const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "Orris Medical Education";
pres.title = "Myocardial Protection during Cardiopulmonary Bypass";

// ─── Color Palette ────────────────────────────────────────────────────────────
const C = {
  navy:      "0D1B3E",   // dominant background
  darkBlue:  "112244",   // secondary bg panels
  midBlue:   "1A3A6B",   // accent panels
  accent:    "2E86DE",   // bright accent blue
  iceBlue:   "6EC6F5",   // hypothermia cold
  warm:      "E86A2C",   // warm cardioplegia / danger
  gold:      "F4C430",   // callout highlight
  white:     "FFFFFF",
  offWhite:  "E8F0FE",
  light:     "B0C4DE",
  red:       "C0392B",
  green:     "27AE60",
};

// Fetch images via the shared helper
function fetchImages(urls) {
  try {
    const json = execSync(
      `node /home/daytona/skills/shared/scripts/fetch_images.js ${urls.map(u => `"${u}"`).join(" ")}`,
      { timeout: 30000 }
    ).toString();
    return JSON.parse(json);
  } catch (e) {
    console.error("Image fetch error:", e.message);
    return urls.map(() => ({ base64: null, error: e.message }));
  }
}

// Image URLs from search_image results
const IMG_CANNULATION = "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_9aa3b0bcf014f877d1d5c328fa5dc11234d521b426ae7f4c1dccf3ccfbb00bee.jpg";
const IMG_AORTIC_CLAMP = "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_0776e18fd66c71362d6475a9576a0aef7dc4019092ce8534e4b65b3aec5a6c85.jpg";
const IMG_CPB_SETUP    = "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_bf7f0c72a22cb764174bc789e8911ee4328f8d0ae5f47ef7929a4ae0ecb2bf0a.jpg";
const IMG_CABG         = "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_148664081f9ed0032a43b154039df98817fffefae9870b6292adb94e20449411.jpg";

console.log("Fetching images...");
const imgs = fetchImages([IMG_CANNULATION, IMG_AORTIC_CLAMP, IMG_CPB_SETUP, IMG_CABG]);
const [imgCannulation, imgAorticClamp, imgCPBSetup, imgCABG] = imgs;

// ─── Helper: standard slide header ───────────────────────────────────────────
function addHeader(slide, title, subtitle) {
  // top accent bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.07, fill: { color: C.accent }, line: { type: "none" } });
  // nav strip
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.07, w: 10, h: 0.55, fill: { color: C.midBlue }, line: { type: "none" } });
  // title
  slide.addText(title, {
    x: 0.35, y: 0.07, w: 9.3, h: 0.55,
    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri",
    valign: "middle", margin: 0,
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 0.35, y: 0.62, w: 9.3, h: 0.28,
      fontSize: 11, color: C.iceBlue, fontFace: "Calibri", italic: true,
      valign: "middle", margin: 0,
    });
  }
}

// ─── Helper: slide background ─────────────────────────────────────────────────
function bgDark(slide) {
  slide.background = { color: C.navy };
}

// ─── Helper: bullet block ────────────────────────────────────────────────────
function bulletBlock(slide, items, opts = {}) {
  const {
    x = 0.35, y = 1.1, w = 9.3, h = 3.8,
    fontSize = 14, color = C.offWhite, indent = 0.2,
  } = opts;
  const textArr = items.map((item, i) => ({
    text: typeof item === "string" ? item : item.text,
    options: {
      bullet: { type: "bullet", indent: indent },
      fontSize: typeof item === "object" && item.sub ? fontSize - 1.5 : fontSize,
      color: typeof item === "object" && item.sub ? C.light : color,
      bold: typeof item === "object" && item.bold ? true : false,
      breakLine: i < items.length - 1,
    },
  }));
  slide.addText(textArr, { x, y, w, h, fontFace: "Calibri", valign: "top" });
}

// ─── SLIDE 1 — Title slide ────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.background = { color: C.navy };

  // left accent stripe
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.accent }, line: { type: "none" } });
  // large bottom gradient bar
  s.addShape(pres.ShapeType.rect, { x: 0.18, y: 4.2, w: 9.82, h: 1.425, fill: { color: C.midBlue }, line: { type: "none" } });

  // heart icon placeholder (decorative circle)
  s.addShape(pres.ShapeType.ellipse, { x: 6.5, y: 0.5, w: 3.0, h: 3.0,
    fill: { type: "solid", color: C.midBlue }, line: { color: C.accent, width: 3 } });
  s.addText("❤", { x: 6.5, y: 0.5, w: 3.0, h: 3.0, fontSize: 80, align: "center", valign: "middle", color: C.accent });

  s.addText("MYOCARDIAL PROTECTION", {
    x: 0.5, y: 0.6, w: 5.8, h: 0.7,
    fontSize: 28, bold: true, color: C.white, fontFace: "Calibri", charSpacing: 2,
  });
  s.addText("during Cardiopulmonary Bypass", {
    x: 0.5, y: 1.25, w: 5.8, h: 0.55,
    fontSize: 22, color: C.iceBlue, fontFace: "Calibri", italic: true,
  });
  s.addShape(pres.ShapeType.line, { x: 0.5, y: 1.85, w: 5.0, h: 0, line: { color: C.accent, width: 2.5 } });
  s.addText([
    { text: "Principles of Myocardial Preservation  •  Cardioplegia  •  Hypothermia  •  Reperfusion Strategies", options: {} }
  ], { x: 0.5, y: 2.0, w: 5.8, h: 0.5, fontSize: 10, color: C.light, fontFace: "Calibri" });

  s.addText("Sources: Morgan & Mikhail's Clinical Anesthesiology 7e  |  Barash Clinical Anesthesia 9e  |  Miller's Anesthesia 10e", {
    x: 0.5, y: 4.3, w: 9.0, h: 0.35,
    fontSize: 9, color: C.light, fontFace: "Calibri",
  });
  s.addText("Cardiac Surgery  •  Anesthesiology", {
    x: 0.5, y: 4.7, w: 9.0, h: 0.35,
    fontSize: 9, color: C.gold, fontFace: "Calibri", bold: true,
  });
}

// ─── SLIDE 2 — Overview / Agenda ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "Overview", "Key domains of myocardial protection during CPB");

  const topics = [
    { n: "01", title: "The Problem", desc: "Myocardial injury during CPB — mechanisms & risk factors" },
    { n: "02", title: "Aortic Cross-Clamping", desc: "Ischemia from coronary exclusion, safe clamp times" },
    { n: "03", title: "Hypothermia", desc: "Systemic & topical cooling — metabolic rationale" },
    { n: "04", title: "Cardioplegia — Composition", desc: "K⁺, Ca²⁺, Mg²⁺, buffers, substrates, blood vs crystalloid" },
    { n: "05", title: "Delivery Routes", desc: "Antegrade, retrograde, combined strategies" },
    { n: "06", title: "Warm vs Cold Cardioplegia", desc: "Temperature considerations & del Nido solution" },
    { n: "07", title: "Ischemia–Reperfusion Injury", desc: "Free radicals, Ca²⁺ overload, hot shot, reperfusion control" },
    { n: "08", title: "LV Venting & Monitoring", desc: "Decompression, TEE assessment, ECG limitations" },
    { n: "09", title: "Anesthetic Preconditioning", desc: "Volatile agents & ischemic preconditioning" },
    { n: "10", title: "Weaning & Post-Bypass Care", desc: "Protamine, inotropes, hemodynamic support" },
  ];

  const cols = 2;
  const rows = 5;
  const bw = 4.5, bh = 0.72;
  const startX = [0.28, 5.22];
  const startY = 1.05;
  const gap = 0.04;

  topics.forEach((t, i) => {
    const col = i % cols;
    const row = Math.floor(i / cols);
    const x = startX[col];
    const y = startY + row * (bh + gap);

    s.addShape(pres.ShapeType.rect, { x, y, w: bw, h: bh, fill: { color: C.darkBlue }, line: { color: C.midBlue, width: 1 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 0.45, h: bh, fill: { color: C.accent }, line: { type: "none" } });
    s.addText(t.n, { x, y, w: 0.45, h: bh, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });
    s.addText(t.title, { x: x + 0.48, y: y + 0.03, w: bw - 0.55, h: 0.3, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", margin: 0 });
    s.addText(t.desc, { x: x + 0.48, y: y + 0.33, w: bw - 0.55, h: 0.35, fontSize: 9, color: C.light, fontFace: "Calibri", margin: 0 });
  });
}

// ─── SLIDE 3 — The Problem ────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "The Problem: Myocardial Injury during CPB", "Morgan & Mikhail 7e; Barash 9e");

  // left column — mechanisms
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 0.95, w: 4.5, h: 4.3, fill: { color: C.darkBlue }, line: { color: C.midBlue, width: 1 } });
  s.addText("MECHANISMS OF INJURY", { x: 0.28, y: 0.95, w: 4.5, h: 0.38, fontSize: 11, bold: true, color: C.gold, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "O₂ demand–supply imbalance → cell ischemia",
    "Aortic cross-clamping stops coronary flow",
    "Ventricular fibrillation → ↑ O₂ consumption",
    "LV distension → ↑ wall tension + ↓ subendocardial flow",
    "Reperfusion: free radicals, Ca²⁺ overload, leukocyte–endothelial interaction",
    "Coronary embolism (air, thrombus, fat, atheromatous debris)",
    "Graft occlusion / vasospasm / kinking",
    "Anaerobic metabolism → ATP depletion + acidosis",
  ], { x: 0.38, y: 1.38, w: 4.25, h: 3.8, fontSize: 12 });

  // right column — risk factors + manifestations
  s.addShape(pres.ShapeType.rect, { x: 5.22, y: 0.95, w: 4.5, h: 2.0, fill: { color: C.darkBlue }, line: { color: C.accent, width: 1 } });
  s.addText("HIGH-RISK PATIENTS", { x: 5.22, y: 0.95, w: 4.5, h: 0.38, fontSize: 11, bold: true, color: C.accent, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Poor preoperative ventricular function",
    "Ventricular hypertrophy (pressure/volume overload)",
    "Diffuse severe coronary artery disease",
    "Combination of above factors",
  ], { x: 5.32, y: 1.38, w: 4.3, h: 1.5, fontSize: 12 });

  s.addShape(pres.ShapeType.rect, { x: 5.22, y: 3.0, w: 4.5, h: 2.3, fill: { color: C.darkBlue }, line: { color: C.warm, width: 1 } });
  s.addText("CLINICAL MANIFESTATIONS", { x: 5.22, y: 3.0, w: 4.5, h: 0.38, fontSize: 11, bold: true, color: C.warm, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "↓ Cardiac output at end of bypass",
    "Worsened ventricular function (TEE)",
    "Cardiac arrhythmias",
    "Myocardial stunning → systolic & diastolic dysfunction (reversible)",
    "Myocardial necrosis → irreversible injury",
    { text: "ECG changes often masked by pacing", sub: true },
  ], { x: 5.32, y: 3.43, w: 4.3, h: 1.8, fontSize: 12 });
}

// ─── SLIDE 4 — Aortic Cross-Clamping ─────────────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "Aortic Cross-Clamping & Ischemia", "Morgan & Mikhail 7e, p. 817–818");

  // image
  if (imgAorticClamp && imgAorticClamp.base64) {
    s.addImage({ data: imgAorticClamp.base64, x: 5.5, y: 1.0, w: 4.2, h: 3.5 });
    s.addText("Aortic cross-clamp with cardioplegia cannula in situ", {
      x: 5.5, y: 4.45, w: 4.2, h: 0.4, fontSize: 8, color: C.light, italic: true, align: "center",
    });
  }

  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 0.95, w: 5.0, h: 4.3, fill: { color: C.darkBlue }, line: { color: C.midBlue, width: 1 } });
  s.addText("KEY CONCEPTS", { x: 0.28, y: 0.95, w: 5.0, h: 0.35, fontSize: 11, bold: true, color: C.gold, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Cross-clamping completely excludes coronary arteries from bypass flow",
    "Coronary blood flow halts → ischemia begins",
    { text: "Safe cross-clamp time: difficult to define; >120 min ↑ risk", bold: true },
    "Ischemia causes:",
    { text: "Depletion of high-energy phosphates (ATP)", sub: true },
    { text: "Intracellular Ca²⁺ accumulation", sub: true },
    { text: "Shift to anaerobic metabolism → acidosis", sub: true },
    { text: "Fatty acid oxidation impaired", sub: true },
    "Post-clamp ischemia possible via:",
    { text: "Low perfusion pressure, coronary emboli (air/thrombus/fat/plaque)", sub: true },
    { text: "Graft occlusion, vasospasm, cardiac contortion", sub: true },
    "Myocardium distal to high-grade obstruction — most at risk",
  ], { x: 0.38, y: 1.35, w: 4.8, h: 3.8, fontSize: 12 });
}

// ─── SLIDE 5 — Hypothermia ────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "Hypothermia: Systemic & Topical", "Barash 9e, p. 3340; Morgan & Mikhail 7e, p. 818");

  // Temperature range graphic
  const tempRanges = [
    { label: "NORMOTHERMIA", temp: "37°C", color: C.warm, x: 0.3 },
    { label: "TEPID", temp: "30–35°C", color: C.gold, x: 2.45 },
    { label: "MILD", temp: "28–32°C", color: C.iceBlue, x: 4.6 },
    { label: "MODERATE", temp: "20–28°C", color: C.accent, x: 6.75 },
    { label: "DEEP", temp: "≤20°C", color: "4169E1", x: 8.5 },
  ];
  const barY = 1.08;
  tempRanges.forEach(t => {
    s.addShape(pres.ShapeType.rect, { x: t.x, y: barY, w: 1.45, h: 0.65, fill: { color: t.color }, line: { type: "none" } });
    s.addText(t.label, { x: t.x, y: barY, w: 1.45, h: 0.35, fontSize: 8, bold: true, color: C.navy, align: "center", valign: "middle", margin: 0 });
    s.addText(t.temp, { x: t.x, y: barY + 0.32, w: 1.45, h: 0.33, fontSize: 9, bold: true, color: C.navy, align: "center", valign: "middle", margin: 0 });
  });

  // two columns
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 1.85, w: 4.6, h: 3.45, fill: { color: C.darkBlue }, line: { color: C.iceBlue, width: 1 } });
  s.addText("SYSTEMIC HYPOTHERMIA", { x: 0.28, y: 1.85, w: 4.6, h: 0.35, fontSize: 11, bold: true, color: C.iceBlue, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Metabolic O₂ requirement halved per 10°C decrease",
    "~8% decrease in cellular metabolism per °C below 37°C",
    "At 28°C: metabolic rate falls to ~50%",
    "Preserves high-energy phosphate substrates",
    "Inhibits excitatory neurotransmitter release (neuroprotection)",
    "VF often occurs below 28–29°C → establish cardioplegia immediately",
    "Adverse effects: platelet dysfunction, coagulopathy, ↓ myocardial contractility",
    "Tepid bypass: drift to 30–35°C gaining popularity",
    "Deep (≤20°C): allows circulatory arrest up to 60 min (aortic arch, PE surgery)",
  ], { x: 0.38, y: 2.24, w: 4.4, h: 3.0, fontSize: 11 });

  s.addShape(pres.ShapeType.rect, { x: 5.12, y: 1.85, w: 4.6, h: 3.45, fill: { color: C.darkBlue }, line: { color: C.accent, width: 1 } });
  s.addText("TOPICAL CARDIAC COOLING", { x: 5.12, y: 1.85, w: 4.6, h: 0.35, fontSize: 11, bold: true, color: C.accent, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Ice slush bathing of the heart surface",
    "Reduces basal metabolic O₂ consumption",
    "Cold cardioplegia solution (10–15°C) infused into coronary vessels",
    "Direct myocardial temperature monitoring: target 10–15°C",
    "Synergistic with systemic hypothermia",
    "Reduces warming from adjacent aorta and ambient OR air",
    "Must be repeated ~every 30 min (washout + rewarming)",
    "Rewarming via heat exchanger restores temperature post-CPB",
  ], { x: 5.22, y: 2.24, w: 4.4, h: 3.0, fontSize: 11 });
}

// ─── SLIDE 6 — Cardioplegia Composition ──────────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "Cardioplegia: Composition", "Morgan & Mikhail 7e, p. 819–820; Barash 9e");

  // Table of components
  const headers = ["Component", "Concentration", "Rationale"];
  const rows = [
    ["Potassium (K⁺)", "10–40 mEq/L (induction)\nLow-K maintenance", "Reduces transmembrane potential → diastolic arrest"],
    ["Sodium (Na⁺)", "< 140 mEq/L (hypotonic)", "Counters ischemic intracellular Na⁺ gain"],
    ["Calcium (Ca²⁺)", "0.7–1.2 mmol/L", "Maintains cellular integrity; avoid excess (Ca²⁺ overload)"],
    ["Magnesium (Mg²⁺)", "1.5–15 mmol/L", "Blocks excessive Ca²⁺ influx into cells"],
    ["Buffer (HCO₃⁻ / Histidine)", "pH ≈ 7.4–7.8", "Neutralise acid metabolites; alkalotic = better preservation"],
    ["Mannitol", "Hyperosmolar", "Free radical scavenger; reduces cellular edema"],
    ["Lidocaine / Steroids", "Membrane stabiliser", "Additional protection; dampens electrical activity"],
    ["Glucose / Glutamate / Aspartate", "Energy substrate", "Supports anaerobic metabolism during arrest"],
    ["Blood (North America)", "4:1 blood:crystalloid (del Nido: 1:4)", "O₂-carrying capacity; metabolic support"],
  ];

  const tColW = [2.2, 2.3, 5.2];
  const tStartX = 0.25;
  const tStartY = 1.0;
  const rowH = 0.42;

  // header row
  let curX = tStartX;
  headers.forEach((h, i) => {
    s.addShape(pres.ShapeType.rect, { x: curX, y: tStartY, w: tColW[i], h: 0.38, fill: { color: C.accent }, line: { type: "none" } });
    s.addText(h, { x: curX + 0.04, y: tStartY, w: tColW[i] - 0.06, h: 0.38, fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
    curX += tColW[i];
  });

  rows.forEach((row, ri) => {
    const rowY = tStartY + 0.38 + ri * rowH;
    const bg = ri % 2 === 0 ? C.darkBlue : C.midBlue;
    let cx = tStartX;
    row.forEach((cell, ci) => {
      s.addShape(pres.ShapeType.rect, { x: cx, y: rowY, w: tColW[ci], h: rowH, fill: { color: bg }, line: { color: C.navy, width: 0.5 } });
      s.addText(cell, {
        x: cx + 0.04, y: rowY, w: tColW[ci] - 0.06, h: rowH,
        fontSize: ci === 0 ? 10 : 9.5,
        bold: ci === 0,
        color: ci === 0 ? C.gold : C.offWhite,
        fontFace: "Calibri", valign: "middle",
      });
      cx += tColW[ci];
    });
  });
}

// ─── SLIDE 7 — Delivery Routes ───────────────────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "Cardioplegia Delivery Routes", "Morgan & Mikhail 7e, p. 820; Barash 9e, p. 3340");

  if (imgCannulation && imgCannulation.base64) {
    s.addImage({ data: imgCannulation.base64, x: 6.55, y: 1.0, w: 3.15, h: 3.0 });
    s.addText("CPB cannulation & cardioplegia cannula setup", {
      x: 6.55, y: 3.95, w: 3.15, h: 0.4, fontSize: 7.5, color: C.light, italic: true, align: "center",
    });
  }

  // ANTEGRADE box
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 0.98, w: 6.0, h: 2.0, fill: { color: C.darkBlue }, line: { color: C.iceBlue, width: 1.5 } });
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 0.98, w: 6.0, h: 0.38, fill: { color: C.iceBlue }, line: { type: "none" } });
  s.addText("ANTEGRADE", { x: 0.28, y: 0.98, w: 6.0, h: 0.38, fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Delivered proximal to aortic cross-clamp → into aortic root",
    "Pressure: 60–100 mmHg",
    "Directly into coronary ostia if AI or coronary artery disease is present",
    "Rapid arrest: 30–60 sec",
    { text: "Limitation: may not reach areas distal to severe coronary obstructions", bold: true },
  ], { x: 0.38, y: 1.4, w: 5.8, h: 1.5, fontSize: 11.5 });

  // RETROGRADE box
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 3.05, w: 6.0, h: 2.2, fill: { color: C.darkBlue }, line: { color: C.accent, width: 1.5 } });
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 3.05, w: 6.0, h: 0.38, fill: { color: C.accent }, line: { type: "none" } });
  s.addText("RETROGRADE", { x: 0.28, y: 3.05, w: 6.0, h: 0.38, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Catheter placed via right atrium into coronary sinus",
    "Flow: 200–400 mL/min at venous pressure 30–50 mmHg",
    "Often combined with antegrade for maximal protection in severe CAD",
    "Arrest in ~2–4 min (slower than antegrade)",
    "Also used for individual graft delivery after distal anastomoses in CABG",
    { text: "Advantage: bypasses obstructed coronaries; reaches diffuse disease territory", bold: true },
  ], { x: 0.38, y: 3.48, w: 5.8, h: 1.7, fontSize: 11.5 });
}

// ─── SLIDE 8 — Warm vs Cold Cardioplegia & del Nido ───────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "Warm vs Cold Cardioplegia & Special Solutions", "Barash 9e; Morgan & Mikhail 7e, p. 820");

  // Three columns
  const colW = 3.0;
  const colY = 0.98;
  const colH = 4.3;
  const colGap = 0.15;

  // Column 1 — Cold
  s.addShape(pres.ShapeType.rect, { x: 0.2, y: colY, w: colW, h: colH, fill: { color: C.darkBlue }, line: { color: C.iceBlue, width: 1.5 } });
  s.addShape(pres.ShapeType.rect, { x: 0.2, y: colY, w: colW, h: 0.4, fill: { color: C.iceBlue }, line: { type: "none" } });
  s.addText("❄ COLD", { x: 0.2, y: colY, w: colW, h: 0.4, fontSize: 13, bold: true, color: C.navy, align: "center", valign: "middle" });
  bulletBlock(s, [
    "Temperature: 4–15°C",
    "Administered intermittently",
    "Re-dose every 20–30 min",
    "Allows bloodless surgical field",
    "Most widely used globally",
    "Repeated dosing flushes metabolites",
    "Standard potassium arrest solution",
    { text: "May not need continuous monitoring of arrest", sub: true },
  ], { x: 0.3, y: 1.43, w: 2.85, h: 3.8, fontSize: 11 });

  // Column 2 — Warm / Normothermic
  s.addShape(pres.ShapeType.rect, { x: 0.2 + colW + colGap, y: colY, w: colW, h: colH, fill: { color: C.darkBlue }, line: { color: C.warm, width: 1.5 } });
  s.addShape(pres.ShapeType.rect, { x: 0.2 + colW + colGap, y: colY, w: colW, h: 0.4, fill: { color: C.warm }, line: { type: "none" } });
  s.addText("🔥 WARM / TEPID", { x: 0.2 + colW + colGap, y: colY, w: colW, h: 0.4, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle" });
  bulletBlock(s, [
    "Normothermic: 37°C",
    "Must be delivered CONTINUOUSLY",
    "Associated with better post-op cardiac indices",
    "No protective hypothermia benefit",
    "Concerns: cerebral ischemia risk with normothermia",
    "'Hot shot': warm blood cardioplegia just before reperfusion",
    { text: "Hot shot washes metabolites + replenishes substrates", sub: true },
  ], { x: 0.2 + colW + colGap + 0.1, y: 1.43, w: 2.85, h: 3.8, fontSize: 11 });

  // Column 3 — del Nido
  s.addShape(pres.ShapeType.rect, { x: 0.2 + 2 * (colW + colGap), y: colY, w: colW + 0.35, h: colH, fill: { color: C.darkBlue }, line: { color: C.gold, width: 1.5 } });
  s.addShape(pres.ShapeType.rect, { x: 0.2 + 2 * (colW + colGap), y: colY, w: colW + 0.35, h: 0.4, fill: { color: C.gold }, line: { type: "none" } });
  s.addText("★ DEL NIDO SOLUTION", { x: 0.2 + 2 * (colW + colGap), y: colY, w: colW + 0.35, h: 0.4, fontSize: 11.5, bold: true, color: C.navy, align: "center", valign: "middle" });
  bulletBlock(s, [
    "1 part blood + 4 parts crystalloid",
    "Additives: Lidocaine, MgSO₄, NaHCO₃, Mannitol, KCl",
    "Single-shot for short aortic cross-clamp cases",
    "Arrest lasts longer between re-doses",
    "Popular for congenital cardiac surgery",
    "Reduces interruptions to surgical field",
    { text: "Gaining wide adoption in adult cardiac surgery", sub: true },
  ], { x: 0.2 + 2 * (colW + colGap) + 0.1, y: 1.43, w: colW + 0.2, h: 3.8, fontSize: 11 });
}

// ─── SLIDE 9 — Ischemia–Reperfusion Injury ───────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "Ischemia–Reperfusion Injury & Strategies to Limit It", "Morgan & Mikhail 7e, p. 820–821");

  // left: mechanisms
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 0.98, w: 4.5, h: 2.3, fill: { color: C.darkBlue }, line: { color: C.red, width: 1.5 } });
  s.addText("REPERFUSION INJURY MECHANISMS", { x: 0.28, y: 0.98, w: 4.5, h: 0.38, fontSize: 10.5, bold: true, color: C.red, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Rapid Ca²⁺ accumulation → extensive cell injury / necrosis",
    "Oxygen-derived free radical burst on reperfusion",
    "Abnormal endothelial–leukocyte interactions",
    "Myocardial cellular edema",
    "Altered coronary autoregulation",
  ], { x: 0.38, y: 1.4, w: 4.3, h: 1.8, fontSize: 12 });

  // right: strategies
  s.addShape(pres.ShapeType.rect, { x: 5.22, y: 0.98, w: 4.5, h: 2.3, fill: { color: C.darkBlue }, line: { color: C.green, width: 1.5 } });
  s.addText("PROTECTIVE STRATEGIES", { x: 5.22, y: 0.98, w: 4.5, h: 0.38, fontSize: 10.5, bold: true, color: C.green, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Hot shot: warm blood cardioplegia pre-reperfusion",
    "Low-K wash-out solution just before unclamping",
    "Avoid hypercalcemia in immediate reperfusion period",
    "Controlled reperfusion pressure: start ~40 mmHg → gradually 70 mmHg",
    "Free radical scavengers in priming solution (mannitol)",
  ], { x: 5.32, y: 1.4, w: 4.3, h: 1.8, fontSize: 12 });

  // lower: recovery
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 3.38, w: 9.44, h: 1.92, fill: { color: C.darkBlue }, line: { color: C.gold, width: 1 } });
  s.addText("RECOVERY PHASE — AFTER CLAMP RELEASE", { x: 0.28, y: 3.38, w: 9.44, h: 0.38, fontSize: 11, bold: true, color: C.gold, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Allow heart to recover in empty (decompressed) state before resuming contracting",
    "Stunned myocardium: reversible systolic & diastolic dysfunction — responds to positive inotropic agents",
    "Reperfusion at reduced pressure minimises further endothelial/myocardial damage",
    "Myocardial necrosis (irreversible): prevented by adequate protection during ischemia",
  ], { x: 0.38, y: 3.8, w: 9.24, h: 1.44, fontSize: 12 });
}

// ─── SLIDE 10 — LV Venting & Monitoring ───────────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "LV Venting & Intraoperative Monitoring", "Morgan & Mikhail 7e, p. 816; Barash 9e, p. 3347");

  if (imgCPBSetup && imgCPBSetup.base64) {
    s.addImage({ data: imgCPBSetup.base64, x: 5.6, y: 1.0, w: 4.1, h: 3.3 });
    s.addText("CPB cannulation with LV vent & cardioplegia lines (annotated)", {
      x: 5.6, y: 4.25, w: 4.1, h: 0.4, fontSize: 7.5, color: C.light, italic: true, align: "center",
    });
  }

  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 0.98, w: 5.0, h: 2.35, fill: { color: C.darkBlue }, line: { color: C.accent, width: 1 } });
  s.addText("LV VENTING", { x: 0.28, y: 0.98, w: 5.0, h: 0.35, fontSize: 11, bold: true, color: C.accent, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Blood reaccumulates in LV via bronchial arteries, thebesian veins, or aortic regurgitation",
    "LV distension: ↑ O₂ consumption + ↓ subendocardial flow → impaired preservation",
    "Vent routes: right superior pulmonary vein → LA → across mitral valve, LV apex, or across aortic valve",
    "Aspirated blood → filtered → returned to venous reservoir",
    { text: "TEE is essential: monitor LV filling / distension throughout CPB", bold: true },
    { text: "Special vigilance for severe AI: antegrade cardioplegia may seep into LV cavity", sub: true },
  ], { x: 0.38, y: 1.37, w: 4.8, h: 1.9, fontSize: 11.5 });

  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 3.37, w: 5.0, h: 1.95, fill: { color: C.darkBlue }, line: { color: C.gold, width: 1 } });
  s.addText("MONITORING ADEQUACY OF PROTECTION", { x: 0.28, y: 3.37, w: 5.0, h: 0.35, fontSize: 11, bold: true, color: C.gold, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "ECG quiescence (flat line confirms arrest)",
    "Time since last cardioplegia dose",
    "Direct myocardial temperature: target 10–15°C",
    "Ventricular chamber fullness (via TEE & vent output)",
    { text: "ECG ischemia changes often difficult to interpret intraoperatively due to pacing", sub: true },
  ], { x: 0.38, y: 3.76, w: 4.8, h: 1.5, fontSize: 11.5 });
}

// ─── SLIDE 11 — Anesthetic Preconditioning ───────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "Anesthetic & Ischemic Preconditioning", "Barash 9e, Fuster's Heart 15e");

  // decorative block
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 0.98, w: 9.44, h: 0.5, fill: { color: C.midBlue }, line: { type: "none" } });
  s.addText("Volatile anesthetics can mimic ischemic preconditioning — a powerful endogenous cardioprotective mechanism", {
    x: 0.35, y: 0.98, w: 9.3, h: 0.5, fontSize: 11.5, color: C.gold, fontFace: "Calibri", italic: true, valign: "middle",
  });

  // two col
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 1.55, w: 4.5, h: 3.7, fill: { color: C.darkBlue }, line: { color: C.accent, width: 1 } });
  s.addText("ISCHEMIC PRECONDITIONING", { x: 0.28, y: 1.55, w: 4.5, h: 0.38, fontSize: 11, bold: true, color: C.accent, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Brief, sublethal ischemia renders myocardium resistant to subsequent prolonged ischemia",
    "Endogenous protective mechanism activated by ischemia itself",
    "Reduces infarct size, arrhythmias, and reperfusion injury",
    "Mechanisms: KATP channels, adenosine, PKC pathways",
    "Classic IPC: 2–5 min ischemia / reperfusion cycles prior to index ischemia",
  ], { x: 0.38, y: 1.97, w: 4.3, h: 3.2, fontSize: 12 });

  s.addShape(pres.ShapeType.rect, { x: 5.22, y: 1.55, w: 4.5, h: 3.7, fill: { color: C.darkBlue }, line: { color: C.warm, width: 1 } });
  s.addText("VOLATILE ANESTHETIC PRECONDITIONING", { x: 5.22, y: 1.55, w: 4.5, h: 0.38, fontSize: 10, bold: true, color: C.warm, fontFace: "Calibri", align: "center", valign: "middle" });
  bulletBlock(s, [
    "Potent volatile agents (isoflurane, sevoflurane, desflurane) given before (preconditioning) or after (postconditioning) ischemia",
    "Trigger similar intracellular cascade as IPC",
    "Reduces myocardial injury markers (troponin, CK-MB)",
    "May attenuate post-CABG ventricular dysfunction",
    "Evidence: volatile anesthesia may be preferred over TIVA for cardiac surgery",
    { text: "Complex mechanisms: mitochondrial KATP channels, reactive O₂ species signalling", sub: true },
  ], { x: 5.32, y: 1.97, w: 4.3, h: 3.2, fontSize: 12 });
}

// ─── SLIDE 12 — Cardioplegia Pump & Dosing ───────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "Cardioplegia Pump & Dosing Regimen", "Morgan & Mikhail 7e; Miller's Anesthesia 10e");

  // DOSING TABLE
  const rows2 = [
    ["Induction / Arrest dose", "High-K solution\n(20–30 mEq/L K⁺)", "1000–1500 mL", "Rapid diastolic arrest within 30–60 sec (antegrade)"],
    ["Maintenance doses", "Low-K solution\n(8–15 mEq/L K⁺)", "200–500 mL every 20–30 min", "Delivers nutrients, flushes metabolites, sustains arrest"],
    ["Hot shot (pre-reperfusion)", "Warm normokalemic blood", "200–400 mL", "Washes metabolites, replenishes energy substrates"],
    ["del Nido single-shot", "1:4 blood:crystalloid\n+ Lido / Mg / bicarb / mannitol / KCl", "Single large dose", "Short cross-clamp cases; prolonged arrest without redosing"],
  ];
  const colW2 = [2.2, 2.2, 2.3, 3.0];
  const hdrs2 = ["Dose Type", "Solution", "Volume", "Purpose"];
  let cx = 0.22;
  hdrs2.forEach((h, i) => {
    s.addShape(pres.ShapeType.rect, { x: cx, y: 1.0, w: colW2[i], h: 0.38, fill: { color: C.accent }, line: { type: "none" } });
    s.addText(h, { x: cx + 0.04, y: 1.0, w: colW2[i] - 0.06, h: 0.38, fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
    cx += colW2[i];
  });
  rows2.forEach((row, ri) => {
    const rowY2 = 1.38 + ri * 0.65;
    const bg2 = ri % 2 === 0 ? C.darkBlue : C.midBlue;
    let cx2 = 0.22;
    row.forEach((cell, ci) => {
      s.addShape(pres.ShapeType.rect, { x: cx2, y: rowY2, w: colW2[ci], h: 0.63, fill: { color: bg2 }, line: { color: C.navy, width: 0.5 } });
      s.addText(cell, {
        x: cx2 + 0.04, y: rowY2, w: colW2[ci] - 0.06, h: 0.63,
        fontSize: ci === 0 ? 10.5 : 10,
        bold: ci === 0,
        color: ci === 0 ? C.gold : C.offWhite,
        fontFace: "Calibri", valign: "middle",
      });
      cx2 += colW2[ci];
    });
  });

  // Lower info box
  s.addShape(pres.ShapeType.rect, { x: 0.22, y: 4.04, w: 9.56, h: 1.28, fill: { color: C.darkBlue }, line: { color: C.iceBlue, width: 1 } });
  s.addText("CARDIOPLEGIA PUMP (CPB machine accessory pump):", { x: 0.32, y: 4.07, w: 9.36, h: 0.3, fontSize: 10.5, bold: true, color: C.iceBlue, fontFace: "Calibri" });
  bulletBlock(s, [
    "Provides optimal control over infusion pressure, rate, and temperature  •  Separate heat exchanger for solution temperature control  •  Less common: pressurised cold IV bag",
  ], { x: 0.32, y: 4.37, w: 9.36, h: 0.88, fontSize: 11 });
}

// ─── SLIDE 13 — Weaning & Post-Bypass ────────────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "Weaning from CPB & Post-Bypass Care", "Miller's Anesthesia 10e; Morgan & Mikhail 7e");

  const steps = [
    { n: "1", title: "Rewarm", body: "Restore core temperature to 37°C via heat exchanger. Confirm adequate rewarming before weaning." },
    { n: "2", title: "De-air Heart", body: "Evacuate air from cardiac chambers to prevent coronary / cerebral air embolism." },
    { n: "3", title: "Restore Rhythm", body: "Confirm regular electrical activity; support with pacemaker if needed (heart block common post-ischemia)." },
    { n: "4", title: "Resume Ventilation", body: "Restart ventilation; confirm ABG / electrolytes; correct coagulopathy if present." },
    { n: "5", title: "Wean Bypass Flow", body: "Gradually ↓ venous drainage / arterial pump flow while monitoring haemodynamics and TEE." },
    { n: "6", title: "Terminate CPB", body: "When CO maintained; replace volume from reservoir; support with vasopressors / inotropes as needed." },
    { n: "7", title: "Protamine Reversal", body: "1–1.3 mg protamine per 100 units heparin, given slowly over 5–10 min. Verify reversal with ACT. Communicate with perfusionist before administration." },
    { n: "8", title: "Haemodynamic Support", body: "Inotropes, vasopressors, IABP, or ECMO for inadequate cardiac output. Stunned myocardium may recover with time + inotropic support." },
  ];

  const bw2 = 4.6, bh2 = 0.6;
  const cols2 = 2;
  const gapX = 0.28, gapY = 0.06;
  const sY = 1.0;
  const sX = [0.28, 5.12];

  steps.forEach((st, i) => {
    const col = i % cols2;
    const row = Math.floor(i / cols2);
    const x = sX[col];
    const y = sY + row * (bh2 + gapY);
    s.addShape(pres.ShapeType.rect, { x, y, w: bw2, h: bh2, fill: { color: C.darkBlue }, line: { color: C.midBlue, width: 1 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 0.38, h: bh2, fill: { color: C.accent }, line: { type: "none" } });
    s.addText(st.n, { x, y, w: 0.38, h: bh2, fontSize: 14, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });
    s.addText(st.title, { x: x + 0.42, y: y + 0.02, w: bw2 - 0.5, h: 0.24, fontSize: 11, bold: true, color: C.gold, fontFace: "Calibri", margin: 0 });
    s.addText(st.body, { x: x + 0.42, y: y + 0.26, w: bw2 - 0.5, h: 0.3, fontSize: 9.5, color: C.offWhite, fontFace: "Calibri", margin: 0 });
  });
}

// ─── SLIDE 14 — Summary / Key Takeaways ──────────────────────────────────────
{
  const s = pres.addSlide();
  bgDark(s);
  addHeader(s, "Key Takeaways", "Myocardial Protection during Cardiopulmonary Bypass");

  const points = [
    { icon: "⚡", color: C.red, title: "Ischemia is inevitable", body: "Aortic cross-clamping halts coronary flow; virtually all patients sustain some myocardial injury — minimise it, don't ignore it." },
    { icon: "❄", color: C.iceBlue, title: "Hypothermia is foundational", body: "Systemic + topical cooling reduces O₂ demand ~50% at 28°C. Target myocardial temp 10–15°C." },
    { icon: "💊", color: C.gold, title: "Cardioplegia = electromechanical silence", body: "K⁺-induced diastolic arrest + metabolic additives (buffers, Mg²⁺, mannitol, energy substrates) = minimal energy expenditure." },
    { icon: "🔄", color: C.accent, title: "Route matters for protection", body: "Combined antegrade + retrograde cardioplegia maximises coverage, especially in severe CAD." },
    { icon: "🔥", color: C.warm, title: "Reperfusion is a second injury", body: "Controlled pressure, hot shot, free radical scavengers, and empty-heart recovery limit ischemia–reperfusion injury." },
    { icon: "👁", color: C.green, title: "TEE + vigilance throughout", body: "Monitor LV distension, cardioplegia effectiveness, and ventricular function continuously. Inadequate protection = arrhythmias + low CO on weaning." },
  ];

  const bw3 = 4.55, bh3 = 0.75;
  const sX3 = [0.28, 5.17];
  const sY3 = 0.98;
  const gap3 = 0.05;

  points.forEach((p, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x3 = sX3[col];
    const y3 = sY3 + row * (bh3 + gap3);
    s.addShape(pres.ShapeType.rect, { x: x3, y: y3, w: bw3, h: bh3, fill: { color: C.darkBlue }, line: { color: p.color, width: 1.5 } });
    s.addText(p.icon, { x: x3 + 0.06, y: y3, w: 0.5, h: bh3, fontSize: 22, align: "center", valign: "middle" });
    s.addText(p.title, { x: x3 + 0.6, y: y3 + 0.04, w: bw3 - 0.68, h: 0.3, fontSize: 11.5, bold: true, color: p.color, fontFace: "Calibri" });
    s.addText(p.body, { x: x3 + 0.6, y: y3 + 0.34, w: bw3 - 0.68, h: 0.38, fontSize: 9.5, color: C.offWhite, fontFace: "Calibri" });
  });

  // footer
  s.addShape(pres.ShapeType.line, { x: 0.28, y: 5.22, w: 9.44, h: 0, line: { color: C.accent, width: 1 } });
  s.addText("Sources: Morgan & Mikhail's Clinical Anesthesiology 7e  •  Barash Clinical Anesthesia 9e  •  Miller's Anesthesia 10e  •  Fuster and Hurst's The Heart 15e", {
    x: 0.28, y: 5.27, w: 9.44, h: 0.28, fontSize: 8, color: C.light, fontFace: "Calibri", italic: true,
  });
}

// ─── Write file ───────────────────────────────────────────────────────────────
const outPath = "/home/daytona/workspace/myocardial-protection-pptx/Myocardial_Protection_CPB.pptx";
pres.writeFile({ fileName: outPath })
  .then(() => console.log("✅ PPTX created:", outPath))
  .catch(e => { console.error("Error:", e); process.exit(1); });