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Introduction. Cell salvaging is well established in the blood management of cardiac patients, but there remain some concerns about its effects on perioperative bleeding and transfusion variables. This randomized controlled study investigated the potential effects of the centrifuged end-product on bleeding, transfusion rates, and other transfusion-related variables in adult cardiac surgery patients submitted to extracorporeal circulation. Materials and Methods. Patients were randomly chosen to receive (cell-salvage group, 99 patients) or not to receive (control group, 110 patients) the centrifuged product of a cell salvage apparatus. Bleeding and transfusion rates according to the universal definition of perioperative bleeding (UDPB) classification, postoperative hemoglobin, coagulation, and oxygenation indices were recorded and compared between the groups. Results. Both groups had almost identical bleeding and transfusion rates (median value: 2 units of red blood cells (RBC) and no units of fresh frozen plasma (FFP) and platelets (PLT) for both groups, p > 0.05). Patients in the cell-salvage group presented slightly higher hemoglobin concentrations (10.6 ± 1.1 vs. 10.1 ± 1.7 g/dL, p < 0.05 , respectively) and a tendency towards better oxygenation indices (PaO2/FiO2: 241 ± 94 vs. 207 ± 84, p = 0.013) in the postoperative period albeit with a tendency for prolongation of prothrombin time (INR: 1.31 ± 0.18 vs. 1.26 ± 0.12, p = 0.008). Conclusion. Within the study's constraints, the perioperative use of the cell salvage concentrate does not seem to affect bleeding or transfusion variables, although it could probably ameliorate postoperative oxygenation in adult cardiac surgery patients. A tendency to promote coagulation disturbances was detected. [ABSTRACT FROM AUTHOR]

Introduction: Despite their suboptimal long-term patency, saphenous vein grafts are the most widely used conduits to achieve complete revascularization during coronary artery bypass grafting (CABG). Although vein storage critically impairs endothelial integrity, contradictory data concerning optimal storage solutions exist. The aim of this study is to explore any in vitro impact of cardioplegic solutions and temperature on vein grafts endothelial integrity during their storage.Materials and Methods: A single-center, prospective trial including 40 consecutive patients was conducted. Eligibility criteria included patients submitted to CABG receiving at least one vein graft. An excess segment of the graft was harvested and divided into four different parts. Each one of them was stored under different conditions; either in a conventional heparin-enriched blood solution or in a cardioplegic solution, at room temperature (20°C-22°C) and in the refrigerator (5°C). Endothelial integrity was evaluated via immunohistochemistry using an antibody against CD31.Results: Endothelial integrity (measured in a scale from 1-worst to 5-best) was significantly better after cardioplegic solution storage (2.83 ± 0.15 and 3.10 ± 0.13 in cold and room temperature, respectively) compared with storage in conventional solutions (2.23 ± 0.16 and 2.0 ± 0.15 in cold and room temperature, respectively). A significant effect of cardioplegic storage solution, as well as of cold temperature and cardioplegic solution interaction on endothelial preservation was reported, whereas storage temperature did not prove a significant factor by its own.Conclusions: Cardioplegic storage solutions result in significantly better endothelial preservation compared with conventional heparin-enriched blood solutions. The association with superior clinical outcomes remains to be proved. [ABSTRACT FROM AUTHOR]

In patients with chronic atrial fibrillation, 90% of clots are located in the left atrial appendage (LAA). Therefore, LAA exclusion is a means of preventing thrombus formation and subsequent thromboembolic events in these patients. The LAA can be excluded from the systemic circulation via surgical, percutaneous, or thoracoscopic approaches. The surgical aim is complete obliteration of the appendage without a significant increase in either postoperative complications (bleeding, arrhythmias) or recurrence. We discuss the current surgical techniques available for LAA obliteration and review their results. doi: 10.1111/jocs.12055 (J Card Surg 2013;28:199-206) [ABSTRACT FROM AUTHOR]

Background: It is well known by now that during open heart surgery many detrimental factors are involved in lung injury. The influence mainly of cardiopulmonary bypass (CPB), anesthesia, hypothermia, operation itself, as well as medication and transfusion, can cause a diffuse injury in the lungs, which most often leads to a postoperative pulmonary edema and abnormal gas exchange. Methods: We performed an unrestricted search of Pubmed Medline and EMBASE from 1966 through 2008. Clinical, experimental, basic science, and review papers were included. Results: The hypothesis that a systemic inflammatory reaction takes place after the use of CPB, could explain most of these effects influences in the lung. On the other hand, the release of various pro-inflammatory cytokines like TNF-á, IL-1, IL-2, IL-6, IL-8, and endotoxin during CPB can lead to the entrapment of neutrophils in the pulmonary capillaries. Consequently, the following chain of reactions is likely to occur: an endothelial cell swelling, plasma and protein extravasation into the interstitial tissue, release of proteolytic enzymes, congestion of the alveoli with plasma, erythrocytes and inflammatory debris. Conclusion: In this review we highlight the possible pathophysiological mechanisms implicated in the observed postoperative lung dysfunction. (J Card Surg 2010;25:47-55) [ABSTRACT FROM AUTHOR]

Aim: In this article, the hemodynamic, humoral, and immunological perturbations following brain death (BD) are going to be discussed in a stepwise manner. Materials and Methods: BD produces derangements in cardiac function, through a not-yet-well-explained mechanism. Using literature review, we attempted to delineate the “pathophysiology” involved. Results: A severe a-adrenergic stimulation following catecholamine storm results in conditions such that the pulmonary capillary pressure is massively increased. Furthermore, cytokine up-regulation, endothelial expression molecules, and neutrophil infiltration produce tissue damage. The end result reflects myocardial necrosis due to reduction of the calcium ATPase activity that leads to myocyte calcium overload and cell death. Conclusions: Delineation of the mechanisms responsible for donor heart dysfunction (DHD) would be presented. Furthermore, an attempt would be made to apply this knowledge into the clinical practice in order to increase the suitability of donor hearts for transplantation. (J Card Surg 2010;25:98-106) [ABSTRACT FROM AUTHOR]

Background: The inferior vena cava (IVC) is involved in almost 5% to 10% of renal tumors. Their intraluminar extension to the cardiac cavities occurs with a tumor-thrombus formation at a percentage of 1%. The aim of this study is to present the principles of “radical” management that should be targeted to excision of the kidney together with the cavoatrial tumor-thrombus. Material: From 2003 through 2008, we treated six patients with renal-cell carcinoma involving the IVC and/or the right cardiac chambers. The main symptoms leading to the diagnosis were hematuria, dyspnea, or lower limb edema. The extension of the tumor was type IV in three cases, type III in two, and type II in one case. Method: Extracorporeal circulation combined with a short period of hypothermic circulatory arrest was the method used. Radical nephrectomy combined with cavotomy and atriotomy was performed to an “en-block” extirpation of the tumor-thrombus and allowed oncologic surgical clearance of the disease. Results: There was no operative death. The mean postoperative course duration was 11 days, apart from one obese patient who presented postoperative pancreatitis and died on the 44th postoperative day due to respiratory failure. During the cumulative postoperative follow-up of 171 months the patients remain free of recurrence. Conclusions: The use of extracorporeal circulation and deep hypothermic circulatory arrest provides a good method for radical excision of renal carcinomas involving the IVC with satisfactory morbidity and long-term survival results. Cooperation of urologists and cardiac surgeons is necessary for this type of operation. [ABSTRACT FROM AUTHOR]

Thymic epithelial tumors are characterized by slow growth and variable malignant behavior. We present our experience on the surgical management of these tumors. We conducted a retrospective analysis of patients with thymomas undergoing modified maximal thymectomy over a period of 16 years. Evaluated parameters included gender, age, Masaoka stage, WHO histology, R0 resection, myasthenia gravis, and adjuvant radiotherapy. In thymoma-associated myasthenia gravis, further analysis was made according the Osserman stage, the time from myasthenia diagnosis to thymectomy, and the steroid treatment. End points were survival for the total study group and achievement of complete stable remission (CSR) in patients with myasthenia gravis. The study group consisted of 15 male and 24 female patients. There was no perioperative mortality. Overall survival was 91.6% and 75.1% at 5 and 10 years. Univariate analysis identified the following predictors of survival: myasthenia ( P < 0.001), Masaoka stage ( P < 0.001), R0 resection ( P < 0.001), and WHO histology ( P = 0.007). Only the WHO histology was an independent predictor of survival in multivariate analysis ( P = 0.003). Myasthenia patients had CSR prediction of 51.9% and 75.9% at 10 and 15 years. Preoperative steroid treatment ( P = 0.007) and WHO histology ( P = 0.021) were independent predictors of CSR on multivariate analysis. Modified maximal thymectomy is safe and efficient in the treatment of thymomas. WHO histology is the prime determinant of tumor aggressiveness and patient survival. Paraneoplastic myasthenia gravis and its outcome after thymectomy is significantly correlated with the WHO classification subtypes; however, lower CSR rates are not necessarily associated with more aggressive histological subgroups. [ABSTRACT FROM AUTHOR]

We report the one-stage surgical management of a 68-year-old patient with renal cell carcinoma and serious hematuria combined with coronary artery disease and unstable angina. After the accomplishment of coronary revascularization without cardiopulmonary bypass, we proceeded to nephrectomy and resection of the renal tumor at the same time. The patient's postoperative course was uneventful, and at 17 months of follow-up, the patient showed no signs of recurrence. To the best of our knowledge, such a case has never been reported before in the literature. [ABSTRACT FROM AUTHOR]

The decision to proceed to simple underwater seal drainage or apply active suction to the underwater seal after lung resection is mostly based on surgeon preference. The purpose of this study was to test whether routine application of active suction is necessary after lobectomy. This was a prospective randomized controlled trial conducted in the Patras University Hospital. Ninety-one patients who underwent lobectomy or bilobectomy for lung cancer and met the eligibility criteria were enrolled. Group I included 47 patients and group II had 44 patients. The two groups were comparable. At the end of surgical procedure patients were randomly assigned to receive −15 to −20 cm H2O active suction applied to the underwater seal drainage (group I) or simple underwater seal drainage (group II). The primary end point was the time elapsed between placement and removal of drains. No statistically significant differences were observed between the two groups in terms of time elapsed between the removal of chest drains, mortality, morbidity, adequacy of drainage system, and postoperative hospital stay. Suction applied to the underwater seal to re-expand the lung succeeded in 3 of 10 cases of persistent pneumothorax in group II. Discontinuing suction in 7 patients with persistent air leak in group I resulted in leak resolution in 4 patients. Routine application of active drain suction to the underwater seal is not necessary after lobectomy. However, it could be useful in persistent pneumothorax with sufficient air entry in the lung and clear airways. It is of no help in persistent air leaks when the lung is expanded. [ABSTRACT FROM AUTHOR]

The development and evolution of Greek Cardiac Surgery (GCS) has followed the international cardiothoracic surgery after the invention of cardiopulmonary bypass machine by John Gibbon in 1953. Chronologically, the development of GCS could be divided in four periods: (a) the first or essay period (1950–1960) characterized by the lack of organization, the experimentation and hesitation from the surgeons' side, and the reluctance from the patients' side to have an operation in Greece. (b) The second or stabilization period (1960–1970) is the period during which several separate cardiovascular departments were organized and performed the first valve replacement in 1964. (c) The third or “strengthening” period (1970–1985), during which Greek surgeons were trained abroad and adopted new methods and techniques of surgical therapy. The first operations of coronary artery bypass grafting and aortic aneurysm were performed (1973–1975). Various purely Cardiothoracic Centers were founded in Athens and Thessalonica and cardiac surgery became a routine operation. However, these centers were numerically not enough to cover the demand of patients in need of cardiac surgery. (d) The fourth or maturity period (1985 till today). It is characterized by the creation of private cardiac surgery departments and the gradual establishment of new university centers at the periphery, which along with the Onassis Cardiac Center, eliminated any need for patients to leave the country. [ABSTRACT FROM AUTHOR]

Background: Aortic arch surgery is impossible without the temporary interruption of brain perfusion and therefore is associated with high incidence of neurologic injury. The deep hypothermic circulatory arrest (HCA), in combination with antegrade or retrograde cerebral perfusion (RCP), is a well-established method of brain protection in aortic arch surgery. In this retrospective study, we compare the two methods of brain perfusion. Materials and Methods: From 1998 to 2006, 48 consecutive patients were urgently operated for acute type A aortic dissection and underwent arch replacement under deep hypothermic circulatory arrest (DHCA). All distal anastomoses were performed with open aorta, and the arch was replaced totally in 15 cases and partially in the remaining 33 cases. Our patient cohort is divided into those protected with antegrade cerebral perfusion (ACP) (group A, n = 23) and those protected with RCP (group B, n = 25). Results: No significant difference was found between groups A and B with respect to cardiopulmonary bypass-time, brain-ischemia time, cerebral-perfusion time, permanent neurologic dysfunction, and mortality. The incidence of temporary neurologic dysfunction was 16.0% for group A and 43.50% for group B (p = 0.04). The mean extubation time was 3.39 ± 1.40 days for group A and 4.96 ± 1.83 days for group B (p = 0.0018). The mean ICU-stay was 4.4 ± 2.3 days for group A and 6.9 ± 2.84 days for group B (p = 0.0017). The hospital-stay was 14.38 ± 4.06 days for group A and 19.65 ± 6.91 days for group B (p = 0.0026). Conclusion: The antegrade perfusion seems to be related with significantly lower incidence of temporary neurological complications, earlier extubation, shorter ICU-stay, and hospitalization, and hence lower total cost. [ABSTRACT FROM AUTHOR]

n = 10). Eight patients were supported perioperatively by intraaortic balloon counterpulsation (IABP). In all cases the surgical technique included infarctectomy and ventricular septum reconstruction with synthetic patches. Coronary artery bypass grafting was synchronously performed in four patients. Seven patients died perioperatively (mortality rate 50%) due to heart failure and to multiple organ failure. The most frequent complications were low cardiac output syndrome, hemorrhage, and respiratory and renal insufficiency. The PIVSD needs urgent surgical intervention with the patient hemodynamically stable after cardiac catheterization. Long-term results are favorable for survivors.RID="" ID="" Correspondence to: K. Athanassiadi, M.D., Ph.D., 34A Konstantinoupoleos Str., 15562 Holargos, Athens, Greece [ABSTRACT FROM AUTHOR]

Chylothorax is rare following blunt thoracic trauma; its diagnosis is usually delayed until the puncture or drainage of posttraumatic pleural effusion and its cause is not clear. Mostly, it is attributed to injury or overstretching of major thoracic duct by fractures or other injury of neighboring thoracic spine. We describe of two cases, one unilateral and one bilateral, of chylothorax, both after blunt thoracic trauma. In the first case, there were associated fractures of lower thoracic vertebrae, whereas in the other there was no obvious cause, except striking osteophytic degeneration alongside the thoracic spine. Both cases were successfully treated after 16 and 23 days, respectively, with drainage, starvation, reexpansion of the lung(-s), and total parenteral nutrition. We believe that with the “triad of RST” (“reexpansion, starvation diet, TPN”), conservative treatment will be successful in the majority of cases. [ABSTRACT FROM AUTHOR]

The aim of our study is the presentation of some interesting images of a case with symptomatic penetrating atherosclerotic ulcer (PAU) of the thoracic aorta and its endovascular treatment. Penetrating atherosclerotic ulcer is an ulcerating atherosclerotic lesion that penetrates the elastic lamina and is correlated with intramural hematoma (IMH) formation into the media layer of the aortic wall. PAU is more common in the elderly with severe atherosclerosis, hypertension, and hyperlipidemia. Transesophageal echocardiography, computed tomography, and magnetic resonance imaging are the common diagnostic tools. Surgical treatment may become necessary in cases involving the ascending aorta or in cases of intramural haematoma formation. In the era of minimally invasive surgery stent-grafting is indicated mainly in the elderly patients in presence of serious co-morbidities. [ABSTRACT FROM AUTHOR]

We describe a safe, easy, and fast technique of exposing the left anterior descending artery (LAD), when this is embedded under the myocardium or excessive epicardial fat tissue, during coronary artery bypass grafting (CABG) or off-pump coronary artery bypass (OPCAB). The vessel is opened as distal as possible, then a fine intravascular probe is introduced retrogradely. Through palpation of the tip, the course of LAD is confined together with the site of distal anastomosis formation. The suggested technique minimizes the risk of injuring the vessel or ventricles, reduces the ischemia-time, and allows the performance of anastomosis as paroximal as possible in the cases of OPCAB with embedded LAD. [ABSTRACT FROM AUTHOR]