Extracorporeal membrane oxygenation (ECMO) is a continuously evolving and increasingly utilized life-support therapy. ECMO requires systemic anticoagulation, which exposes patients to an increased risk of heparin-induced thrombocytopenia (HIT). Clinical experience with alternative anticoagulants in this setting remains limited. The 2022 Extracorporeal Life Support Organization (ELSO)—Anticoagulation Guidelines provide no specific recommendations regarding anticoagulant selection for ECMO patients with HIT. This article aims to review current practices, available evidence, and most recent advances concerning the use of alternative anticoagulants in ECMO patients with HIT. In patients with a high suspicion or confirmed diagnosis of HIT, management includes discontinuing all forms of heparin exposure and initiating an alternative anticoagulant, such as a direct thrombin inhibitor and/or factor Xa inhibitor. Direct thrombin inhibitors act independently of antithrombin and have a short half-life, providing a more consistent and predictable anticoagulation effect. Most available data, primarily from retrospective studies, describe the use of argatroban in ECMO patients with HIT. Bivalirudin has also been used as an alternative anticoagulant in this population, with no significant increase in bleeding or thrombotic complications. However, the current evidence remains limited to small, retrospective, single-center or case–control studies. Fondaparinux has shown effectiveness in the HIT setting and appears to have a low risk of complications. Factor XIIa inhibitors represent a novel class of anticoagulants currently under investigation, evaluated only in animal models. Growing clinical experience with alternative anticoagulants, particularly direct thrombin inhibitors, suggests that their use will likely become a primary focus in ECMO anticoagulation management in the coming years.

Open surgical aortic valve replacement (SAVR) is a viable alternative to transcatheter implantation in low-risk patients. In this light, we evaluated the safety and effectiveness of SAVR performed through conventional and less invasive surgical approaches in a high-volume center. We retrospectively reviewed the records of 395 consecutive patients who underwent open SAVR from January 2019 through December 2019 in our center. We evaluated and compared the operative results and postoperative major adverse outcomes of 3 surgical approaches: full median sternotomy (n=267), upper ministernotomy (ministernotomy) (n=106), and right anterior thoracotomy (minithoracotomy) (n=22). Overall, the 30-day all-cause mortality rate was 0.8% (3 patients). Stroke occurred in 8 patients (2%), disabling stroke in 4 patients (1%), myocardial infarction in 1 (0.2%), and surgical site infection in 13 (3.2%). There was no difference in 30-day mortality rate or incidence of postoperative major adverse events among the 3 surgical groups. Stroke and surgical site infection occurred more frequently, but not significantly so, in the full-sternotomy group. The mean hospital stay was longer after full sternotomy (9.1 ± 5.5 d) than after ministernotomy (7.5 ± 2.9 d) or minithoracotomy (7.4 ± 1.9 d) (P=0.012). Our findings suggest that open SAVR performed in a high-volume center is associated with a low early mortality rate and that less invasive approaches result in faster postoperative recovery and shorter hospital stays.

Introduction: The etiology of aortic valve stenosis (AS) is multifactorial; hypertension, hyperlipidemia, and diabetes mellitus are the most common risk factors for the development of the disease. The same factors increase the incidence of atherosclerosis in the peripheral arterial vessels. Hemodynamic disturbance in both diseases increases the risk of cerebrovascular symptomatology. Due to the overlapping of the symptoms in patients with concomitant aortic valve stenosis and carotid artery disease, the indication for treatment is not always straightforward. There are different strategies for treatment; sameday or simultaneous surgery, staged procedure, transcatheter technique, or medical treatment. Aim: The aim of our study is to observe the feasibility and safety of same-day SAVR and CAS in patients with concomitant severe aortic valve and carotid artery stenosis. Material and methods: A prospective non-randomized study performed from August 2015 to August 2023 included thirty-four patients who underwent same-day SAVR (simple or in combination with other cardiac surgery procedures) and CAS intervention. Results: The study included 34 patients with concomitant carotid and aortic disease. The majority of patients had SAVR with CABG procedure. In total, MACCE was reported in 3 patients. Conclusion: The guidelines for treatment strategy are unclear due to a lack of studies about this subject. Surgical aortic valve replacement (SAVR) and carotid artery endarterectomy (CEA) done simultaneously, can yield favorable results but could be excessively invasive for highrisk patients. In these cases, surgical aortic valve replacement and carotid artery stenting (CAS) are feasible, less invasive option.

Background and Objectives: Myocardial protection during on-pump coronary artery bypass grafting (CABG) limits ischaemic injury, particularly in patients with left main coronary artery disease (LMCAD), in whom severe proximal stenosis may compromise antegrade cardioplegia delivery. We investigated whether combined antegrade–retrograde blood cardioplegia reduces postoperative high-sensitivity cardiac troponin I (hs-cTnI) concentrations, a marker of perioperative myocardial injury. Materials and Methods: We conducted a prospective, single-centre, randomised trial involving 60 adults undergoing elective isolated on-pump CABG for significant LMCAD. Patients were assigned (1:1) to antegrade-only or combined antegrade–retrograde blood cardioplegia. Cardiac biomarkers were measured after induction and at 4, 12, 24, and 48 h after ICU admission. The primary endpoint was peak hs-cTnI within 48 h; key secondary endpoints included the hs-cTnI area under the concentration–time curve, CK-MB, immediate myocardial electrical recovery and 30-day outcomes. Results: All patients received the assigned cardioplegia strategy, with no crossover. Peak hs-cTnI did not differ significantly between the antegrade-only and combined groups (median 529.1 [IQR 829.9] vs. 394.1 [503.4] ng/L; p = 0.21), nor did the hs-cTnI area under the concentration–time curve from 4 to 48 h (12,910.6 [23,127.4] vs. 8112.2 [11,686.2] ng·h/L; p = 0.16). Serial hs-cTnI, CK-MB, total creatine kinase, serum creatinine, immediate myocardial electrical recovery, and 30-day outcomes also did not differ significantly. No deaths, coronary sinus injuries, or other cardioplegia-related complications occurred. Conclusions: In patients undergoing isolated on-pump CABG for significant LMCAD, combined antegrade–retrograde blood cardioplegia did not significantly decrease peak hs-cTnI levels compared to the antegrade-only method. The combined approach was feasible with no cardioplegia-related complications, suggesting that an individualised strategy may be preferable to a routine one. Larger prospective studies are needed to determine whether higher-risk patients may derive greater benefit.