This article describes the development of aortic valve-sparing operations and their current status in surgical practice. They are classified into two general types of operations: aortic root remodeling and aortic valve reimplantation. Both techniques have been modified over the years from their original descriptions, but both remain useful in appropriately selected patients with aortic root and proximal aortic aneurysms, provided the aortic valve cusps are reasonable. Aortic valve reimplantation has proven more durable in young patients with aortic root aneurysms associated with genetic syndromes, whereas remodeling of the aortic root may be appropriate for older patients with ascending aortic aneurysms, dilated sinotubular junction, and secondarily dilated aortic sinuses. These operations were developed to preserve the native aortic valve and have expanded the armamentarium to treat patients with aortic root aneurysms and reasonably normal aortic cusps. In addition to a description of their development, a summary of current results of aortic valve reimplantation worldwide is presented, along with the author's personal perspective on its reproducibility.

The treatment of aortic diseases has undergone profound transformation over the last decades, with the progressive incorporation of endovascular techniques either replacing or complementing conventional open surgical repair. The development of aortic stents represents one of the most significant milestones in this transition. This article reviews the historical, experimental, and clinical evolution of aortic stents, with emphasis on pioneering Brazilian contributions, including the experimental phase in animal models, the first clinical applications in aortic dissection, and the role of the national industry in the development and dissemination of these technologies. The impact of these innovations on contemporary cardiovascular surgical practice and future perspectives are also discussed.

Transcatheter aortic valve implantation (TAVI) has profoundly changed the management of severe aortic stenosis (AS), evolving from a treatment reserved for inoperable and high-risk patients to an established therapeutic option across a wide surgical risk spectrum. Although the expansion of TAVI indications has been largely supported by randomized clinical trials conducted in high-income countries, real-world experience and technological contributions from distinct healthcare systems are increasingly relevant. Brazil has played a significant role in the early adoption, structured implementation, and clinical evaluation of TAVI in Latin America. Since the first procedures performed in 2008, Brazilian centers have developed Heart Team models, contributed to national and regional registries, and generated real-world evidence demonstrating procedural safety and effectiveness comparable to international benchmarks, despite the presence of resource limitations and a higher prevalence of complex clinical and anatomical scenarios. The incorporation of TAVI into the Brazilian public health system in 2022 marked a major milestone in expanding access to minimally invasive therapy for patients with severe AS. In parallel, Brazilian scientific societies have adapted international guideline recommendations to local practice, supporting evidence-based patient selection across different surgical risk categories. Notably, Brazil has also emerged as a developer of locally engineered transcatheter valve technologies, highlighting its transition from a technology consumer to an active contributor in the field of structural heart disease. This review summarizes the historical evolution, national experience, clinical outcomes, guideline integration, technological innovation, and health economic considerations of TAVI in Brazil.

This article summarizes the author's experience with aortic valve reimplantation, focusing on technical errors that may adversely affect outcome. This is a complex surgical procedure that requires detailed knowledge of the functional anatomy of the aortic valve and how disease affects its components. The procedure was developed to correct abnormal components of the aortic root in patients with aortic root aneurysms, both sporadic and associated with genetic syndromes, with the aim of restoring the native aortic valve anatomy and function. When applied to properly selected patients and performed correctly, the very long-term outcomes are gratifying for both the patient and the surgeon.

INTRODUCTION: Right ventricular dysfunction (RVD) may influence perioperative hemodynamics after coronary artery bypass grafting (CABG). This study evaluated the association between preoperative RVD, defined by tricuspid annular plane systolic excursion (TAPSE), and postoperative acute kidney injury (AKI) and major adverse cardiac and cerebrovascular events (MACCE) after isolated CABG.
METHODS: This retrospective single-center cohort included 392 adults undergoing isolated CABG between 2020 and 2023. RVD was defined as TAPSE < 17 mm. AKI was assessed at 24 and 48 hours according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. MACCE was evaluated as a predefined composite outcome. Logistic regression was used to explore factors associated with AKI and MACCE.
RESULTS: Preoperative RVD was present in 2.3% of patients and was associated with a higher rate of KDIGO stage 1 AKI at 24 hours (P < 0.001). RVD was not independently associated with MACCE. Higher preoperative white blood cell count (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.03 – 1.24; P = 0.013) and KDIGO stage at 48 hours (OR 7.44, 95% CI 3.32 – 18.77; P < 0.001) were associated with MACCE.
CONCLUSION: Preoperative RVD was associated with early renal vulnerability after CABG but not with MACCE. Postoperative AKI severity and preoperative inflammatory status were independently associated with MACCE. These exploratory findings require validation in larger cohorts and suggest that right ventricular assessment may improve perioperative risk stratification.

INTRODUCTION: While current cardiac surgery risk scores do not account for preoperative functional status, it has been linked to adverse outcomes in transcatheter aortic valve replacement (TAVR). However, in surgical aortic valve replacement (SAVR), preoperative functional status remains underexplored.
OBJECTIVE: To examine the impact of preoperative functional status on 30-day SAVR outcomes to provide insights into clinical decision-making and postoperative care.
METHODS: Patients undergoing SAVR were identified from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2021. A 1:3 propensity-score matching was applied to patients with dependent (DFS) and independent (IFS) functional status. Thirty-day outcomes were assessed.
RESULTS: After propensity-score matching, DFS and IFS patients showed similar mortality (11.11% vs. 9.42%, P = 0.39) and major adverse cardiovascular events (9.91% vs. 9.11%, P = 0.66). Patients with DFS had higher risks of pulmonary complications (29.43% vs. 21.64%, P < 0.01) including pneumonia (13.21% vs. 9.21%, P = 0.04) and prolonged mechanical ventilation over 48 hours (25.83% vs. 15.42%, P < 0.01) but lower bleeding requiring transfusion (51.65% vs. 67.49%, P < 0.01). DFS patients were more likely to be discharged not to home (71.52% vs. 47.75%, P < 0.01) and had longer operation time (315.2 ± 130.5 vs. 293.5 ± 119.8 min, P < 0.01) and LOS (18.47 ± 14.30 vs. 15.07 ± 12.83 days, P < 0.01).
CONCLUSION: While SAVR is relatively safe in eligible DFS patients considering its mortality and cardiac outcomes, it is imperative to emphasize preoperative functional status assessments and closely monitor postoperative pulmonary complications.

INTRODUCTION: The optimal timing of cardiac surgery in infective endocarditis (IE) patients with neurological complications remains controversial.
OBJECTIVE: To evaluate the effects of early surgical intervention compared with medical therapy on in-hospital and one-year mortality, highlighting the prognostic value of neurological severity and clinical variables.
METHODS: This retrospective study included 109 patients with neurological complications out of a total of 452 patients diagnosed with infective endocarditis at our hospital between January 2013 and December 2023. The patients were divided into a surgical group (n = 48) and a medical therapy group (n = 61). Surgical cases were further classified as early (≤ 7 days) and late (> 7 days). Demographic data, echocardiographic findings, vegetation size (≥ 1 cm), mobility, causative microorganisms, and stroke severity were assessed using the National Institutes of Health Stroke Scale (NIHSS) method (mild-moderate-severe). Mortality predictors over a one-year period were evaluated using multivariate logistic regression.
RESULT: When comparing one-year in-hospital and post-discharge mortality between the medical and surgical patient groups, mortality was significantly higher in the medically treated group (54.1% and 46.4%, respectively) compared to the surgical group (16.7% and 0%, respectively, P < 0.001). No significant difference was observed between the early and late surgical subgroups. Age and NIHSS were independent predictors of in-hospital mortality, while age, treatment type, NIHSS, white blood cells, and hemoglobin were associated with one-year mortality.
CONCLUSION: In IE patients with neurological complications, early cardiac surgery, when carefully selected and managed using a multidisciplinary approach, does not increase mortality compared to late surgery and may improve long-term survival.

INTRODUCTION: Permanent pacemaker (PPM) implantation is standard therapy for symptomatic bradyarrhythmias. In emergencies, limited assessment may lead to underdiagnosis of concomitant coronary artery disease (CAD).
OBJECTIVE: To evaluate the impact of coronary cineangiography (CAG) before urgent PPM implantation on mortality.
METHODS: This cohort included patients undergoing urgent PPM implantation between July 2016 and June 2021, divided into those undergoing CAG (Group A) and those not undergoing CAG (Group B). The primary endpoint was all-cause mortality; secondary endpoints included mortality/readmission, acute coronary syndrome (ACS), and hospital stay.
RESULTS: Of 895 patients, 841 were included (Group A: 160; Group B: 681). Group A patients were younger (70.2 vs. 75.2 years; P < 0.001), more frequently male (63.1% vs. 51.8%; P = 0.010), had more CAD (36.2% vs. 19%; P < 0.001), and less frequently had estimated glomerular filtration rate < 45 ml/min/1.73 m² (10.2% vs. 22.9%; P < 0.001). Mortality (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.56 – 1.66; P = 0.898) and mortality/readmission (HR 1.05, 95% CI 0.74 – 1.50; P = 0.776) did not differ between groups. Multivariate analysis showed no significant impact of CAG on either outcome. ACS was more frequent in Group A (7.5% vs. 2.7%; P = 0.005), and hospital stay was shorter in Group B (6 vs. 9 days; P < 0.001).
CONCLUSION: In our study, CAG before PPM implantation was not associated with mortality or mortality/readmission but was associated with longer hospitalization and a higher incidence of ACS

INTRODUCTION: Postoperative atrial fibrillation (POAF), the most common arrhythmia after coronary artery bypass grafting (CABG), occurs in 15 - 50% of cases.
OBJECTIVES: To investigate the incidence and risk factors of POAF after off-pump CABG (OPCABG) and to establish a nomogram prediction model.
METHODS: This retrospective study enrolled 179 patients who underwent OPCABG between October 2018 and October 2022. Patients were divided into POAF (n = 43) and non-POAF (n = 136) groups. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors. A nomogram was developed and evaluated for discrimination, calibration, and clinical utility.
RESULTS: POAF incidence after OPCABG was 24.04%, peaking on postoperative day two. Independent predictors identified were age, hypertension, left atrium anteroposterior dimension > 40 mm, New York Heart Association (NYHA) class ≥ III, and intraoperative potassium < 4.5 mmol/L. A nomogram incorporating these factors was developed. Validation showed excellent discriminative power (area under the curve = 0.919, 95% confidence interval: 0.8747 - 0.9637), good calibration (Hosmer-Lemeshow P = 0.80), and significant clinical utility via decision curve analysis across a wide probability range (0.2% – 98%).
CONCLUSION: Age, hypertension, left atrium anteroposterior dimension > 40 mm, NYHA class ≥ III, and intraoperative potassium < 4.5 mmol/L were identified as independent risk factors for POAF after OPCABG, and these factors can serve as predictors for POAF. By implementing appropriate health management strategies, the POAF complications following OPCABG may be reduced.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) significantly increases the risk of morbidity and mortality following coronary artery bypass grafting (CABG). Identifying preoperative prognostic indicators is critical for improving postoperative outcomes in this patient population.
METHODS: This study aimed to investigate the relationship between the preoperative Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) score and postoperative complications and mortality in T2DM patients undergoing isolated CABG surgery. A total of 675 T2DM patients who underwent isolated CABG surgery between 2018 and 2024 were retrospectively analyzed. Patients were grouped according to their preoperative HALP scores. Demographic characteristics, postoperative complications, intensive care and hospital stay durations, revascularization needs, and one-year mortality rates were compared between groups.
RESULTS: Patients with lower HALP scores experienced significantly higher rates of postoperative infections, pneumonia, renal dysfunction, longer intensive care unit/hospital stays, and increased one-year mortality (P < 0.001). These findings indicate a strong correlation between nutritional/immune status and surgical outcomes in diabetic patients.
CONCLUSION: Preoperative HALP score may serve as a reliable, cost-effective associated factor of postoperative complications and mortality in T2DM patients undergoing CABG. Incorporating HALP scoring into routine preoperative assessment could enhance risk stratification and perioperative management strategies