Background: Pheochromocytoma and paraganglioma are catecholamine-secreting tumors, rarely presenting with pheochromocytoma multisystem crisis (PMC), a life-threatening endocrine emergency. The severity of the condition includes a refractory cardiogenic shock and may therefore require the use of temporary mechanical circulatory support. The aim of this review is to describe the incidence of pheochromocytoma and paraganglioma crises associated with refractory cardiogenic shock, the physiopathological impact of this condition on the myocardial function, the role of temporary mechanical circulatory support (tMCS) in its management, and the outcomes of this specific population. Methods: For the purpose of this narrative review, a literature search of PubMed was conducted as of 16 November 2024. Medical Subject Headings (MeSH) terms used included extracorporeal circulation”, “Impella”, “pheochromocytoma”, “paraganglioma”, and “cardiogenic shock”, combined with Boolean “OR” and “AND”. Data from case series, retrospective studies, and systematic reviews were considered. Seven studies reporting on 45 patients who developed PMC with cardiogenic shock requiring tMCS were included. Patients were young, with a median age of 43 years (range 25–65) at presentation. Most cases presented with severe hemodynamic instability, blood pressure lability, and rapid progression to severe left ventricular dysfunction. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was the most common tMCS used to stabilize patients, initiate specific pheochromocytoma treatments, and, in some cases, provide circulatory support during emergent surgery. The median duration of VA-ECMO support was 4 days (range 1–7) and the reported mean in-hospital survival rate was 93.5%. Following VA-ECMO weaning, survivors showed full recovery of the left ventricular ejection fraction (LVEF). Conclusions: The cardiac dysfunction observed in PMC-associated cardiogenic shock may be severe and life-threatening but appears reversible. tMCS should therefore be considered in eligible cases, as a bridge to recovery, treatment, or surgery. The reported survival rates are impressively high, suggesting possibly a substantial risk of publication bias.

The aorta, once viewed as a passive conduit, is now recognized as an active organ crucial for hemodynamic regulation and vascular homeostasis. Thoracic aortic aneurysms (TAAs), particularly those involving the ascending aorta, often remain silent until life-threatening complications such as dissection or rupture occur. Current management primarily relies on aortic diameter criteria, yet up to 60% of type A dissections occur at sizes below the 5.5 cm surgical threshold, revealing the limitations of this approach. This narrative review summarizes recent advances in understanding ascending aortic aneurysms, including insights into their genetic and degenerative mechanisms, the role of novel morphological and hemodynamic markers, and the potential of advanced imaging techniques. It also explores evolving surgical strategies, from conventional open repair, still the gold standard, to minimally invasive and investigational endovascular approaches. By integrating biological, morphological, and clinical factors, emerging strategies aim to move beyond diameter alone toward more personalized risk assessment. This paradigm shift may improve early detection, optimize surgical timing, and ultimately enhance outcomes for patients with ascending aortic aneurysms.

Background and Aim: Floating aortic thrombi are rare but potentially life-threatening entities, associated with a high risk of systemic embolization and subsequent complications such as ischemic stroke or mesenteric infarction. Therapeutic strategies range from urgent surgical intervention to conservative medical management with anticoagulation, depending on the patient’s clinical status and thrombus morphology. This report presents two cases of floating aortic thrombi managed with distinct approaches, surgical and medical, underscoring the importance of individualized treatment guided by embolic risk and comorbidities. Patients and Methods: The first case involves a 59-year-old male presenting with abdominal pain and emesis. Imaging confirmed mesenteric ischemia, necessitating emergent laparotomy and extensive jejunal resection. Postoperative imaging identified a mobile thrombus at the ascending aorta–aortic arch junction, with evidence of cerebral embolism. The patient underwent urgent surgical thrombectomy, ascending aortic resection, and hemiarch replacement. The second case describes an 88-year-old male who presented with bilateral upper limb paresthesia. Neuroimaging revealed acute supra- and infratentorial ischemic lesions suggestive of embolic stroke. A floating thrombus was identified in the ascending aorta, with an additional thrombus in the descending thoracic aorta. Given the patient’s advanced age, comorbid conditions, and thrombus stability, a conservative approach with systemic anticoagulation and close radiologic surveillance was chosen. Conclusions: These cases illustrate the need for tailored management of floating aortic thrombi. While surgical resection remains indicated in unstable or high-risk embolic cases, anticoagulation may suffice for stable lesions in patients with elevated surgical risk. Further studies are needed to establish standardized therapeutic guidelines.

Myocardial protection during cardiac surgery is critical for preserving cardiac function, minimizing ischemia-reperfusion injury, and preventing myocardial stunning. Although advances in cardioplegia formulations, delivery techniques, pharmacologic agents, and controlled reperfusion strategies have entered clinical practice, substantial variability in protocols and limited comparative evidence continue to hinder optimization and standardization. This narrative review is aimed at highlighting critical current evidence, identifying key gaps in perioperative myocardial protection, and discussing emerging opportunities for innovation and personalized strategies. A comprehensive literature search was conducted in PubMed and Embase through June 2025, with a combination of MeSH terms and keywords related to cardioplegia and myocardial protection. High-quality studies, including randomized trials, systematic reviews, and authoritative expert opinions, were selected according to relevance to key themes, including cardioplegia types, delivery techniques, risk populations, pharmacologic adjuncts, and real-time monitoring technologies. No cardioplegia strategy is universally accepted, and cardioplegic formulation composition, temperature, and delivery methods widely vary across institutions. Although modified del Nido solutions have gained popularity, comparative evidence remains inconsistent. Small volume cardioplegia solutions (e.g., Cardioplexol®) show future promise. High-risk populations, such as those with diabetes or left ventricular hypertrophy, continue to experience suboptimal outcomes, probably because of distinct metabolic and structural vulnerabilities. Pharmacologic agents mimicking ischemic preconditioning have achieved limited translation into routine practice, and remote ischemic conditioning remains underused, owing to inconsistent evidence. Real-time intraoperative monitoring of myocardial injury and established threshold values for early myocardial injury biomarkers are notably lacking. Emerging modalities such as intramyocardial pH sensors and coronary sinus metabolite sampling offer promise for early injury detection but are far from achieving widespread use. Substantial gaps persist in the personalization and standardization of myocardial protection in cardiac surgery. Innovative approaches are required to advance intraoperative sensing technologies and adjunct protective interventions tailored to patient risk profiles. Incorporating artificial intelligence, leveraging omics data, and fostering multi-institutional collaboration are key steps toward a new era of precision myocardial protection.

Background and Aim: Floating aortic thrombi are rare but potentially life-threatening conditions, with a high risk of systemic embolization, leading to severe complications such as stroke, mesenteric or other organ ischemia. Treatment approaches vary widely, ranging from urgent surgical resection to conservative medical management with anticoagulation, depending on the patient’s overall condition and thrombus characteristics. In this report, we present two cases of floating aortic thrombi managed with different strategies: one with surgical intervention and the other with anticoagulation. The aim is to illustrate how individualized treatment approaches are determined based on clinical presentation and the risk of embolic events. Patients and Methods: The first case concerns a 59-year-old male who presented with abdominal pain and vomiting, with subsequent imaging revealing mesenteric ischemia. Emergency laparotomy confirmed intestinal necrosis, necessitating resection of a large portion of the jejunum. Postoperatively, a floating thrombus was discovered at the junction of the ascending aorta and aortic arch, associated with cerebral embolization. The patient underwent urgent surgical intervention, including resection of the aortic thrombus and resection of the ascending aorta, with an hemiarch replacement. The second case involves an 88-year-old male who presented with bilateral paresthesia in both hands, raising suspicion of a stroke. The MRI showed acute supra- and infratentorial ischemic lesions, suggesting an embolic origin. Additional imaging revealed a floating thrombus in the ascending aorta, along with a second thrombus in the descending aorta. Given the stability of the thrombi, the absence of acute ischemic events and the patient’s age and comorbidities, which increase the risk of surgical treatment, the patient was managed conservatively with anticoagulation and close radiologic monitoring. Conclusion: These two cases highlight the varied approaches in managing floating aortic thrombi, emphasizing the importance of individualized treatment based on thrombus stability, patient comorbidities, and embolic risk. While surgical resection is warranted in high-risk cases, as demonstrated in the first patient, anticoagulation can be effective for stable thrombi and high operative risk or inoperable patients, as seen in the second case. Multidisciplinary collaboration and vigilant follow-up are critical to optimizing outcomes. Further research is necessary to refine treatment guidelines for this rare but dangerous condition.