Left ventricular (LV) hypertrophy in aortic stenosis (AS) is characterized by reduced myocardial perfusion reserve due to coronary microvascular dysfunction. However, whether this hypoperfusion leads to tissue deoxygenation is unknown. We aimed to assess myocardial oxygenation in severe AS without obstructive coronary artery disease, and to investigate its association with myocardial energetics and function. Twenty-eight patients with isolated severe AS and 15 controls underwent cardiovascular magnetic resonance (CMR) for assessment of perfusion (myocardial perfusion reserve index-MPRI) and oxygenation (blood-oxygen level dependent-BOLD signal intensity-SI change) during adenosine stress. LV circumferential strain and phosphocreatine/adenosine triphosphate (PCr/ATP) ratios were assessed using tagging CMR and ³¹P MR spectroscopy, respectively. AS patients had reduced MPRI (1.1 ± 0.3 vs. controls 1.7 ± 0.3, p < 0.001) and BOLD SI change during stress (5.1 ± 8.9% vs. controls 18.2 ± 10.1%, p = 0.001), as well as reduced PCr/ATP (1.45 ± 0.21 vs. 2.00 ± 0.25, p < 0.001) and LV strain (−16.4 ± 2.7% vs. controls −21.3 ± 1.9%, p < 0.001). Both perfusion reserve and oxygenation showed positive correlations with energetics and LV strain. Furthermore, impaired energetics correlated with reduced strain. Eight months post aortic valve replacement (AVR) (n = 14), perfusion (MPRI 1.6 ± 0.5), oxygenation (BOLD SI change 15.6 ± 7.0%), energetics (PCr/ATP 1.86 ± 0.48) and circumferential strain (−19.4 ± 2.5%) improved significantly. Severe AS is characterized by impaired perfusion reserve and oxygenation which are related to the degree of derangement in energetics and associated LV dysfunction. These changes are reversible on relief of pressure overload and hypertrophy regression. Strategies aimed at improving oxygen demand–supply balance to preserve myocardial energetics and LV function are promising future therapies.

End-stage cardiac failure where appropriate is best treated with cardiac transplantation. With improvements in medical therapy, the emergence of primary percutaneous coronary intervention, and an increasingly ageing population, patients with right, left or biventricular failure, who are not suitable for cardiac transplantation or long-term ventricular assist device therapy, present for cardiac surgery. The modern cardiac surgeon needs to have a safe strategy for dealing with these complex cases. We report two cases that illustrate simple and safe cannulation techniques for temporary left and right ventricular failure.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) support for ARDS treatment after cardiac surgery has progressed remarkably in the last 20 years. However, one of the limitations of a successful recover is age, being a powerful predictor of mortality. In this case report we discuss a 78-year-old man who underwent aortic valve and aortic root replacement. The postoperative period was complicated by ARDS following aspiration pneumonia treated with VV-ECMO weaned after 6 days. At two-year follow up, the patient made an excellent recover, being the second oldest person to survive VV-ECMO following cardiac surgery in the world. In the literature there is no consensus regarding a specific age limit and results, in the use of ECMO in the elderly are scarce and inconsistent. We do not think advanced age is a contraindication to the use of ECMO.

Aortic arch surgery remains associated with significant mortality and morbidity especially in the setting of acute type A aortic dissection. Adequate cerebral protection is essential, and several methods have been proposed to avoid neurological injury during aortic arch surgery. The most common techniques include selective antegrade perfusion of brachiocephalic arteries or an interval of deep hypothermic circulatory arrest. A range of cannulation strategies have been employed safely to provide adequate cerebral protection. Optimal cannulation selection is based on the consideration of air or particulate embolism risk; limitation in operative field visibility; end organ perfusion; and interactions with surgical maneuvers. Overall, no technique has been shown to fully mitigate the risk of neurological injury, rather each has utility in different scenarios. Innominate artery cannulation offers high flows on CPB and avoids additional incisions. Right axillary artery is rarely involved in aortic dissections, versatile for use in redo surgery, and altered blood flow patterns reduce embolic stroke rates. Left axillary artery can be utilized when both right axillary and femoral arteries are involved in a dissection process. Novel bi-axillary approach has additionally shown good results. Future multicenter, randomized trials should focus on establishing the relative benefits and risks of each cannulation approach with the aim of delineating the optimal cannulation strategy for different clinical situations to guide aortic surgeons, particularly in the emergency setting of aortic dissection.

Aortitis and mycotic aneurysm are vascular conditions characterized by inflammation of the aortic wall or the presence of an aneurysm resulting from microbial infection. This is a rare case of aortic aneurysm caused by atherosclerosis, with Streptococcus constellatus and Parvovirus B19 infection, in a 60-year-old male. The patient presented with rigors and pleuritic chest pain, and was found to have a saccular aneurysm of the ascending aorta and pericardial effusion. The patient underwent urgent replacement of the ascending aorta and completed 6 weeks of antibiotics with good recovery. This case emphasizes the importance of considering rare organisms in patients with aortitis and mycotic aneurysm, particularly in cases with blood cultures without microbial growth. Early diagnosis and treatment may be essential for the prevention of life-threatening complications.