Minimally invasive and robotic cardiac surgery have been developed to reduce surgical trauma, shorten recovery, and improve cosmetic and functional outcomes. However, these approaches often require longer cardiopulmonary bypass (CPB) and aortic cross-clamp times than conventional full sternotomy, and CPB duration remains an independent predictor of postoperative morbidity and mortality, particularly in frail patients with reduced physiological reserve. The resulting less invasive access/prolonged extracorporeal support duration paradox poses a major physiological and clinical challenge. Contemporary evidence from randomized and observational studies reports that while minimally invasive and robotic procedures achieve comparable or improved survival and functional recovery, extended CPB and aortic clamp times can amplify the risk of renal dysfunction, neurological events, and systemic inflammation. Advances in digital health are now transforming intraoperative perfusion management: high-frequency data acquisition, automated oxygen delivery and consumption analytics, and real-time artificial intelligence-driven predictive models enable early detection of perfusion imbalance and metabolic distress. Integration of these data streams within interoperable platforms and patient-specific digital twins may allow dynamic modeling of perfusion adequacy and adaptive control of pump flow, temperature, and hemodynamics. By converting CPB duration from a static procedural metric into a digitally monitored, optimizable variable, precision perfusion could reconcile minimal invasiveness with physiological safety. Future research should validate these digital frameworks in multicenter studies and establish standards for transparency, interoperability, and ethical implementation in real-world cardiac surgery.

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.

Goal-Directed Perfusion represents an evolving physiological framework for the management of cardiopulmonary bypass, designed to preserve tissue oxygenatio

Background: Blood oxygen content and management during cardiopulmonary bypass (CPB), particularly during reperfusion phase after cross-clamping related ischemia, may influence systemic oxygen utilization, oxidative stress, and organ ischemia/reperfusion injury. These conditions may be highly relevant in patients undergoing coronary artery bypass grafting (CABG) due to coronary artery disease. The impact of a hyperoxia/normoxia strategy on metabolic efficiency, myocardial injury, and early clinical outcomes remains incompletely defined. Materials and methods: We conducted a retrospective study including 50 patients undergoing isolated elective CABG with CPB. Patients were stratified into a normoxia (N) group (PaO ₂ 90–130 mmHg; n = 25) and a hyperoxia (H) group (PaO ₂ >200 mmHg; n = 25). CPB trend parameters including PaO ₂ , mixed venous oxygen saturation (SvO ₂ ), indexed oxygen extraction ratio, and lactate levels were analyzed intraoperatively. Myocardial injury was assessed by serial troponin measurements. Early postoperative left ventricular ejection fraction (LVEF), need for inotropic support, ICU and hospital length of stay, as well as biomarkers of oxidative stress and hypoxia-related pathways, were evaluated. Exploratory outcomes included lactate kinetics (0, 6, 12, and 24 h), acute kidney injury (KDIGO criteria), new-onset atrial fibrillation within 48 h, duration of mechanical ventilation, and 30-days major adverse cardiac events (MACEs). Results: Baseline, including preoperative LVEF, as well as operative characteristics, including types of grafts, modalities of revascularization (single vs jumpgraft) as well as cardiopulmonary bypass and aortic cross-clamp durations, were similar between groups. All grafts underwent flow assessment at the end of the operation to confirm the quality and appropriateness of perfusion. During CPB, indexed oxygen delivery was comparable; however, the hyperoxia group showed significantly higher arterial and mixed venous oxygen partial pressures, associated with a lower oxygen extraction ratio and higher lactate concentrations, indicating reduced metabolic efficiency. Troponin levels were significantly lower in the normoxia group during CPB and at 6, 12, and 24 h postoperatively, reflecting attenuated myocardial injury. Post-CPB LVEF was higher in the normoxia group (51.8 ± 8.9 vs 46.3 ± 10.1%, p = 0.041), accompanied by a reduced need for inotropic support (24% vs 56%, p = 0.021). Intensive care unit and hospital length of stay were significantly shorter in normoxic patients. Hyperoxic oxygenation was associated with significantly higher perioperative levels of hypoxia-inducible factor-1α, total oxidant status, and oxidative stress index, along with reduced total antioxidant status. Conclusions: In patients undergoing CABG with CPB, normoxia was associated with more efficient oxygen utilization, reduced oxidative stress, , attenuated perioperative myocardial injury, improved early postoperative ventricular function, and shorter ICU and hospital stay compared with hyperoxic oxygenation. These findings support a physiology-guided oxygenation strategy during cardiac surgery.

Background: The increasing digitization of perfusion practice has led to the integration of advanced data management systems (DMS) that record and analyze intraoperative variables in real time. While these systems improve accuracy, traceability, and clinical decision-making, they also expose perfusion workflows to significant cybersecurity risks. Given that perfusion data directly reflect artificial circulation, any loss of integrity or service can have immediate clinical consequences. Materials and Methods: A comprehensive narrative review was conducted to synthesize current knowledge on cybersecurity in perfusion informatics and performance. The research strategy combined systematic database searches (PubMed, Scopus, IEEE Xplore, and Web of Science) with targeted grey literature review (regulatory frameworks and institutional reports). Inclusion criteria focused on articles published between 2010 and 2024 addressing healthcare cybersecurity, perfusion informatics, and medical device security. Studies were analyzed qualitatively to identify recurring themes, technological approaches, and governance models. Reference cross-checking ensured comprehensive coverage, and terminology was standardized according to ISO/IEC 27001 principles. The review followed an integrative, non-meta-analytic design, emphasizing conceptual synthesis rather than statistical aggregation. Results: Thirty-three primary and secondary sources were identified. The literature reveals a consistent pattern of vulnerabilities across clinical DMS, with perfusion systems being particularly exposed to ransomware, data tampering, and service interruption. The review highlights the centrality of the Confidentiality–Integrity–Assurance of Service triad as a guiding model. Key strategies identified include encryption and role-based access control, blockchain audit trails, federated learning, and post-quantum cryptography. However, empirical studies focusing specifically on perfusion remain scarce, underscoring a major research gap. Conclusions: Cybersecurity in perfusion informatics must evolve from a technical adjunct to a clinical mandate. Integrating security frameworks into perfusion workflows supported by legal compliance (HIPAA, GDPR, ISO 27001) and ethical governance is essential to preserve patient safety. Future research should prioritize multicenter simulations, resilience testing, and cross-disciplinary training to ensure the continuity, integrity, and trustworthiness of digital perfusion systems.

Background: Extracorporeal circulation (ECC) is increasingly supported by biomaterials engineered to minimize chemical leaching, and many biomedical manufacturers have now removed or substantially reduced phthalate plasticizers particularly di(2-ethylhexyl) phthalate (DEHP) from tubing and circuit components. Nevertheless, emerging evidence highlights a parallel and underexplored concern: the generation of microplastic particles, especially during manual cutting and customization of circuit segments in the operating room. While screen and depth filters used in CPB and ECMO circuits efficiently remove particles above defined size thresholds, the fate of smaller microplastics potentially capable of transiting through current filtration systems remains largely unknown. This raises new biocompatibility questions in an area where evidence is sparse and risk assessment remains incomplete. Materials and methods: A structured narrative review was conducted using PubMed and Web of Science, supplemented by manual reference screening. Search terms included “phthalates,” “DEHP-free circuits,” “microplastics,” “extracorporeal circulation,” “cardiopulmonary bypass,” “ECMO,” “biomaterials,” and “particle shedding.” Studies published between 1989 and 2025 addressing chemical migration, particulate release, biomaterial–blood interactions, or clinical exposure were eligible. After screening titles, abstracts, and full texts, 15 relevant studies were identified and included for qualitative synthesis. Results: Across included studies, phthalate reduction strategies such as the adoption of DEHP-free materials (e.g., TOTM-based tubing) demonstrably decreased chemical migration during ECC. However, the shift toward alternative materials does not preclude the mechanical generation of microplastic particles. Evidence from biomaterial studies suggests that shear stress, handling, and intraoperative cutting may contribute to particulate release. Unlike phthalates, microplastic contamination has not been systematically quantified in ECC settings, and current filters are optimized for macro- and microdebris but not necessarily for sub-micron or small-microplastic fractions. This gap contrasts with the well-characterized exposure profiles of phthalates, leaving the particulate dimension of ECC biocompatibility largely uncharted. Preliminary mechanistic data indicate that microplastics may act as carriers for residual plasticizers or other adsorbed molecules, potentially amplifying biological interactions. Conclusions: Although phthalate exposure has decreased with industry-wide adoption of alternative plasticizers, microplastic release particularly from manual circuit preparation represents an emerging and insufficiently characterized risk in ECC. Existing filtration technologies may not capture the smallest particles, and no standardized monitoring or exposure-reduction protocols currently address this issue. These findings underscore critical knowledge gaps and highlight the need for targeted research on microplastic generation, trans-filter passage, biological effects, and mitigation strategies. Open questions regarding particulate contamination challenge the current definition of biocompatibility and call for a broadened translational framework to ensure safer extracorporeal technologies.