prothrombotic genetic profile. The aneurysm was successfully excised, and the atrial septal defect was closed. The postoperative course was uneventful, and the patient was discharged home on the 8th postoperative day. Conclusions: Left atrial appendage aneurysm is rare in children and often asymptomatic, yet it may be life-threatening due to stroke or thromboembolism. Fetal echocardiography may be considered in selected high-risk pregnancies, and routine postnatal assessment is advised, with surgical intervention recommended particularly for patients with risk factors for thrombus formation in the left atrium or its appendage.

Background: Mitral valve prolapse is a common valvular heart disorder, usually associated with a benign prognosis in the absence of significant mitral regurgitation. However, a subset of patients is at increased risk for complex ventricular arrhythmias and sudden cardiac death. Identifying these high-risk individuals remains a major clinical challenge. Case Summary: We present the case of a 71-year-old female patient with recurrent syncopal episodes, a strong family history of sudden cardiac death, and complex ventricular ectopy. Multimodality imaging revealed bileaflet mitral valve prolapse, severe mitral regurgitation, mitral annular disjunction, and the Pickelhaube sign, with no evidence of myocardial fibrosis on cardiac magnetic resonance imaging. The patient underwent minimally invasive mitral valve repair and received an implantable cardioverter-defibrillator for primary prevention of sudden cardiac death. Follow-up revealed significant reverse cardiac remodeling, marked reduction in arrhythmic burden, and restoration of mitral valve function. Family screening identified mitral annular disjunction in both of her daughters, who were asymptomatic and without arrhythmias. Discussion: Mitral annular disjunction has emerged as a potentially arrhythmogenic substrate, especially in patients with familial clustering, raising the possibility of a genetic predisposition. Risk stratification remains difficult, as no individual clinical, electrocardiographic, or imaging marker has demonstrated consistent predictive value. Surgical correction of mitral valve prolapse with associated mitral annular disjunction may lead to a reduction in arrhythmic risk and promote favorable structural remodeling. Conclusions: This case-based review emphasizes the importance of advanced imaging techniques in the identification and management of high-risk mitral valve prolapse phenotypes. Early surgical intervention and close arrhythmic surveillance may improve outcomes, although further research is necessary to define risk assessment tools and explore the genetic background of arrhythmogenic mitral valve disease.