Nitric oxide (NO) is a central regulator of vascular homeostasis and a key determinant of saphenous vein graft (SVG) outcomes in coronary artery bypass grafting (CABG). Endothelial dysfunction, driven by altered shear stress, oxidative stress, and cardiovascular risk factors, impairs NO production and release, contributing to SVG thrombosis, intimal hyperplasia, and atherosclerosis. SVG harvesting technique, storage, and intraoperative handling affects endothelial integrity, inflammatory response, and vascular remodeling, influencing arterialization, long-term patency, and clinical outcomes. Preservation of perivascular adipose tissue (PVAT) during vein harvesting enhances NO bioavailability, reduces inflammation and oxidative stress, and supports graft adaptation. Internal thoracic artery (ITA) grafts provide durable patency, survival benefit, and NO-mediated vasoprotection, improving SVG function and mitigating maladaptive remodeling. Graft configuration further determines SVG adaptation. ITA-composite SVGs confer continuous NO exposure, promote arterial-like remodeling, and attenuate low shear stress. Optimal secondary prevention, including antiplatelet therapy, statins and lifestyle modifications further preserves endothelial function and reduces SVG failure. Targeting NO through surgical technique, graft configuration, and pharmacologic intervention represents a unifying strategy to enhance SVG performance, arterialization, and long-term outcomes, addressing the current limitation of SVG in CABG.

Robotic assisted minimally invasive direct coronary artery bypass grafting (RA-MIDCAB) represents an effective alternative to conventional coronary artery bypass grafting for revascularization of the left anterior descending artery (LAD) with the left internal thoracic artery (LITA). The first LITA-LAD bypass using a robot was performed in 1998. Since then, progress has been made, bringing the benefits of reduced surgical trauma and faster patient recovery. We report on our single-center initial experience of RA-MIDCAB surgery. This retrospective study included the first 27 patients who underwent RA-MIDCAB between July 2024 and September 2025. Baseline characteristics, perioperative and postoperative outcomes were collected from institutional databases and patient records. All RA-MIDCAB procedures were successfully performed by 2 expert surgeons. Intraoperative graft patency was measured. No mortality was registered, neither on 30-day nor long-term. Conversion to sternotomy never occurred. The mean surgery time was 245.7 minutes. Early outcomes included postoperative new onset atrial fibrillation (n = 2; 7.4%) and respiratory failure (n = 1; 3.7%). Mean length of intensive care unit stay and hospital stay were, respectively, 2.4 and 3.9 days. No patients underwent repeat revascularization or suffered major adverse cardiovascular events. RA-MIDCAB surgery can be performed safely with excellent results. Despite an initial investment, starting a RA-MIDCAB program improves quality of care.

Background and Objectives: Overt perioperative stroke remains a feared complication of adult cardiac surgery. Diffusion-weighted magnetic resonance imaging (DWI-MRI) has revealed a more prevalent form of cerebral injury, termed silent stroke or silent brain injury (SBI). Covert ischemic lesions occur without focal neurological deficits but are increasingly associated with postoperative delirium, cognitive decline, and elevated long-term cerebrovascular risk. Despite growing recognition, the true burden, mechanisms, and clinical relevance of SBI remain incompletely integrated into perioperative practice. Materials and Methods: We performed a narrative review of the literature published between January 2000 and December 2025, identified through PubMed/MEDLINE and Scopus. Eligible studies included prospective and retrospective cohorts, randomized trials, systematic reviews, and meta-analyses involving adult patients undergoing coronary artery bypass grafting, valve surgery, or minimally invasive cardiac procedures, with or without cardiopulmonary bypass, and reporting MRI-detected ischemic lesions or validated surrogate markers of cerebral injury. Pediatric studies, transcatheter interventions, case reports, and non-English publications were excluded. Sixty studies met the inclusion criteria. Results: Silent stroke occurred more frequently than clinically apparent stroke, with new DWI-MRI lesions detected in approximately 20–60% of patients following cardiac surgery. Lesions were typically small, multifocal, and embolic in distribution, predominantly affecting cortical and watershed regions. Cardiopulmonary bypass-related factors, including aortic manipulation, cerebral microembolization, hemodilution, hypoperfusion, and impaired oxygen delivery, emerged as key contributors. Several studies demonstrated associations between SBI burden and postoperative delirium, early cognitive dysfunction, and functional decline. Perfusion-based neuroprotective strategies showed mechanistic benefit, although no single intervention conclusively prevented SBI. Conclusions: Silent stroke represents the most frequent form of neurological injury in adult cardiac surgery. Evidence suggests that these covert lesions reflect clinically meaningful cerebral injury, with potential short- and long-term consequences. Recognition of silent stroke as a relevant neurological endpoint supports a shift toward multimodal, perfusion-driven neuroprotective strategies and the routine incorporation of MRI-based outcomes in future cardiac surgical research.

Background: Elevated body mass index (BMI) is associated with adverse outcomes after cardiac surgery, but its impact in acute type A aortic dissection (ATAAD) surgery is unclear. We assessed the relationship between BMI and outcomes after ATAAD repair. Methods: An institutional retrospective cohort review was undertaken of all consecutive patients who underwent repair of ATAAD between July 2014 and December 2022 ( n = 398). Patients were stratified by BMI into three groups: ‘non-obese’ [BMI < 30 kg/m ² ; median 26.0 (23.0, 27.7) kg/m ² ] ( n = 248), ‘Obesity Class I’ [30 ≤ BMI < 35 kg/m ² ; median 31.9 (30.8, 33.4) kg/m ² ] ( n = 81), and ‘Obesity Class II+’ [BMI ≥ 35 kg/m ² ; median 38.9 (36.4, 41.9) kg/m ² ] ( n = 69). Multivariable logistic regression was utilized to assess the relationship between BMI and 30-day mortality, stroke, and duration of ventilation. Results: Thirty-day operative mortality for the entire cohort was 12.8% ( n = 51). The Obesity Class I cohort was associated with decreased odds of 30-day mortality [OR = 0.18, 95% CI: (0.06–0.62), p = 0.006] compared to the non-obese cohort, whereas the Obesity Class II + was not. Diabetes [OR = 2.9, 95% CI: (1.32–6.41), p = 0.008], history of lower extremity ischemia [OR = 4.27, 95% CI: (2.11–8.62), p < 0.001], age [OR = 1.04, 95% CI: (1.01–1.07), p = 0.005], duration of cardiopulmonary bypass [OR = 1.005, 95% CI: (1.00–1.01), p = 0.027], and units of intraoperative red blood cells received [OR = 1.08, 95% CI: (1.01–1.16), p = 0.028] were associated with increased 30-day mortality. There was no significant association between BMI groups and post-operative stroke or duration of ventilation. Conclusion: The obesity paradox in cardiac surgery remains incompletely understood. In this cohort, BMI was not associated with increased 30-day mortality following ATAAD repair, with class I obesity demonstrating lower adjusted mortality. These findings support the continued practice of expeditious surgical intervention for ATAAD regardless of BMI.

In the treatment of a moderately dilated ascending aorta, external wrapping of the ascending aorta may represent an alternative to the gold standard ascending aorta replacement. Concerns regarding the safety and long-term durability of external wrapping of the ascending aorta have limited its widespread adoption. We conducted a systematic review and meta-analysis comparing external wrapping of the ascending aorta with ascending aorta replacement. The primary outcome was 30-day mortality, defined as 30-day and/or in-hospital mortality, and midterm mortality, as reported by the source studies. Secondary outcomes included intensive care unit and hospital length of stay, cardiopulmonary bypass time, cardiac crossclamp time, reoperation for bleeding, stroke, acute kidney injury, wound infection, concomitant surgeries, and midterm outcomes. Between-group differences were quantified using standardized mean difference. Effect estimates were expressed as odds ratios for binary outcomes, incidence rate ratios for time-dependent mortality, and standardized mean differences for continuous outcomes, each with 95% confidence intervals. Eight comparative studies comprising 851 patients were identified. A total of 433 patients (50.9%) underwent external wrapping of the ascending aorta, and 418 (49.1%) underwent ascending aorta replacement. The mean follow-up duration was 3.9 years (95% confidence interval, 1.8-8.4 years). No statistically significant differences were observed in 30-day mortality (odds ratio, 0.61; 95% confidence interval, 0.24-1.56), midterm mortality (incidence rate ratio, 0.97; 95% confidence interval, 0.57-1.66), acute kidney injury (odds ratio, 0.66; 95% confidence interval, 0.22-1.96), stroke (odds ratio, 0.67; 95% confidence interval, 0.23-1.93), wound infection (odds ratio, 1.37; 95% confidence interval, 0.41-4.53), concomitant aortic valve replacement (odds ratio, 0.92; 95% confidence interval, 0.42-2.00), coronary artery bypass grafting (odds ratio, 0.86; 95% confidence interval, 0.37-1.99), mitral valve procedures (odds ratio, 0.71; 95% confidence interval, 0.20-2.56), reoperation for bleeding (odds ratio, 0.48; 95% confidence interval, 0.15-1.58), proximal ascending aorta diameter (standardized mean difference, 0.19; 95% confidence interval, -0.21 to 0.59) or midascending aorta diameter at follow-up (standardized mean difference, -0.53; 95% confidence interval, -1.67 to 0.60). External wrapping of the ascending aorta was associated with shorter cardiopulmonary bypass time (unweighted mean absolute difference, 42.4 minutes; standardized mean difference, -2.46; 95% confidence interval, -3.49 to -1.43), crossclamp time (unweighted mean absolute difference, 30.6 minutes; standardized mean difference, -2.12; 95% confidence interval, -3.18 to -1.07), intensive care unit length of stay (unweighted mean absolute difference, 22.6 hours; standardized mean difference, -0.58; 95% confidence interval, -0.81 to -0.36), and hospital length of stay (unweighted mean absolute difference, 2.4 days; standardized mean difference, -0.36; 95% confidence interval, -0.63 to -0.10). Thirty-day and midterm mortality did not significantly differ between external wrapping of the ascending aorta and ascending aorta replacement. In addition, external wrapping of the ascending aorta was associated with shorter cardiopulmonary bypass and crossclamp times and reduced intensive care unit and hospital length of stay. However, this study did not establish the clinical equivalence of external wrapping of the ascending aorta. Ascending aorta replacement remains the gold standard surgical technique for a moderately dilated ascending aorta. The retrospective design, limited follow-up, heterogeneous patient selection, and inconsistent outcomes reporting of the included studies limit the applicability of these findings to clinical practice.