Hemodynamic Stability Research Articles (Page 1)

Acute colonic pseudo-obstruction: A case series and literature review.

Awake craniotomy and deep brain stimulation (DBS) procedures require the patient to be awake and adequate anesthesia conditions are typically achieved using ascalp block. These procedures inherently involve some degree of pain from local anesthetic injections during scalp block administration. We aimed to reduce the injection pain in scalp blocks using avibration stimulus. Atotal of 56patients aged between 18and 75years undergoing awake craniotomy and DBS procedures were enrolled in the study. All patients received aloading dose of dexmedetomidine before scalp block administration. Local anesthetic injections were applied sequentially to the identically named nerves on the right and left sides of the head. Avibration device was used during injections on one side, while injections on the other side were performed without vibration. The numeric rating scale (NRS) score and hemodynamic measurements during each injection, including heart rate and mean arterial pressure were compared between vibration and nonvibration sides. The NRS scores were lower on the side where vibration was used during scalp block injections (P < 0.001). Additionally, there was adecrease in heart rate and mean arterial pressure on the side where vibration was used compared to the baseline value (P < 0.005). The study showed that using topical vibration during ascalp block can decrease the pain of alocal anesthetic injection and maintain hemodynamic stability. ClinicalTrials.gov (NCT06038825).

Hemodynamic instability during cardiac surgery, particularly procedures requiring cardiopulmonary bypass, increases the risk of mortality and adverse events. Conventional anesthetics such as propofol and etomidate have limitations in maintaining stability, prompting investigation of remimazolam, an ultra-short-acting benzodiazepine with a potentially favorable cardiovascular profile. This systematic review and meta-analysis evaluated the effects of remimazolam versus conventional anesthetics on hemodynamic stability, vasopressor use, extubation time, and recovery in cardiac surgery. Seven randomized controlled trials involving 557 patients were included following literature searches in PubMed, Scopus, and Cochrane Central Register of Controlled Trials. Data extraction and risk-of-bias assessment were conducted using the Cochrane RoB 2 tool, and certainty of evidence was graded with the Grading of Recommendations Assessment, Development, and Evaluation approach. Pooled analysis showed no significant differences in operative time (mean difference: 1.91 minutes, P = 0.53) or mean arterial pressure (mean difference: -0.90 mm Hg, P = 0.80). The risk of intraoperative hypotension was higher but not statistically significant with remimazolam (risk ratios: 1.25, P = 0.57); however, sensitivity analysis excluding one study demonstrated a significant 64% increase in hypotension risk (risk ratios: 1.64, P = 0.005), suggesting possible hemodynamic vulnerability. Remimazolam significantly shortened extubation time by 27.98 minutes (P = 0.04), while hospital stay, vasopressor use, and postoperative nausea and vomiting showed no significant differences. Overall, remimazolam did not significantly improve intraoperative hemodynamic stability compared with conventional anesthetics, but its main potential advantage may lie in enhancing recovery through faster extubation. The clinical importance of this finding remains uncertain, and remimazolam should not currently be regarded as superior for stability in cardiac anesthesia. Large, standardized randomized controlled trials are required to further define its safety and efficacy in cardiac surgery.

The margay (Leopardus wiedii) is a small wild feline endemic to Central and South America. Due to increasing habitat fragmentation and human expansion, margays are frequently involved in road traffic accidents, leading to severe traumatic injuries. Effective veterinary intervention is crucial for their rehabilitation and reintroduction into the wild. However, limited literature exists on appropriate anesthetic and surgical management strategies for wild felids. A free-ranging adult female margay (2.3 kg) was admitted with a complete displaced fracture of the right sacral wing, multiple pubis, and ischium fractures. Anesthetic management included premedication with tiletamine-zolazepam (5 mg/kg IM) and methadone (0.3 mg/kg IM), induction with propofol (3 mg/kg IV), and maintenance with isoflurane in oxygen. A sacrococcygeal epidural block (L7-S1) with lidocaine (3 mg/kg) was performed to reduce inhalant anesthetic requirements and enhance analgesia. Physiological parameters remained stable throughout the procedure, and postoperative recovery was uneventful. The patient was discharged to wildlife rehabilitation authorities 27 days post-surgery. The combination of tiletaminezolazepam, methadone, and epidural lidocaine effectively provided immobilization, analgesia, and hemodynamic stability. This case highlights the importance of multimodal analgesia and careful anesthetic monitoring to ensure successful surgical outcomes in wildlife conservation medicine. The anesthetic and surgical approach described in this report contributed to the successful rehabilitation of a margay with pelvic fractures caused by a road traffic accident. The findings support the efficacy of multimodal anesthesia and epidural analgesia in wild feline trauma management, providing valuable insights for future veterinary interventions in conservation medicine.

This pilot study aims to compare advanced and standard haemodynamic monitoring during TAVI in terms of predicting and avoiding hypotension. Intraoperative hypotension influences postoperative outcomes by increasing mortality, renal failure, and cardiac complications. In TAVI (transaortic valve implantation), haemodynamic stability is essential because the patients are usually old and vulnerable. Fifty patients underwent transfemoral TAVI under standard anaesthetic care. Blood pressure was measured invasively, using Edwards Acumen sensors connected to a HemoSphere monitor. The signal was simultaneously fed to anaesthesia monitors. Patients were randomly divided into two groups: in the test group, the Edwards monitor with the HPI (hypotension prediction index) values was available to the anaesthetist, whereas in the control group, the HemoSphere monitor was covered. The primary endpoint of the study was the time-weighted average of intraoperative hypotension, which is calculated from the intensity and duration of hypotension, adjusted for the duration of surgery (TWA65). Secondary endpoints were the cumulative time of hypotensive episodes adjusted for the duration of the procedure (TWAtotal). No difference in intraoperative hypotension in terms of TWA65 between control and intervention group could be detected, the overall duration of intraoperative hypotension was reduced in the intervention group, and the administration of intraoperative volume was higher in the intervention group when compared to controls. The use of HPI during TAVI leads to improved haemodynamic stability, and this is particularly important in these extremely vulnerable patients. Not only is it possible to reduce overall intraoperative hypotension with HPI, but postoperative complications associated with intraoperative hypotension that might occur will also be diminished.

Anesthesiologic management of Transcatheter Aortic Valve Implantation (TAVI) is a key factor in procedural success and effectiveness. Although general anesthesia was the main anesthesiologic approach during the early years of the development of TAVI, over the last decade, there has been a shift towards sedation. Hemodynamic stability is the main concern of intraoperative anesthesiologic management. Preprocedural, multidisciplinary assessment of the patient is essential prior to TAVI and should include a full anesthesiologic evaluation. TAVI offers a number of advantages to patients and medical teams, but important accompanying complications and anesthesiologic risks remain. In this narrative review, all aspects of sedation in TAVI are presented and analyzed, including methods, patient selection, contraindications, drug administration, intraprocedural parameters, outcomes, and future developments in this field.

Objective To evaluate the effects of a remazolam-alfentanil combination versus a propofol-alfentanil combination on intraoperative hemodynamics, postoperative cognitive function, and cardiovascular adverse events in elderly patients undergoing laparoscopic cholecystectomy. Methods This prospective, randomized controlled trial enrolled 116 elderly patients (aged 60–80 years, ASA I–III) undergoing laparoscopic cholecystectomy from January 2022 to June 2023. Patients were randomly assigned (1:1) to receive either remazolam-alfentanil (n = 58) or propofol-alfentanil (n = 58). Primary outcomes included intraoperative hemodynamic parameters (MAP, HR, CO, CI, SVR), cognitive function (MMSE and MoCA scores, and incidence of postoperative delirium [POD]), and incidence of cardiovascular events. Secondary outcomes included recovery times and postoperative VAS and Ramsay scores. Results A total of 112 patients (56 per group) completed the study. The remazolam group had significantly shorter times to awakening (10.41 ± 2.09 vs. 12.68 ± 2.73 min), extubation (11.17 ± 2.11 vs. 14.34 ± 2.62 min), and anesthesia duration (22.53 ± 6.66 vs. 28.81 ± 7.05 min) (all P &amp;lt; 0.001). Intraoperatively, the remazolam group showed more stable hemodynamics with higher MAP, HR, CO, and CI (P &amp;lt; 0.05). Postoperative MMSE and MoCA scores were significantly higher on days 3 and 7 (P &amp;lt; 0.05). The incidence of POD at day 7 was significantly lower in the remazolam group (3.6% vs. 16.1%, P = 0.031). The incidence of cardiovascular events was lower in the remazolam group (21.4% vs. 71.4%, P &amp;lt; 0.001), particularly hypotension (7.1% vs. 62.5%) and bradycardia (14.3% vs. 53.6%). VAS and Ramsay scores were also lower at 6 and 12 h postoperatively (P &amp;lt; 0.001). Conclusion The remazolam-alfentanil combination provided faster recovery, improved hemodynamic stability, better cognitive outcomes, and fewer cardiovascular events than propofol-alfentanil in elderly laparoscopic cholecystectomy patients. While promising, these findings warrant confirmation in larger, multicenter trials. Clinical Trial Registration https://www.chictr.org.cn/showproj.html?proj=210389 , Identifier ChiCTR2300077536.

Metaraminol, a synthetic sympathomimetic amine with predominant alpha-1 adrenergic agonist activity, is increasingly used to manage arterial hypotension in critical care and anesthesia. Its pharmacological effects include peripheral vasoconstriction and indirect stimulation of norepinephrine release, producing effective hemodynamic support through intravenous bolus or infusion. Compared with norepinephrine, metaraminol may offer advantages such as reduced arrhythmogenic potential, improved coronary and renal perfusion, and suitability for peripheral administration, minimizing risks associated with central venous access. However, evidence supporting its broader use outside obstetric anesthesia remains limited, largely derived from small observational studies. Uncertainties persist regarding optimal dosing, pharmacokinetic variability, and dose equivalence with norepinephrine. Reported adverse effects include prolonged hypertension, tissue ischemia, and reflex bradycardia. Despite these gaps, surveys indicate widespread clinical use, reflecting its practicality for rapid hemodynamic stabilization. Current data suggest non-inferiority to norepinephrine in obstetric anesthesia, but robust randomized trials are needed to define efficacy, safety, and pharmacodynamic profiles across patient populations. Standardization of dosing strategies and further evaluation in critical care settings are essential to clarify metaraminol’s role as a safe and effective vasopressor alternative.

The impact of mildly elevated pulmonary artery systolic pressure (PASP) on perioperative hemodynamic stability and myocardial injury during thoracoscopic lobectomy remains inadequately characterized despite its prevalence in the surgical population. This retrospective cohort study analyzed 3579 patients who underwent thoracoscopic lobectomy. Patients were categorized as having normal or mildly elevated PASP. Propensity score matching (PSM) was used to balance baseline characteristics between groups. Primary outcome was intraoperative hypotension. Secondary outcomes included myocardial injury after noncardiac surgery (MINS), hypoxemia, new-onset atrial fibrillation, postoperative pulmonary complications, 30-day readmission, and 30-day mortality. Sensitivity analyses using inverse probability of treatment weighting (IPTW) and overlap weighting were performed to validate the robustness of findings. Among 3579 patients, 16.6% (n=594) had mildly elevated PASP. After PSM (491 pairs), patients with mildly elevated PASP experienced significantly higher rates of intraoperative hypotension (46.4% vs. 35.2%; odds ratio [OR]=1.525; 95% CI: 1.190-1.957; P<0.001). Both short-duration (<15minutes) and prolonged (≥15minutes) hypotensive episodes occurred more frequently in the mildly elevated PASP group (30.1% vs. 22% and 16.3% vs. 13.2%, respectively). Mildly elevated PASP was also associated with higher postoperative NT-proBNP and hsTnT levels, and increased incidence of MINS (20.4% vs. 12.4%; OR=1.803; 95% CI: 1.279-2.56; P<0.001). These associations remained consistent across IPTW and overlap weighting analyses. Independent predictors of elevated PASP included smoking history (OR=2.817), COPD (OR=2.199), higher BMI (OR=1.168 per unit), and older age (OR=1.095 per year). Mildly elevated PASP significantly increases the risk of intraoperative hypotension and myocardial injury during thoracoscopic lobectomy. These findings identify patients with mildly elevated PASP as a high-risk population requiring careful hemodynamic monitoring and management. Preoperative assessment of PASP may enhance risk stratification for patients undergoing thoracoscopic lobectomy.

Clinical Case: A 62-year-old male with a history of HTN, HLD, and AUD, presented with an inferior STEMI. Angiography revealed a 95% mid RCA culprit lesion and severe multivessel disease: 50% distal LM, 99% ostial LAD, 80% mid LAD stenosis, and 100% proximal LCx occlusion with L-L, R-L collateral filling. An Impella CP was placed for narrow pulse pressure and LVEDP of 50 mmHg. The patient was referred for CABG, which was aborted due to access site bleeding, poor conduits and surgical targets. PCI of the RCA showed restoration of TIMI 3 flow. TTE revealed a LVEDVI of 127 ml/m2 with an EF of 16%, LBBB dyssynchrony, and severe MR. An Impella 5.5 was placed via the right axillary artery. He underwent complex IVUS guided, atherectomy facilitated PCI of the distal LM and ostial LAD. Revascularization of the LCx was unsuccessful. He required prolonged intubation due to dynamic MR causing recurrent flash pulmonary edema. He underwent percutaneous mitral valve repair with reduction in MR. A BiV–ICD was placed for recurrent VT and resynchronization therapy. He was liberated from the ventilator and discharged on GDMT. Discussion: Here we present a patient with a STEMI causing acute-on-chronic heart failure, as suggested from his baseline LBBB and dilated LV, complicated by monomorphic VT and severe MR. This poses the challenges of addressing each contributor to his cardiogenic shock versus upfront advanced heart replacement therapies such as OHT or LVAD. The patient’s AUD and smoking history precluded him from OHT and he was a poor candidate for LVAD given recurrent VT. Thus, we were left with an approach of weighing each targeted intervention’s expected benefits against the benefits of LVAD therapy. CABG in our patient was infeasible so the revascularization strategy was driven by hemodynamic stability. In hemodynamically unstable patients, revascularizing only the culprit lesion has demonstrated a reduction in all-cause mortality as compared to multivessel PCI. A percutaneous repair was deemed to be the only feasible option to reduce the patient’s secondary MR. Attention was paid to the trans-mitral gradient should an LVAD be needed downstream. The decision to pursue CRT-D was made given LBBB and prolonged QRS. This case underscores the complexity of managing multifactorial cardiogenic shock in which advanced heart replacement therapies are contraindicated. A multidisciplinary, stepwise approach can achieve favorable clinical outcomes.

Case Presentation: An 87-year-old woman with atrial fibrillation, Parkinson’s disease and cardiovascular risk factors, presented to the ED with two weeks of progressive dyspnea and orthopnea. Chest X-rays from 2021 through 2023 showed progressive cardiomegaly, but there was no history of known heart failure or prior echocardiography. On admission, her labs showed proBNP was 3,474 pg/mL and troponin-I HS was 101 ng/L. TTE demonstrated a large right ventricular mass with near-complete cavity obliteration and reduced RV systolic function and normal LVEF. Cardiac MRI showed an 8.7 x 4.1 x 3.8 cm lobulated mass adherent to the myocardium, obstructing inflow and outflow tracts and creating pseudo-stenosis of the tricuspid and pulmonic valves. Despite markedly reduced RV stroke volume and compression, the patient was clinically stable, normotensive, and denied chest pain or syncope. She underwent right heart catheterization with biopsy, which confirmed intimal sarcoma, a rare and normally aggressive mesenchymal malignancy. She was deemed not to be a surgical candidate due to her comorbidities. She has otherwise been asymptomatic and will follow up with her oncologist in the outpatient setting. Discussion: This case demonstrates an extraordinarily rare intimal sarcoma of the right ventricle causing both inflow and outflow tract obstruction and severely reduced stroke volume, yet presenting with minimal clinical instability. The patient’s hemodynamic resilience, despite dramatic structural compromise, likely reflects chronic tumor progression, an uncommon occurrence in this otherwise aggressive tumor type. This has allowed for physiologic adaptation, reflected in her hemodynamic stability. The findings underscore the importance of correlating anatomic imaging with clinical and hemodynamic presentation, especially in elderly patients. Previous cardiomegaly without cardiac workup suggests missed opportunities for earlier detection. This case also emphasizes the role of multimodality imaging, histopathologic confirmation, and flexible, goal-concordant care planning in cardio-oncology. Cardiac MRI with the use of parametric mapping, perfusion and late gadolinium enhancement is a pivotal step in the evaluation of undifferentiated cardiac masses which can then be confirmed with biopsy. Intimal sarcoma should be considered in patients with unexplained RV dysfunction or intracardiac masses, even in the absence of systemic symptoms.

Background Opioid-free anesthesia (OFA) is a multimodal strategy to avoid intraoperative opioids and minimize associated complications, though evidence remains variable. Methods A systematic search of PubMed and Google Scholar (2010–2025), supplemented by AI tools (Google Gemini) for earlier publications, summarized eligible studies (RCTs, cohorts, systematic reviews, and meta-analyses) comparing OFA to opioid-based anesthesia (OBA). Data were summarized following PRISMA-ScR guidelines. Results Across 23 randomized controlled trials and one cohort study, OFA consistently reduced PONV, while demonstrating analgesia and recovery outcomes comparable to OBA. Hemodynamic stability was variable, with dexmedetomidine-based OFA regimens sometimes associated with increased bradycardia and hypotension. PACU stay varied, ranging from 9 min shorter to 15–35 min longer with OFA. Long-term outcome data are limited. Conclusion OFA is a feasible approach that significantly reduces PONV while maintaining comparable analgesia and recovery. However, heterogeneous protocols, small sample sizes, and scarce long-term data limit external validity. Large, multicenter trials are needed to standardize OFA protocols and clarify long-term outcomes.

Adverse drug reactions represent a major clinical and public health concern, with hypersensitivity reactions accounting for up to 20% of cases and associated with potentially life-threatening events such as anaphylaxis. When no therapeutic alternatives exist, drug desensitization becomes a critical strategy, inducing temporary tolerance through progressive dose escalation of the culprit agent. Common targets include acetylsalicylic acid, iodinated contrast media, antibiotics, diuretics, and antituberculosis drugs. This study aimed to characterize the drug desensitization process in patients from a level IV clinic in Barranquilla, Colombia, between 2021 and 2025. An observational, descriptive, and retrospective study was conducted, including all patients undergoing desensitization protocols. Demographic, clinical, pharmacological, and immunological variables were collected, alongside protocol details (drug, monitoring, outcome) and clinical courses (ICU stay, vital signs, adverse events). Descriptive statistics were applied using RStudio. Desensitization was performed in ICU or equivalent units under continuous monitoring by a multidisciplinary team. Protocols were adapted from validated international guidelines or developed de novo when no standardized approach was available. Thirty-one patients underwent desensitization, with a mean age of 58.5 years (range 30–85) and balanced gender distribution. Most had high cardiovascular risk, with hypertension (67.7%), acute coronary syndromes (45.2%), and type II diabetes mellitus (38.7%) as predominant comorbidities. The most frequent hypersensitivity involved nonsteroidal anti-inflammatory drugs and acetylsalicylic acid (58.1%), followed by iodinated contrast media (22.6%). Acetylsalicylic acid was the main target of desensitization (58.1%), particularly in the context of percutaneous coronary interventions, while contrast media accounted for 32.2%. Less common protocols involved furosemide, pyrazinamide, and even saline solution. Cardiac catheterization was the most frequent associated procedure (54.8%). Hemodynamic stability was preserved, with mean blood pressure 137/78 mmHg, heart rate 75 bpm, and oxygen saturation 98.5%. Overall, desensitization was successful in 96.8% of cases; only one patient (3.2%) experienced a mild mucocutaneous reaction, without discontinuation. Protocol implementation increased progressively, reflecting institutional expertise. Drug desensitization in a high-complexity setting proved to be safe and effective, enabling access to essential drugs in patients with confirmed hypersensitivity. The integration of clinical pharmacists was pivotal to ensuring safety, individualized protocol adaptation, and improved outcomes. Prospective studies are needed to consolidate standardized protocols and expand institutional capacity in allergy and immunology.

A 23-year-old woman at 28 weeks of gestation with a childhood history of SVT managed with beta-blockers and no follow-up presented with sudden-onset palpitations, dyspnea, and fatigue. Initial ECG showed narrow complex tachycardia at 268 bpm, absent P waves, and left axis deviation. Differential diagnoses included PSVT, FAT, AVNRT, and AVRT. She became asymptomatic after admission. Management included two doses of adenosine with transient effect, and escalating doses of metoprolol and propafenone with partial response. TTE revealed biatrial enlargement and diastolic dysfunction. Serial ECGs confirmed arrhythmia persistence. Fetal ultrasound was reassuring. After seven days without rhythm control, she underwent zero-fluoroscopy catheter ablation with CARTO mapping. A microreentrant focus was identified between the right superior pulmonary vein and superior vena cava, confirming FAT. No complications occurred. She was discharged in sinus rhythm at 90 bpm on metoprolol and propafenone. Follow-up showed no recurrence. Pregnancy is a proarrhythmic state due to increased cardiac output, sympathetic tone, and atrial stretch. Hemodynamic stability does not rule out risk: Wang et al. reported 67% of pregnant women with FAT developed tachycardia-induced cardiomyopathy, many without overt instability. Guidelines recommend structural assessment and early intervention if HR exceeds 130 bpm, even in asymptomatic patients. Despite normotension, persistent dyspnea, fatigue, and tachycardia &gt;48 hours could have justified cardioversion, which is safe during all trimesters. Although a multidisciplinary team chose ablation, earlier cardioversion might have prevented atrial remodeling. FAT in pregnancy remains underrecognized despite its potential to cause persistent symptoms and remodeling. Unlike AVNRT or AVRT, FAT is usually driven by abnormal automaticity, often incessant and unresponsive to vagal maneuvers or drugs. In &gt;75% of reviewed cases, FAT was persistent or recurrent, often requiring multiple agents before ablation. Zero-fluoroscopy ablation is safe and effective. A prospective study of 47 pregnant patients showed 100% acute success, no 24-month recurrence, and favorable obstetric outcomes. Multidisciplinary care improves outcomes in pregnant patients with arrhythmias, where coordination among electrophysiology, cardiology, and obstetrics is essential for timely and individualized decision-making.

Background: Pericarditis is a rare obstetric complication. Severe pericardial disease may lead to tamponade physiology, jeopardizing both the mother and fetus. We report a case of a 29-year-old woman, G1P0 at 21 weeks gestation, presenting with recurrent pericarditis complicated by early signs of cardiac tamponade. Methods: A 29-year-old (G1P0) female with a history of Graves' disease on methimazole, drug-induced lupus, and recent pericarditis presented to the hospital at 21-weeks gestation due to recurrent chest pain. She was recently admitted for pericarditis and placed on aspirin and colchicine. Transthoracic echocardiogram (TTE) revealed a small pericardial effusion with diastolic inversion. Thyroid function tests were elevated, and methimazole was increased to 20 mg daily. The patient remained home for two weeks until developing recurrent positional chest pain. On admission, the patient was hemodynamically stable. EKG revealed sinus tachycardia. Repeat TTE confirmed recurrence of acute pericarditis, now with pericardial thickening, fibrinous material adjacent to the visceral pericardium, and a large 2-centimeter pericardial effusion (Figure 1). Evidence of RV inversion and a plethoric IVC were present, concerning for early tamponade physiology. Results: Differential diagnosis at the time was broad, including pericarditis of viral etiology or secondary to drug-induced lupus or Graves disease. Given early tamponade physiology and hemodynamic stability, a multidisciplinary team chose medical management over pericardial window due to ongoing pregnancy, suboptimal window for drainage, and procedure-related risks. Aspirin was started at 650 mg twice a day along with 20 mg methylprednisolone and 0.6 mg colchicine. Intravenous fluid resuscitation was provided to maintain preload. Serial TTE was utilized to monitor the progression of the effusion. Methimazole was maintained at 20 mg daily. Viral and autoimmune pericarditis workup was unremarkable. After two weeks of serial echocardiograms, the patient was gradually tapered to aspirin 81 mg daily, prednisone 15 mg daily, and colchicine 0.6 mg daily and discharged. The rest of her pregnancy was uncomplicated, and she delivered a healthy baby at 38 weeks gestation. Conclusion: This case highlights the complexities of managing pericarditis in pregnant patients with autoimmune conditions. Medical management and serial TTE were useful in managing early tamponade while minimizing risks to both the mother and fetus.

Introduction: Acute Type A aortic dissection (ATAAD) carries a substantial risk of perioperative cerebral injury, especially during complex aortic arch reconstructions employing the Frozen Elephant Trunk (FET) technique. Extended circulatory arrest and prolonged cardiopulmonary bypass can compromise cerebral perfusion. Early initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) may provide targeted neuroprotection during this vulnerable intraoperative window. We present a case exemplifying the neuroprotective potential of early ECMO support in extensive aortic surgery. Case Description: A 42-year-old woman with hypertension and chronic kidney disease presented with acute chest and neck pain. Imaging confirmed a DeBakey type I dissection extending into the descending thoracic aorta. Surgical intervention included valve-sparing root and total arch replacement with FET, under deep hypothermic circulatory arrest at 24°C and bilateral antegrade cerebral perfusion. During rewarming, she developed severe left ventricular dysfunction, worsening acidosis, and cerebral hypoperfusion evidenced by near-infrared spectroscopy. VA-ECMO was promptly initiated via femoral cannulation prior to weaning from bypass, with the explicit aim of preserving cerebral perfusion. Results: ECMO resulted in immediate hemodynamic stabilization and correction of metabolic derangements. Cerebral oximetry confirmed continuous, symmetric perfusion without evidence of ischemia. Progressive myocardial recovery allowed ECMO discontinuation on postoperative day five. The patient was extubated on day six, neurologically intact. At three months, both cardiac and neurologic functions were preserved. Discussion: This case underscores the value of early VA-ECMO not merely as circulatory support, but as an active neuroprotective intervention. Intraoperative cerebral monitoring was essential in identifying perfusion deficits and guiding timely escalation. When deployed proactively, ECMO can mitigate ischemic risk during critical phases of complex ATAAD repair. Conclusion: In ATAAD requiring FET, early VA-ECMO should be considered a core component of neuroprotective strategy. Integrating ECMO into institutional protocols, guided by real-time cerebral monitoring, may optimize neurologic outcomes and should be adopted in high-risk surgical algorithms.

Introduction: Endovascular stents are commonly used for vascular access in patients undergoing hemodialysis. While these devices are generally safe, rare but serious complications such as stent migration and associated endocarditis can occur. Migration into cardiac chambers has been reported, often requiring surgical intervention due to the high risk of valvular damage. Case presentation: A 71-year-old male with a medical history of end-stage kidney disease on dialysis and hyperlipidemia, presented with fevers and shortness of breath. On presentation vital signs were notable for tachycardia. Sepsis was suspected, and blood cultures grew Streptococcus gallolyticus, and subsequently started on Ceftriaxone. Echocardiogram revealed a large, migrated endovascular stent in the right atrium, measuring approximately 6 cm × 1.4 cm. Stent appeared to be attached to the anterior leaflet of the tricuspid valve. Left ventricular function ejection fraction was 55%. No vegetations or pericardial effusion were appreciated. Patient reported undergoing an uncomplicated creation of the left arm fistula with vascular stent approximately two years prior. Percutaneous retrieval was attempted twice unsuccessfully. Later, his course was complicated by cardiac tamponade requiring pericardiocentesis, with drainage of approximately 550 mL of sanguineous fluid. This complication was suspected due to myocardial microperforation during the attempted stent retrieval. Following hemodynamic stabilization, the patient underwent cardiac surgery with successful removal of the migrated stent and bioprosthetic tricuspid valve replacement. He then completed a full course of antibiotics for bacteremia and was discharged to a physical rehabilitation facility. Discussion: Stent migration into the heart is a rare but potentially life-threatening complication. It’s commonly associated with improper sizing, placement, or vessel wall degradation over time. Once in the cardiac chambers, stents can cause mechanical damage, serve as a nidus for infection, and impair valvular function. While percutaneous retrieval is typically the first-line approach, surgical intervention is often necessary when complications like tamponade or valve involvement occur. This case calls attention to the importance of long-term monitoring of intravascular devices, especially in patients with dialysis access, and highlights the need and importance for multidisciplinary management when complications arise.

Introduction: Postural Orthostatic Tachycardia Syndrome (POTS) is a chronic autonomic disorder mainly found in a younger female demographic and is characterized by orthostatic intolerance, often presenting with a combination of cardiovascular, neurological, and musculoskeletal symptoms. Despite the central role of blood pressure and heart rate dysregulation in its pathophysiology, POTS is misclassified as psychosomatic frequently. Many patients see 8 to 10 providers before a diagnosis and ultimately self-refer to cardiology after prolonged symptom burden. This study evaluates quality-of-life (QoL) outcomes in POTS patients treated with a cardiologist-led protocol focused on hemodynamic stabilization and symptom control. Methods: This single-center study included patients with a diagnosis of POTS (ICD G90.A) or autonomic dysfunction (ICD G90.8) who received care between May and December 2024. All patients were managed using a non-invasive, multifaceted treatment protocol developed and overseen by a cardiologist, focusing on blood pressure and heart rate regulation. Patients completed the 36-Item Short Form Survey (SF-36) before and after the intervention, with primary follow-up occurring at 3 months. All patients had complete pre- and post-treatment data. Paired t-tests were used to assess statistical significance across SF-36 domains, with Cohen’s d reported for clinical effect size. Results: Among 109 patients (92.6% female; Table 1), all SF-36 domains saw statistically significant improvements (p &lt; 0.001). Physical functioning, energy/fatigue, emotional well-being, and social functioning showed the most notable gains. The largest effect size was seen in the Health Change domain (Cd = 0.53), reflecting patients’ perception of meaningful improvement (Table 2). Despite a short follow-up interval, the consistency of gains supports the statistical and clinical significance of cardiologist-led management in this population. Conclusion: POTS remains underrecognized and undertreated in medicine. This study demonstrates that targeted, cardiologist-directed interventions can lead to measurable and meaningful improvements in QoL for POTS patients. These findings underscore the need to reframe POTS as a condition that warrants early and ongoing symptom management. Increasing POTS presentation awareness among physicians may reduce diagnostic delays and improve outcomes for a historically underserved population.

Background/Objectives: Pulmonary embolism (PE) remains a leading cause of morbidity and mortality, with outcomes influenced by patient demographics, comorbidities, and anticoagulation strategy. While vitamin K antagonists (VKA) have been standard therapy, direct oral anticoagulants (DOACs) are increasingly adopted, yet real-world data in cancer-associated and non-cancer populations are limited. This study aimed to compare demographics, clinical features, therapeutic strategies, and outcomes between oncologic patients with acute PE (experimental group) and non-cancer patients with PE (control group). Methods: We performed a multicentric retrospective cohort study of adults admitted with acute PE between January 2019 and December 2021. The cohort comprised 120 non-cancer and 106 cancer patients. Standard management was low-molecular-weight heparin with transition to (VKA) or (DOAC), when not contraindicated. Data on demographics, comorbidities, and laboratory biomarkers (including NT-proBNP, threshold 600 pg/mL) were analyzed. Primary outcomes were early (≤30 days) and late (31–365 days) all-cause mortality. Secondary outcomes included PE recurrence and bleeding events. Results: Among 226 PE patients (non-oncological n = 120; oncological n = 106), the cancer group was older (69.2 ± 12.6 vs. 62.6 ± 17.3 years; p = 0.001) with similar ECG findings and hemodynamic stability at presentation. NT-proBNP &gt; 600 pg/mL was more frequent in cancer (37.7% vs. 23.3%; p = 0.018), whereas D-dimer &gt; 5 mg/L was more common in non-cancer (74.2% vs. 55.7%; p = 0.003). DOAC use was lower in cancer patients (40.6% vs. 65.0%; p &lt; 0.001). Early mortality was comparable (17.9% vs. 13.3%; p = 0.341), but late mortality was higher in the cancer patient subgroup (38.7% vs. 3.3%; p &lt; 0.001). In multivariable analysis, belonging to the cancer subgroup was associated with NT-proBNP ≥ 600 (OR 2.08, 95% CI 1.08–4.01; p = 0.029) and older age (OR 1.025 per year, 95% CI 1.005–1.045; p = 0.016), and inversely associated with D-dimer &gt; 5 mg/L (OR 0.35, 95% CI 0.19–0.64; p &lt; 0.001). Conclusions: Prompt anticoagulation was associated with lower early mortality, while differences in late mortality appeared to be largely confounded by age and cancer status. NT-proBNP may serve as a useful risk-stratification biomarker, but confirmation in larger, prospective studies is required.

Background: Unstable ventricular tachycardia (VT) in the setting of multivessel coronary artery disease (MVCAD) poses significant clinical and hemodynamic challenges. This case highlights the use of Impella CP for circulatory support in a patient with VT storm, cardiogenic shock, and severe metabolic acidosis, enabling high-risk PCI. Case description: A 72-year-old male with chronic obstructive pulmonary disease, peripheral artery disease, heart failure with reduced ejection fraction (25–30%), diabetes, hypertension, and stage III chronic kidney disease presented with acute hypoxic respiratory failure. Initial labs showed severe acidosis. He experienced pulseless electrical activity arrest followed by asystole, requiring resuscitation and intubation. After return of spontaneous circulation, complete heart block developed, requiring transvenous pacemaker (TP) placement. The patient had multiple episodes of unstable VT, needing five defibrillations before catheterization and maximal pressor support (Figure 1). Right heart catheterization revealed cardiogenic shock; left heart catheterization showed severe three-vessel coronary artery disease, including critical left main stenosis. VT recurred during catheterization, requiring six more shocks despite amiodarone and lidocaine. Due to refractory VT and acidosis, an Impella CP was placed. VT resolved post-placement with no further cardioversion. Hemodynamic stability enabled continuous renal replacement therapy. Bypass surgery was deemed unsuitable. High-risk PCI with rotational atherectomy and drug-eluting stents was performed to the left main, anterior descending, and circumflex arteries. Intravascular ultrasound optimized stent deployment. TP was maintained during PCI. Following the procedure, Impella was weaned, and left ventricular function improved significantly (Figure 2). He was discharged in stable condition. This course is outlined in Figure 3. Discussion: Refractory VT storms in severe MVCAD with cardiogenic shock may not respond to antiarrhythmics or defibrillation alone. Mechanical support with pLVADs can offload the left ventricle, enhance coronary perfusion, and allow time for metabolic correction. This case illustrates Impella’s value in bridging patients to revascularization while stabilizing VT storms. Though pLVADs are well established in acute coronary syndromes and high-risk PCI, their role in VT storm remains underexplored. Further studies are needed to clarify their utility in this setting.