The failure of saphenous vein grafts following coronary artery bypass grafting (CABG) remains a significant issue, as it limits the durability of vein-based surgical revascularisation compared to arterial conduits. Venous graft disease is a dynamic process that begins early in the perioperative period as a consequence of harvesting trauma, ex vivo preservation, and the sudden exposure of the conduit to the arterial haemodynamic environment. This narrative review summarises the available evidence on local graft protection strategies, focusing on intraoperative and perioperative approaches aimed at preserving endothelial integrity, attenuating initial inflammation, and limiting maladaptive remodelling. Specifically, the review analyses the role of endothelium-protective preservation solutions, external support devices, biodegradable drug-eluting biomaterials, and locally targeted RNA therapies. Preclinical and early clinical evidence suggests that local graft protection is biologically plausible and may reduce intimal hyperplasia, luminal irregularity and adverse graft remodelling. However, its impact on long-term clinical outcomes remains uncertain. An integrated approach combining harvest optimisation, conduit preservation, mechanical support, and local delivery of drugs or regulatory molecules may represent a promising framework for improving vein graft biology; however, its ability to translate into durable patency gains and improved clinical outcomes after CABG requires further clinical validation.

Circle of Willis (CoW) variations are present in a significant number of patients. In patients undergoing non-emergent surgery for aortic dissection (e.g., chronic dissection or planned complex aortic arch surgery), an extensive preoperative examination is warranted as anatomic completeness, variation, patency, and functional assessment of CoW is crucial to optimize neuroprotection strategies. In non-emergent clinical presentations, unilateral or bilateral selective cerebral perfusion should be tailored to patient’s anatomy to minimize intraoperative risk and improve outcomes. A new classification system provides a simple and comprehensive ontology of the described anatomical variations of the CoW. An accurate preoperative assessment might indicate the need for adjunctive perfusion in selected CoW configurations.

The management of obstructive hypertrophic cardiomyopathy (HCM) has been transformed by the advent of cardiac myosin inhibitors (CMIs), such as mavacamten and aficamten. Unlike traditional pharmacotherapy, which primarily addresses symptoms, CMIs target the underlying mechanism of sarcomeric hypercontractility, offering significant reductions in left ventricular outflow tract (LVOT) gradients and improved functional capacity. This review evaluates the evolving role of CMIs in refining surgical candidate selection and postoperative care. Clinically, CMIs function as an in vivo “biological test” to distinguish between dynamic, functional obstruction—often manageable with medication—and fixed anatomical obstruction driven by complex septal or mitral substrates. While clinical trials demonstrate that CMIs can delay or prevent the need for SRT in a significant proportion of patients, surgery remains the definitive solution for those with dominant structural anomalies or drug intolerance. Consequently, the therapeutic paradigm is shifting from a binary “drugs or surgery” approach to a synergistic model. In this framework, CMIs optimize the identification of patients truly requiring structural myectomy while serving as a valuable adjunct for managing residual hypercontractility, ultimately facilitating a personalized, multidisciplinary approach to HCM treatment.

Background:Heterotopic transcatheter caval valve implantation (CAVI) has emerged as a palliative yet promising therapeutic strategy for treating severe tricuspid regurgitation (TR), which aims to reduce systemic venous congestion by implanting bioprosthetic valves in the venae cavae rather than in the native tricuspid annulus. However, despite encouraging procedural success, clinical improvement and survival remain highly variable.Methods:A systematic review of published registries and case series was performed, focusing on the outcomes, procedural success, mortality, and safety of CAVI. Data were extracted from multicenter registries and observational series describing the use of transcatheter stented bioprosthesis or bioprosthesis alone.Results:Across published cohorts and registries, procedural success rates ranged from 90% to 100%, with 30-day mortality ranging from 5% to 25%. The TRICUS EURO study, which included 35 patients across 12 European centers, demonstrated significant improvements in New York Heart Association (NYHA) functional class and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores at 6 months, with minimal device-related complications and adverse events. The ongoing TRICAV-II pivotal trial (NCT06458907) and EuroTR registry (NCT06307262) are expected to provide larger real-world datasets. Smaller case series and individual reports, typically involving ≤10 patients, confirmed feasibility and symptomatic benefits, particularly reductions in peripheral edema and ascites. However, long-term outcome data remain limited. This study highlights right ventricle (RV) dysfunction, severe pulmonary hypertension, advanced end-organ failure, and clinical frailty as major determinants of unfavorable outcomes.Conclusions:Heterotopic CAVI represents a viable alternative for high-risk patients with severe TR, offering symptomatic improvement and reduced venous congestion when conventional surgery or orthotopic repair is not feasible. However, current evidence is derived primarily from non-randomized studies and limited registries. Ongoing prospective registries and pivotal trials are crucial for defining patient selection, procedural optimization, and long-term survival benefit. Early intervention and multidisciplinary patient selection appear crucial for avoiding futile procedures and identifying patients who may derive true symptomatic and prognostic benefit from CAVI.

Background and objectives: In cases of acute type A aortic dissection, including iatrogenic cases following transcatheter procedures, the choice of arterial cannulation site has a critical influence on early haemodynamics, organ protection and the risk of malperfusion. Transapical left ventricular cannulation has been suggested as a ‘central’ approach for rapidly establishing cardiopulmonary bypass with antegrade true-lumen flow. This review summarises the current evidence on TAC in acute type A dissection, focusing on indications, technical aspects and clinical outcomes. Materials and methods: We conducted a narrative review of observational studies and technical reports describing TAC for the surgical repair of acute type A aortic dissection. Particular attention was paid to patient selection, operative technique, perioperative complications, and early and mid-term results. Results: Across the published series, TAC is primarily employed in haemodynamically unstable patients or when the peripheral arteries are dissected, diseased, or unsuitable. A long arterial cannula is introduced through the left ventricular apex, crosses the aortic valve and is positioned in the true lumen of the ascending aorta under echocardiographic guidance. This configuration enables the rapid initiation of CPB, shortens skin-to-pump times, and provides reliable antegrade inflow. Early mortality and stroke rates are comparable to those associated with other cannulation strategies. Reported complications include malperfusion requiring site conversion, apical bleeding and rare local structural damage. These can be minimised through standardised technique and systematic imaging. Conclusions: TAC is a valuable bail-out option and, in selected patients, a primary cannulation option for acute type A aortic dissection when conventional arterial access is unsafe or ineffective. Although it offers fast and reproducible establishment of antegrade true-lumen flow, it requires specific expertise in apical exposure and intraoperative echocardiography. It should therefore be integrated into a structured perfusion and repair strategy.