We report the case of a 60-year-old man with repaired Tetralogy of Fallot and long-standing severe pulmonary insufficiency, complicated by asymmetric pulmonary blood flow and anatomy unsuitable for standard right ventricular outflow tract valve implantation. Cardiac imaging demonstrated a pyramidal right ventricular outflow tract that did not meet the oversizing criteria for a Harmony TPV 25, with the lack of interference with the inflow part of the device. In addition, the left pulmonary artery was severely hypoplastic with proximal stenosis. To avoid jailing the left pulmonary artery and high-risk unstable right ventricular outflow tract implant, a transcatheter Harmony valve was deployed in the right pulmonary artery while protecting the left pulmonary artery, followed by stenting of the left pulmonary artery. The goal was to ultimately eliminate the vast majority of pulmonary insufficiency and maintain antegrade flow across the left pulmonary artery. Hemodynamics demonstrated elevated right-sided pressures prior to intervention, which improved post-procedure. The patient tolerated the procedure well, with a transient postoperative diuretic requirement. At 10-month follow-up, he remained asymptomatic with improved left ventricular ejection fraction and a well-functioning Harmony valve on echocardiography. This case highlights the feasibility of branch pulmonary artery valve implantation using the Harmony valve in patients with unfavourable right ventricular outflow tract anatomy and demonstrates the value of simultaneous left pulmonary artery stenting to maintain relatively balanced pulmonary perfusion. Transcatheter branch pulmonary artery implantation may represent a viable option in carefully selected patients for whom conventional right ventricular outflow tract implantation is not possible.

With improving survival, periviable neonates (≤25 weeks' gestation) represent a dynamic, but under-studied population in neonatal care, with persistently high cardiopulmonary and vascular vulnerability. Immature cardiovascular structure and function as a consequence of immature myocardial architecture, altered calcium handling, relative adrenal insufficiency, and persistent fetal shunts contribute to complex and dynamic cardiovascular physiology in this population. This may be present clinically in the form of hypotension and low end-organ perfusion. Traditional paradigms of blood pressure-based definitions of hypotension are poorly validated in this population and do not accurately reflect systemic blood flow or end-organ perfusion. Emerging evidence supports a phenotype-based multi-parametric approach to cardiovascular assessment, to distinguish ongoing physiological changes such as ductal physiology, pulmonary hypertension, low systemic vascular resistance and primary myocardial dysfunction phenotypes. However, significant knowledge gaps remain, including lack of normative hemodynamic values, and limited evidence guiding pharmacologic therapies. This narrative review focuses on the cardiovascular challenges in the management of periviable neonates as they transition to extrauterine life, delineating cardiac phenotypes, describing modalities of cardiovascular assessment and identifying existing knowledge gaps. We propose a physiology-based approach to cardiovascular management strategies based on existing, albeit limited, evidence. IMPACT: Periviable neonates present unique hemodynamic challenges due to structural and functional cardiovascular system immaturity, which can be categorized into different hemodynamic phenotypes dictated by baseline cardiac function, lung compliance and directionality of intracardiac shunts, especially the patent ductus arteriosus. In the absence of established normative reference values for common modalities of cardiac assessment, optimal care should consist of early identification of cardiac phenotypes, continuous surveillance, physiology-based management strategies, and frequent reassessment to guide individualized treatment.

Absent pulmonary valve syndrome is a rare congenital cardiac anomaly characterized by severe pulmonary valve insufficiency and progressive dilation of the right ventricular outflow tract and pulmonary arteries. Although primary surgical repair is typically performed during childhood, long-term outcomes are frequently limited by structural degeneration of bioprosthetic valves, often leading to the need for reintervention in early adulthood. We present the case of a 22-year-old woman with a history of pulmonary valve agenesis who underwent surgical correction during childhood, including implantation of an Edwards N21 bioprosthetic pulmonary valve and pulmonary artery plication. During follow-up, she developed progressive exertional dyspnea associated with a decline in functional capacity and was in New York Heart Association functional class III at the time of reoperation. Imaging studies demonstrated structural deterioration of the prosthetic valve, with evidence of right ventricular outflow tract involvement and hemodynamic compromise, supporting the indication for surgical reintervention. Pulmonary valve re-replacement was successfully performed through a left mini-thoracotomy approach, allowing adequate exposure of the right ventricular outflow tract and main pulmonary artery while avoiding the risks associated with repeat sternotomy. The degenerated prosthesis was explanted and replaced with a new 25 mm Edwards bioprosthetic pulmonary valve, achieving satisfactory intraoperative hemodynamics and valve function. The postoperative course was uneventful, and the patient was discharged with significant clinical improvement and recovery of functional status. This case highlights that a left mini-thoracotomy approach represents a feasible and safe alternative for pulmonary valve re-replacement in selected patients with prior sternotomy. In addition to providing effective surgical exposure, this strategy may reduce operative trauma and facilitate postoperative recovery in complex reoperative congenital cardiac cases.

Patient self-inflicted lung injury (P-SILI) describes a pathophysiological concept in which patients with acute hypoxemic respiratory failure (AHRF) may exacerbate lung injury through excessive respiratory drive and vigorous spontaneous breathing efforts, thereby perpetuating respiratory failure. Spontaneous breathing-related lung injury is thought to be mediated by 4 main mechanisms: 1. increased mechanical stress on lung tissue, 2. heterogeneous ventilation with intrapulmonary gas redistribution (pendelluft), 3. augmented pulmonary blood flow leading to microvascular injury, and 4. Patient-ventilator asynchrony (PVA) in the setting of non-invasive ventilation (NIV). All of these mechanisms are closely linked to an elevated respiratory drive, which primarily arises from the underlying lung pathology, particularly alveolar flooding due to plasma leakage. Clinical monitoring of respiratory effort and neural respiratory drive is possible using techniques such as esophageal pressure measurement. However, these methods are often invasive, not fully validated, time- and resource-intensive, costly, and may be associated with reduced patient comfort.In the management of acute respiratory failure, including acute respiratory distress syndrome (ARDS) and AHRF, prevention of P-SILI is essential. Recent evidence suggests that late failure of NIV followed by delayed intubation is associated with the highest mortality rates. Consequently, the choice of ventilatory support must be individualized and continuously reassessed, taking into account the risk of both P-SILI and ventilator-induced lung injury. Non-invasive ventilation, high-flow nasal cannula therapy, pharmacological interventions, and prone positioning during spontaneous breathing all have therapeutic limits that require continuous, round-the-clock evaluation. To date, robust evidence from large clinical trials regarding their impact on the prevention and treatment of P-SILI, as well as the optimal timing of intubation, remains lacking.

Allergic bronchopulmonary aspergillosis (ABPA) is a T helper 2 cell-mediated hypersensitive lung disorder in response to Aspergillus that usually affects asthmatic and cystic fibrosis patients. However, it rarely presents as lung collapse.We report a case of an elderly male who presented in the emergency department with respiratory distress, with oxygen saturation 80% with room air (RA). On evaluation with examination and radiology, the case was revealed as left lung collapse. Fibreoptic bronchoscopy revealed a huge mucus plug (MP) obliterating the left main bronchus, causing collapse of the entire left lung. The MP could not be completely removed by suction and was extracted with a cryoprobe. Post procedure, SpO2 improved to 99% RA with X-ray showing complete lung aeration restoration. A suspicion of ABPA was made. Aspergillus-specific IgE and IgG came positive, along with raised total IgE and peripheral eosinophilia. The patient was started on itraconazole and oral corticosteroids and discharged in stable condition.This case highlights that it is important to consider an MP with ABPA as a differential in cases of lung collapse after ruling out malignancy.

Choroidal melanoma (CM) is the most common intraocular malignant tumor in adults, with a high rate of metastasis and mortality. This study reports a case of systemic cardiac migration of perfluorocarbon liquid (PFCL) following an unsuccessful endoresection of CM. A 61-year-old woman underwent gamma knife radiosurgery and pars plana vitrectomy endoresection for CM in her left eye. The procedure was complicated by intraocular bleeding, leading to incomplete tumor removal, with the eye filled with PFCL and blood before closure. The patient refused further surgery and later developed secondary glaucoma. Nearly three years later, during an acute increase in intraocular pressure reaching 50 mmHg, she experienced severe respiratory insufficiency requiring intubation and veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Echocardiography showed a severely dilated right ventricle and echogenic material in the left atrium and ventricle, while acute coronary syndrome and pulmonary embolism were ruled out. The patient's respiratory status stabilized, and intracardiac echogenic material was observed during the first three days of V-A ECMO but was absent afterward. In summary, cardiac PFCL migration can occur after endoresection for choroidal melanoma; therefore, specific precautions should be taken to prevent and promptly detect this complication.

We report the case of a 47-year-old male patient with a history of tetralogy of Fallot surgically corrected in childhood using the Waterston-Cooley and Cooley techniques. In adulthood, he developed severe pulmonary insufficiency, treated percutaneously with the implantation of a bioprosthetic valve. The patient was admitted for an elective surgery procedure. Following the administration of spinal anesthesia, ECG monitoring revealed the onset of atrioventricular block progressing to asystole, requiring immediate external cardiac massage. During the subsequent period, the patient also experienced a 5 s third-degree atrioventricular block associated with dizziness following carotid sinus massage. After multidisciplinary evaluation, the decision was made to implant a leadless pacemaker (Abbott Aveir VR). The procedure presented technical challenges, primarily due to the altered cardiac anatomy resulting from the underlying congenital heart disease and previous surgical corrections. Despite these difficulties, successful implantation was achieved. To our knowledge, this represents one of the few reported cases in the literature of leadless pacemaker implantation in a patient with corrected congenital heart disease. Given the absence of standardized procedural guidelines for such complex cases, we present our experience and discuss the associated technical considerations.

Tricuspid transcatheter edge-to-edge repair alleviates symptoms, but survival benefit remains inconsistent. The authors conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020-compliant systematic review and meta-analysis (CRD42024600438) to identify multivariable predictors of procedural success and adverse outcomes. PubMed, Scopus, the Cochrane Library, and Google Scholar were searched (from January 2008 to March 2025) for adjusted predictors of mortality, heart failure hospitalization, major adverse cardiovascular events, and procedural success. Random-effects meta-analysis was performed when ≥2 independent cohorts reported comparable estimates. Fifty-nine studies met the inclusion criteria. Baseline tricuspid regurgitation severity (OR: 2.50; 95% CI: 1.33-4.71), nonanteroseptal jet location (OR: 2.46; 95% CI: 1.08-5.60), and increasing coaptation gap (HR: 1.19 per mm; 95% CI: 1.07-1.33) predicted residual tricuspid regurgitation. Residual tricuspid regurgitation ≥3+ was the only predictor suitable for pooled synthesis across endpoints and was associated with all-cause mortality (HR: 2.19; 95% CI: 1.60-3.00) and major adverse cardiovascular events (HR: 1.84; 95% CI: 1.37-2.48) (I[2] = 0%-2%.) Renal dysfunction, impaired right ventricular function and remodeling, pulmonary hypertension, and right ventricular-pulmonary arterial uncoupling reflect advanced disease substrate and demonstrated consistent associations with adverse outcomes. Among surgical risk models, the European System for Cardiac Operative Risk Evaluation II score showed limited discrimination, whereas the TRI-SCORE performed better; tricuspid transcatheter edge-to-edge repair-specific clinical models remain limited, and validated procedural prediction models are emerging. Limited data suggest that an intermediate disease profile may derive the greatest benefit, but this finding is confined to single-registry analyses. Further work is required to define optimal disease-stage thresholds and develop integrated risk models incorporating procedural outcome predictors.

The arteriovenous fistula (AVF) is a preferred access for haemodialysis (HD) in patients with end-stage renal disease. However, its haemodynamic effect on the heart is not negligible; it may cause or exacerbate heart failure and pulmonary hypertension, especially when the flow is excessively high. After the transplantation, a decrease in cardiac output leads to reduced kidney graft perfusion, which can result in the development of cardiorenal syndrome. The guidelines for managing AVF after transplantation are still not well defined, so care and surveillance are based on the experience of transplantation centres. We present a case of a kidney transplant recipient with deterioration of graft function and sepsis. He received a kidney graft in 2005, and since then, he has had a functioning enlarged AVF, which has not been used since the transplantation. At the time of admission, the flow through the fistula exceeded 7000 mL/min. Blood culture results suggested Staphylococcus haemolyticus as the causative pathogen. The patient was treated with a prolonged course of meropenem and vancomycin based on the antibiogram. Due to radiological findings suggestive of mycotic pneumonia, voriconazole was added. Because of cardiac failure, he was disqualified from surgical treatment of the mycotic pneumonia. He required repeated HD and ultrafiltration for a month using a non-tunnelled catheter. To treat cardiac insufficiency and improve graft function, the fistula was surgically removed. After the surgery, the patient no longer required HD, and his serum creatinine concentration decreased. This case demonstrates that graft function might be restored even after prolonged HD. Therefore, the decision whether to discontinue immunosuppressive therapy to treat the infection must be made carefully. Ligation of a high-flow AVF may contribute to the treatment of cardiac insufficiency, thereby improving graft function. AVF should be monitored regularly to prevent its adverse effects on both cardiac and graft function, which could complicate the management of emerging conditions, as in this case, mycotic pneumonia.