Complex ascending and aortic arch surgery requires the implementation of different cerebral protection strategies to avoid or limit the probability of intraoperative brain damage during circulatory arrest. The etiology of the damage is multifactorial, involving cerebral embolism, hypoperfusion, hypoxia and inflammatory response. These protective strategies include the use of deep or moderate hypothermia to reduce the cerebral oxygen consumption, allowing the toleration of a variable period of absence of cerebral blood flow, and the use of different cerebral perfusion techniques, both anterograde and retrograde, on top of hypothermia, to avoid any period of intraoperative brain ischemia. In this narrative review, the pathophysiology of cerebral damage during aortic surgery is described. The different options for brain protection, including hypothermia, anterograde or retrograde cerebral perfusion, are also analyzed, with a critical review of the advantages and limitations under a technical point of view. Finally, the current systems of intraoperative brain monitoring are also discussed.

Pulmonary embolism represents the leading cause of maternal mortality in developed countries. The optimal treatment of high-risk pulmonary embolism with cardiovascular instability and at high hemorrhagic risk is still debated but surgical embolectomy represents an effective option. We describe the case of a 35-year-old woman in week 34 of pregnancy who was referred to our hospital because of exertional dyspnea and tachycardia and a few hours later became hypotensive and hypoxic. Pulmonary embolism was detected by performing an angio-computed tomography (CT) scan. After a successful cesarean section, emergent embolectomy was performed without inducing uterine hemorrhage. Both mother and the newborn recovered without postoperative sequelae.

Background: Temporary mechanical circulatory support (t-MCS) with Impella CP has recently attracted considerable interest as a therapeutic option for cardiogenic shock (CS) complicating acute myocardial infarction (AMI). In contrast, evidence regarding the use of the larger Impella 5+ (5.0/5.5) in this clinical setting remains limited. This single-centre retrospective study aimed to evaluate the clinical impact of Impella 5+ in patients with AMI-related cardiogenic shock (AMI-CS) Methods and results: Between January 2022 and August 2024, 28 patients referred for AMI-CS were treated with Impella 5+. 11 patients were classified as SCAI C, 11 as SCAI D and 6 as SCAI E. On admission, median inotropic score was 10.5 and median left ventricular ejection fraction was 17.5%. 12 patients required concomitant ECMO support (ECPella). 19 patients were escalated from IABPM to Impella 5+. The median length of support was 8 days, 2 patients (7%) received the support for more than 30 days. 1 patient experienced a major bleeding complication. The overall survival during index hospitalization was 79%: 3 patients were bridged to a durable left ventricular assist device (LVAD) and 2 received heart transplantation (HTx). Conclusions: Impella 5+ appears to be a safe and effective option in AMI-CS, associated with improved survival and a relatively low incidence of vascular and non-vascular complications. Its advanced features broaden the therapeutic potential of microaxial flow pumps in this high-risk setting.

Left ventricular (LV) distension is a life-threatening complication of venoarterial extracorporeal membrane oxygenation (VA-ECMO), requiring prompt venting in the setting of uncertain neurological prognosis. Current strategies, microaxial devices and surgical venting, are costly or invasive. A 55 year old male with cardiac arrest on VA-ECMO developed severe LV distension with refractory ventricular fibrillation. A 17 French Bio-Medicus cannula was inserted percutaneously via the right axillary artery and connected to the ECMO venous limb, achieving effective LV unloading in 8 minutes. Hemodynamic stability was maintained for 48 hours, enabling neurological assessment and successful organ donation. Percutaneous axillary venting is a cost-effective, rapidly deployable option for LV decompression during VA-ECMO, preserving therapeutic flexibility for cardiac recovery or organ donation.