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Purpose: Adipokines produced by adipose tissue have been found to be involved in the pathophysiology of metabolic and cardiovascular diseases. We aimed to investigate the relationships of resistin, retinol-binding protein 4 (RBP4) and adiponectin produced by epicardial adipose tissue with coronary artery disease (CAD) and cardiac structure and function., Methods: Forty-one non-diabetic males scheduled for cardiothoracic surgery were examined. Anthropometric measurements, echocardiography, coronary angiography, and blood analysis were performed preoperatively. We measured the serum levels of resistin, RBP4, and adiponectin and their mRNA expression in thoracic subcutaneous adipose tissue and two epicardial adipose tissue samples, one close to left anterior descending artery (LAD) (resistin-LAD, RBP4-LAD, adiponectin-LAD), and another close to the right coronary artery (RCA) (resistin-RCA, RBP4-RCA, adiponectin-RCA)., Results: Left ventricular (LV) ejection fraction correlated negatively with adiponectin-LAD (rho =  - 0.390, p = 0.025). The ratio of early to late diastolic transmitral flow velocity, as an index of LV diastolic function, correlated negatively with resistin-LAD (rho =  - 0.529, p = 0.024) and RBP4-LAD (rho =  - 0.458, p = 0.049). There was no difference in epicardial adipose tissue mRNA expression of resistin, RBP4, and adiponectin between individuals with CAD and those without CAD. When we compared the individuals with CAD in the LAD with those without CAD in the LAD, there was no difference in resistin-LAD, RBP4-LAD, and adiponectin-LAD. There was no difference in resistin-RCA, RBP4-RCA, and adiponectin-RCA between the individuals with CAD in the RCA and those without CAD in the RCA., Conclusion: Elevation of epicardial adipose tissue mRNA expression of adiponectin was associated with LV systolic dysfunction, while that of both resistin and RBP4 was linked to LV diastolic dysfunction., (© 2023. The Author(s).)

(1) Background: The present study aims to investigate the effect of administration of Levosimendan and Exenatide in various concentrations, as well as of the coadministration of those agents in an ischemia-reperfusion injury isolated heart model. (2) Methods: After 30 min of perfusion, the hearts underwent a 30 min period of regional ischemia followed by a 120 min period of reperfusion. All animals were randomly divided into 12 experimental groups of nine animals in each group: (1) Control, (2) Sham, (3) Digox (Negative control, Digoxin 1.67 μg/min), (4) Levo 1 (Levosimendan 0.01 μg/min), (5) Levo 2 (Levosimendan 0.03 μg/mL), (6) Levo 3 (Levosimendan 0.1 μg/min), (7) Levo 4 (Levosimendan 0.3 μg/min), (8) Levo 5 (Levosimendan 1 μg/min), (9) Exen 1 (Exenatide 0.001 μg/min), (10) Exen 2 (Exenatide 0.01 μg/min), (11) Exen 3 (Exenatide 0.1 μg/min) and (12) Combi (Levosimendan 0.1 µg/mL + Exenatide 0.001 μg/min). The hemodynamic parameters were recorded throughout the experiment. Arrhythmias and coronary flow were also evaluated. After every experiment the heart was suitably prepared and infarct size was measured. Markers of myocardial injury were also measured. Finally, oxidative stress was evaluated measuring reactive oxygen species. (3) Results: A dose-dependent improvement of the haemodynamic response was observed after the administration of both Levosimendan and Exenatide. The coadministration of both agents presented an even greater effect, improving the haemodynamic parameters further than the two agents separately. Levosimendan offered an increase of the coronary flow and both agents offered a reduction of arrhythmias. A dose-dependent reduction of the size of myocardial infarction and myocardial injury was observed after administration of Levosimendan and Exenatide. The coadministration of both agents offered a further improving the above parameters. Levosimendan also offered a significant reduction of oxidative stress. (4) Conclusions: The administration of Levosimendan and Exenatide offers a significant benefit by improving the haemodynamic response, increasing the coronary flow and reducing the occurrence of arrhythmias, the size of myocardial injury and myocardial oxidative stress in isolated rat hearts.

Alexander the Great was a world-class leader with tremendous courage. He paid no heed to the dangers of the battlefield, so he was always in the front lines. However, his excessive courage put his life in danger. Herein, we present an analysis of the information contained in the chronicles about a very severe, life-threatening thoracic trauma that nearly killed the great stratelates . The detailed descriptions made by Arrianus allow us to conclude that Alexander the Great experienced a nearly fatal case of tension pneumothorax. Information on how he was managed is also presented., Competing Interests: Conflict of interest No potential conflict of interest relevant to this article was reported.

The purpose of this paper is to describe a novel minimally invasive endovascular model of progressive myocardial hypertrophy in rabbits as an experimental protocol of hypertrophic cardiomyopathy. Nine New Zealand White rabbits underwent transauricular aortic catheterization. Under fluoroscopy a bare metal stent was partially deployed in the descending thoracic aorta (balloon length/stent length=1/2) so as to produce a funnel-shaped thoracic stent. Another nine animals underwent a sham procedure without stent placement (control). Follow-up computed tomography imaging was performed to exclude aortic occlusion. Subjects were killed after 3 months and their hearts were harvested and weighed. Cardiac hypertrophy was assessed with the heart weight-to-body weight (HW/BW) ratio and post-mortem histology was performed. We also used immunohistochemical staining for myogenin to compare the thickness of the wall between the two groups. The stents were polymer embedded for histomorphometry. Expressions of vascular endothelial growth factor (VEGF) and pleiotrophin (PTN) were analyzed by western blot analysis of total protein heart extracts. Computerized image analysis of CD34 and VEGF immunoreactivity was used to quantify myocardial angiogenesis. After 3 months, cross-sectional microscopic analysis of the harvested aortas showed total stent occlusion of the distal underdeployed area and some evidence of thrombus formation at the transitional zone toward the fully deployed stent in all cases. There was a nearly +10% increase of the adjusted HW/BW ratio compared with controls (absolute ratio difference was 0.02±0.01%; P=0.02). VEGF and CD34 expression was significantly suppressed, but expression of PTN was significantly increased in case of myocardial hypertrophy (stent group). Cardiac hypertrophy was evidenced using immunohistochemical staining for myogenin by significantly increased cardiomyocyte cross-sectional area (+38.4%; P<0.0001) compared with the control animals. In conclusion, this minimally invasive novel technique of transauricular funnel-shaped stent insertion in the descending thoracic aorta may achieve progressive myocardial hypertrophy in rabbits.

Purpose: Primary cardiac tumors are uncommon but not extremely rare. Cardiac tumors, mostly intracavitary, include benign and malignant tumors that arise from the endocardium, heart valves or myocardium. This retrospective study summarizes the experience of the Cardiac Surgery Departments of three tertiary Hospitals in this field, and particularly in cardiac myxomas, over the last 29 years. Herein, we present the results of cardiac tumors excision in relation to postoperative morbidity and mortality., Methods: Between 1985 and 2014, 117 patients, aged from 16 to 82 years, underwent resection of a cardiac tumor., Results: Ninety one of the tumors (77.78%) were myxomas, 15 of them (12.82%) were other primary cardiac tumors, 7 of them (5.98%) were infra-diaphragmatic tumors and the remaining 4 tumors (3.42%) were benign intracavitary masses (thrombi). Patients operated on for a cardiac tumor had a 30-day mortality rate of 3.29%. Atrial fibrillation appeared in 21 out of 91 patients (23.07%) operated on for cardiac myxoma, while neurological complications were observed in 3 patients (3.29%). Re-exploration for bleeding was performed in 5 out of 91 cases (5.49%) and recurrence occurred in 4.39% of myxomas., Conclusions: Despite being rare, primary cardiac tumors require open heart intervention soon after their diagnosis in order to prevent complications and achieve low mortality rates.

Thirty to fifty percent of critically ill patients admitted to the intensive care unit suffer from generalized neuromuscular weakness due to critical illness polyneuropathy, critical illness myopathy, or a combination of them, thus prolonging mechanical ventilation and their intensive care unit stay. A distinction between these syndromes and other neuromuscular abnormalities beginning either before or after ICU admission is necessary. These intensive care unit-related diseases are associated with both elevated mortality rates and increased morbidity rates. Generally, over 50 % of patients will completely recover. Most of them recover after 4-12 weeks, but some patients have been reported to keep on suffering from muscle weakness for at least 4 months. Prevention has a key role in the management of critical illness neuromuscular disorders, as no specific therapy has been suggested. Either prevention or aggressive treatment of sepsis can prevent critical illness polyneuropathy and critical illness myopathy. The dose and duration of the administration of neuromuscular blocking drugs should be limited, and their concurrent administration with corticosteroids should be avoided. Intensive insulin therapy has also been proven to reduce their incidence. Finally, early mobilization via active exercise or electrical muscle stimulation plays a significant role in their prevention.

Ligation and dissection of internal mammary vessels is the most under-estimated complication of anterior mediastinotomy. However, patients requiring anterior mediastinotomy may experience long survival that makes the development of ischemic heart disease throughout their life possible. Therefore, the un-judicial sacrifice of the internal mammary pedicle may deprive them from the benefit to have their internal mammary artery used as a graft in order to successfully bypass severe left anterior descending artery stenoses. We recommend the preservation of the internal mammary pedicle during anterior mediastinotomy, which should be a common message among our colleagues from the beginning of their training.

Coronary endarterectomy is an old surgical procedure against coronary artery disease first described by Baily et al. in 1957. Despite its first adverse results, several current publications have shown that coronary endarterectomy with on-pump or off-pump coronary artery bypass grafting can be safely performed with acceptable mortality, morbidity, and angiographic patency rates. Coronary endarterectomy can assure complete revascularization supplying the myocardium with satisfactory blood flow in cases of a diffusely diseased left anterior descending artery or diffuse calcification, thus preventing residual ischemia. Hence, it is important to evaluate current results, rethink this old recipe, and redefine its indications., (Copyright © 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Mini-extracorporeal circulation (MECC) constitutes a novel miniaturized cardiopulmonary bypass (CPB) circuit, heparin-coated and primed with aprotinin. Its membrane oxygenation is similar to conventional cardio-pulmonary bypass (CCPB), but it is a completely closed-volume system due to the lack of the venous reservoir which has been removed. In a mini circuit, the reservoir is the patient himself. Consequently, air entering the venous cannula is avoided. Nevertheless, the capabilities of MECC have been expanded either by the inclusion of a suction device that is only activated on direct contact with liquid in some circuits or by postoperative autotransfusion of the wrecked erythrocytes by a separate suction device with a cell-saver. Although the tubing diameter is similar between the two systems, the tubing length of the MECC is around half that of the CCPB, resulting in the restriction of priming volume. As a consequence, a higher hematocrit thus a limited need for perioperative blood transfusion is achieved due to less hemodilution. In addition, the inflammatory response is also diminished as a result of less artificial surface area interacting with blood. Finally, a lower dose of heparin is required prior to MECC than prior to CCPB., (Copyright © 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Purpose: The infection of cardiac implantable electronic devices (CIED) is a serious and potentially lethal complication. The population at risk is growing, as the device implantation is increasing especially in older patients with associated comorbid conditions. Our purpose was to present the management of this complicated surgical condition and to extract the relevant conclusions., Methods: During a 3-year period 1,508 CIED were implanted in our hospital. We treated six cases of permanent pacemaker infection with localized pocket infection or endocarditis. In accordance to the recent AHA/ACC guidelines, complete device removal was decided in all cases. The devices were removed under general anaesthesia, with a midline sternotomy, under extracorporeal circulation on the beating heart. Epicardial permanent pacing electrodes were placed on the right atrium and ventricle before the end of the procedure., Results: The postoperative course of all patients was uncomplicated and after a follow up period of five years no relapse of infection occurred., Conclusions: Management protocols that include complete device removal are the only effective measure for the eradication of CIED infections. Although newer technologies have emerged and specialized techniques of percutaneous device removal have been developed, the surgical alternative to these methods can be a safe solution in cases of infected devices.

Background: Cardiac myxoma is a benign neoplasm that represents the most prevalent primary tumor of the heart. If not treated with the right surgical technique recurrence occurs. Aim of our study is to present our surgical approach and the histology of the tumors resected., Methods: All patients, except for one, underwent extracorporeal circulation and mild hypothermia, right atrial or both atrial incision and excision of the fossa ovalis, followed by prosthetic patch suturing. All specimens were submitted for microscopic evaluation (haematoxylin-eosin). We contacted personally each patient and asked them to complete a standardized questionnaire, concerning their peri-operative characteristics., Results: Six cases were "active" myxomas, 3 were "mildly active" and 3 were "inactive". "Normal differentiation" was seen in 6, "medium" in 1 and "poor" in 5 cases. In our series there were no recurrences recorded during the follow-up period., Conclusions: The ideal approach, according to our experience is right atrial or both atrial incision as described by Shumacker and King, with excision of the fossa ovalis and the surrounding tissues and closure with a pericardial patch. Such a technique provides an excellent long-term survival in these patients.

Right-sided infective endocarditis (RSIE) accounts for 5-10% of all cases of infective endocarditis (IE), and is predominantly encountered in the injecting drug user (IDU) population, where HIV and HCV coinfections often coexist. Staphylococcus aureus is the most common pathogen. The pathogenesis of RSIE is still not well understood. RSIE usually presents as a persistent fever with respiratory symptoms whilst signs of systemic embolisation as seen in left-sided IE are notably absent. The prompt diagnosis of RSIE thus requires a high index of suspicion. Transthoracic echocardiography (TTE) can detect the majority of RSIE, whilst transoesophageal echocardiography (TOE) can increase sensitivity. Virulence of the causative organism and vegetation size are the major determinants of prognosis. Most cases of RSIE resolve with appropriate antibiotic administration., (Copyright © 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Coronary artery disease was considered a male disease for many years. However, nowadays, coronary artery disease constitutes the leading cause of death in women, although there are a lot of gender-related differences regarding the presentation of acute myocardial infarction, its diagnosis, its treatment, short- and long-term mortality rates, and post-acute myocardial infarction complications. Generally, women have smaller and stiffer hearts and cardiac vessels, suffering a greater extent of atherosclerosis and endothelial and smooth muscle dysfunction. They are usually older than men and they have more comorbidities such as hypertension, renal impairment, and diabetes mellitus. Moreover, female coronary artery disease, the diagnosis of which is more complicated due to more false negative results of some diagnostic methods in women, is more often presented with atypical symptoms and women's symptoms of typical or atypical angina are more severe. Furthermore, women delay significantly more in seeking care and they are more frequently undertreated. Finally, women are associated with generally poorer in-hospital and long-term prognosis having almost two-fold higher early mortality and they are more prone to complications such as bleeding complications, shock, and heart failure, as well as to post-myocardial infarction depression and poorer physical function and mental health. In this review, we discuss these sex-related differences according to current literature., (Copyright © 2013 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

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., (© 2013 Wiley Periodicals, Inc.)

Primary intimal aortic sarcoma represents a very rare and highly lethal medical entity. Diagnosis is made either by embolic events caused by the tumor or by surrounding tissue symptoms such as pain. Herein we report an extremely rare case of a 51-year-old man previously operated for ascending aortic aneurysm, who presented with clinical and radiological findings suggestive of a ruptured thoracoabdominal type IV aneurysm. The patient underwent radical resection of the aorta and surrounding tissue with placement of a composite 4-branched graft. The diagnosis was made by frozen section and regular histopathologic examination of the specimen and the patient received adjuvant chemotherapy. Nine months after surgery the patient is still alive and has no signs of recurrence. We review the literature and discuss the option of postoperative chemotherapy.

Background: Nosocomial infections after cardiac surgery represent serious complications associated with substantial morbidity, mortality and economic burden. This study was undertaken to evaluate the frequency, characteristics, and risk factors of microbiologically documented nosocomial infections after cardiac surgery in a Cardio-Vascular Intensive Care Unit (CVICU)., Methods: All patients who underwent open heart surgery between May 2006 and March 2008 were enrolled in this prospective study. Pre-, intra- and postoperative variables were collected and examined as possible risk factors for development of nosocomial infections. The diagnosis of infection was always microbiologically confirmed., Results: Infection occurred in 24 of 172 patients (13.95%). Out of 172 patients, 8 patients (4.65%) had superficial wound infection at the sternotomy site, 5 patients (2.9%) had central venous catheter infection, 4 patients (2.32%) had pneumonia, 9 patients (5.23%) had bacteremia, one patient (0.58%) had mediastinitis, one (0.58%) had harvest surgical site infection, one (0.58%) had urinary tract infection, and another one patient (0.58%) had other major infection. The mortality rate was 25% among the patients with infection and 3.48% among all patients who underwent cardiac surgery compared with 5.4% of patients who did not develop early postoperative infection after cardiac surgery. Culture results demonstrated equal frequencies of gram-positive cocci and gram-negative bacteria. A backward stepwise multivariable logistic regression model analysis identified diabetes mellitus (OR 5.92, CI 1.56 to 22.42, p = 0.009), duration of mechanical ventilation (OR 1.30, CI 1.005 to 1.69, p = 0.046), development of severe complications in the CICU (OR 18.66, CI 3.36 to 103.61, p = 0.001) and re-admission to the CVICU (OR 8.59, CI 2.02 to 36.45, p = 0.004) as independent risk factors associated with development of nosocomial infection after cardiac surgery., Conclusions: We concluded that diabetes mellitus, the duration of mechanical ventilation, the presence of complications irrelevant to the infection during CVICU stay and CVICU re-admission are independent risk factors for the development of postoperative infection in cardiac surgery patients.

Magnetic resonance imaging (MRI) in patients with implanted cardiac prostheses and metallic cardiovascular electronic devices is sometimes a risky procedure. Thus MRI in these patients should be performed when it is the only examination able to help with the diagnosis. Moreover the diagnostic benefit must outweigh the risks. Coronary artery stents, prosthetic cardiac valves, metal sternal sutures, mediastinal vascular clips, and epicardial pacing wires are not contraindications for MRI, in contrast to pacemakers and implantable cardioverter-defibrillators. Appropriate patient selection and precautions ensure MRI safety. However it is commonly accepted that although hundreds of patients with pacemakers or implantable cardioverter-defibrillators have undergone safe MRI scanning, it is not a safe procedure. Currently, heating of the pacemaker lead is the major problem undermining MRI safety. According to the US Food and Drug Administration (FDA), there are currently neither "MRI-safe" nor "MRI-compatible" pacemakers and implantable cardioverter-defibrillators. In this article we review the international literature in regard to safety during MRI of patients with implanted cardiac prostheses and metallic cardiovascular electronic devices., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

It is common knowledge that cocaine has been linked to the development of various acute and chronic cardiovascular complications including acute coronary syndromes. We present a young, male patient, drug abuser who underwent CABG due to anterolateral myocardial infarction. Our presentation is one of the very rare cases reported in literature regarding acute thrombosis of left main coronary artery related to cocaine use, in a patient with normal coronary arteries, successfully operated. Drug-abusers seem to have increased mortality and morbidity after surgery and high possibility for stent thrombosis after percutaneous coronary interventions, because of their usually terrible medical compliance and coexistent several problems of general health. There are no specific guidelines about treatment of thrombus formation in coronary arteries, as a consequence of cocaine use. So, any decision making concerning the final treatment of these patient is a unique and individualized approach. We strongly recommend that all these patients should be treated surgically, especially patients with thrombus into the left main artery.

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.

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.

Background: Although thymectomy is a standard practice of care in patients with myasthenia gravis, the best approach to thymic resection remains controversial. This study was conducted to assess the effect of maximal resection on neurologic outcome and identify predictors of disease remission., Methods: Data of 78 myasthenic patients who underwent modified maximal thymectomy during a 17-year period were retrospectively analyzed. The primary study end point was the achievement of complete remission. Separate analysis was performed for thymoma and nonthymoma patients regarding the factors predicting the neurologic outcome., Results: No patients died perioperatively. Surgical morbidity was 7.7%. The rate of postoperative myasthenic crisis was 3.8%. Thymoma and nonthymoma patients experienced comparable complete stable remission prediction (74.5% vs 85.7% at 15 years; p = 0.632). The absence of steroids in the preoperative medical treatment was statistically related to the prediction for complete stable remission in both thymoma (95% confidence interval [CI], 2.687 to 339.182, p = 0.006) and nonthymoma patients (95% CI, 1.607 to 19.183; p = 0.007) in multivariate analysis. In thymomatous myasthenia gravis, there was a statistically significant association between disease remission and the World Health Organization (WHO) histologic classification (95% CI, 0.262 to 0.827; p = 0.009)., Conclusions: Maximal resections are recommended in myasthenic patients. Disease severity represents the prime determinant of the neurologic outcome after thymectomy. The neurologic outcome in patients after thymectomy may be statistically associated with the WHO classification subtypes but not necessarily with the aggressiveness of these tumors.

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.

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.

"Directed cardioplegia" is a novel approach in myocardial protection in which a certain volume of cardioplegic solution is diverted into a severely diseased coronary artery after surgical occlusion of the other main branches that can be accessed by the surgeon. In this way, the surgeon is able to eliminate the cardioplegic steal from a severely stenosed vessel through other less severely diseased and/or patent arteries during the nonselective antegrade administration of cardioplegia and to protect myocardial regions, which are poorly perfused. We performed this new technique in 2 patients with severe left main coronary artery disease with excellent results.

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.

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.

In spite of recent advances in thoracic aortic surgery, postoperative neurological injury still remains the main cause of mortality and morbidity after aortic arch operation. The use of cardiopulmonary bypass (CPB) and hypothermic circulatory arrest, temporary interruption of brain circulation, transient cerebral hypoperfusion, and manipulations on the frequently atheromatic aorta all produce neurological damages. The basic established techniques and perfusion strategies during aortic arch replacement number three: hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and retrograde cerebral perfusion (RCP). During the past decade and after several experimental studies, RCP lost its previous place in the armamentarium of brain protection, giving it up to ACP as a major method of brain perfusion during HCA. HCA should be applied at a temperature of asymptotically equal to 20 degrees C with long-lasting cooling and rewarming and should not exceed by itself the time of 20-25 min. RCP does not seem to prolong safe brain-ischemia time beyond 30 min, but it appears to enhance cerebral hypothermia by its massive concentration inside the brain vein sinuses. HCA combined with ACP, however, could prolong safe brain-ischemia time up to 80 min. Cold ACP at 10 degrees -13 degrees C should be initially applied through the right subclavian or axillary artery and continued bihemispherically through the left common carotid artery at first and later the anastomosed graft, with a mean perfusion pressure of 40-70 mm Hg. The safety of temporary perfusion is being confirmed by the meticulous monitoring of brain perfusion through internal jugular bulb O2 saturation, electroencephalogram, and transcranial comparative Doppler velocity of the middle cerebral arteries.

Solitary fibrous tumors are mesenchymal entities integrated in a mixed group of hemangiopericytoma-like neoplasms. Although classically presented as a pleura-based mass, there are extrapleural sites including the lung. We present the clinical, imaging, and histological features of a solitary fibrous tumor of the lung.

Aortoesophageal fistula (AEF) is a rare cause of gastrointestinal bleeding with high mortality. Thoracic aorta aneurysms represent the leading cause of aortoesophageal fistula. Surgery offers the only chance for cure in these patients. So far there are no clear indications on the optimal management of these patients. A review of the literature was undertaken focusing on the surgical management of thoracic aorta aneurysm-related AEFs in an attempt to clarify the indications for the surgical or endovascular treatment of this entity. Only 37 successfully treated patients were identified. Most of them underwent open surgical repair with the intent to control both hemorrhage and mediastinal contamination. Thoracic aorta replacement with a synthetic graft was used in most cases. Cryopreserved homografts, extranatomic bypass, and endovascular stent grafting were used in a small number of patients. Esophageal manipulation using various techniques was undertaken in all patients with open surgical repair of their AEF. Based on the reported results and identified limitations of each approach, the present authors advocate open surgical repair of both aneurysm and esophageal defect as the treatment of choice in all patients with AEF and signs of infection in relatively good general condition. Stent grafting is considered a valid approach only for patients who cannot tolerate open repair. A combined technique of stent grafting for immediate bleeding control followed by open surgical repair of both aneurysm, preferably using homografts, and esophageal defect are extremely promising and may represent a more valid alternative to the classical open approach in the future.

Background: Combined heart surgery and lung resection remains a controversial issue. This method facilitates the treatment of two major problems with one intervention, reducing hospitalization cost with acceptable outcomes. On the other hand, skepticism exists related to the effects of cardiopulmonary bypass on malignancy and to a possible greater risk for perioperative bleeding., Case Reports: A retrospective study is presented of five male patients who underwent combined surgical treatment for heart and lung disease in a one-step procedure between November 2004 and November 2006. Three patients underwent aortic valve replacement with right upper lobectomy. The other two patients underwent pulmonary wedge resection, one combined with coronary bypass and the other with ascending aorta replacement. In all cases, pulmonary resection was performed before cardiopulmonary bypass was established. There was no perioperative death. Three patients had uneventful postoperative recovery, one patient developed atrial fibrillation, and the last one temporary neurological dysfunction. There was no increase in postoperative bleeding or in hospital stay. All patients are under follow-up observation with good performance status. In those patients with pulmonary malignancy, no sign of regional or distant recurrence of the disease is observed., Conclusions: Combined heart surgery and lung resection can be performed without increased mortality and/or morbidity. The synchronous treatment avoids the necessity of a second intervention with economic benefits and excellent results.

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.

Surgery of the aortic arch is a great challenge in cardiovascular surgery. Its partial or total replacement demands the temporary interruption of normal cerebral perfusion, with associated potential for neurological injury. Three methods of cerebral protection have been applied between 1975 and today: hypothermic circulatory arrest as a basic method, either alone or with antegrade cerebral perfusion (ACP), or retrograde cerebral perfusion (RCP) as an adjunctive method. After extensive research regarding the controversies that surround the ideal method of cerebral protection, it is obvious that ACP is superior to RCP for brain protection. ACP obtains a near-physiologic brain perfusion, with homogenous distribution of blood throughout the capillary beds, and extends the safe time of hypothermic circulatory arrest to 80 min, allowing the completion of whatever aortic arch work is necessary. By contrast, RCP perfuses a smaller brain territory than ACP, approximately 10-20%. Hence, RCP is, in our opinion, a 'smaller adjunct' to brain protection than ACP. Detailed evidence and future directions for further research are discussed.

Acute aortic dissection of the thoracic aorta represents a medical emergency that, despite its rare occurrence, is characterized by severe morbidity and mortality. Prompt diagnosis is the key to a desired outcome. According to current clinical data, diagnosis is mostly based on a high index of suspicion and diagnostic imaging and less on clinical manifestations. On the other hand, a biochemical approach to the entity is still falling short in terms of diagnostic practice, although optimistic efforts are being made towards the development of such methods. Myocin heavy-chain concentrations, D-dimer levels, and soluble elastin fragment measurement are some of the new promising tools emerging in the battle of acute diagnosis. Despite their potentials, all three still need to be reevaluated. More prospective clinical trials should be performed so as to improve and ensure a biochemical diagnostic method for acute aortic dissection of high sensitivity and specificity and thus of great clinical value. Search of the Literature: Two reviewers performed a literature search, identified the relevant studies to be included in this review, and extracted the data. Relevant studies for inclusion in this review were identified through PubMed as well as from references of the initially found articles. The search terms used were "myocin-heavy chains", "D-dimers", "soluble elastin fragments", "biochemical diagnosis", "aortic dissection", "sensitivity", "specificity", and "performance characteristics".

Background: Descending necrotizing mediastinitis (DNM) is a life-threatening complication secondary to oropharyngeal abscesses, esophageal perforation, or neck infections spreading into the mediastium, but very uncommon after thyroidectomy. Early diagnosis and close clinical and laboratory monitoring are crucial for patient survival. CT scanning of the cervical and thoracic area is a useful tool for diagnosis and follow-up. Different surgical approaches in the management of DNM have been proposed, the most widely accepted being a combined cervicotomy with lateral thoracotomy procedure., Case Report: A rare case of DNM with group A ss-hemolytic streptococci, in a 47-year-old patient developing after thyroidectomy for multinodular goiter is presented. A more conservative approach through a cervical incision was followed and thoracic drains for pleural effusion evacuation were inserted. After re-operation, repeated CT scanning for disease progression and prompt surgical wound cleaning were performed. Antibiotic therapy was continued up to one month after release. The patient's recovery was uneventful and continues well., Conclusions: To the best of the authors' knowledge this is the second case of post-thyroidectomy DNM reported. According to present data it is recommend that a less invasive approach could be satisfactory when prompt diagnosis is established and the thoracic drainage is effective. This case suggests that repeated postoperative CT scanning and close clinical and laboratory monitoring could make an additional thoracotomy a second-line procedure. Moreover, due to the fact that only two cases of post-thyroidectomy DNM are reported worldwide, therapy of this condition remains an open question.

Background: In this study the possible relation of Bax (an apoptosis promoter) to Bcl-2 (an apoptosis inhibitor) ratio with the apoptosis co-ordination enzyme, caspase-3, in the thymus of patients with myasthenia gravis (MG) was investigated in correlation with long-term clinical prognosis., Patients and Methods: The study included 46 patients (17M/29F, mean age 36.60 +/- 16.09 yr) with MG, who underwent thymectomy for treatment. The clinical staging (Osserman classification) included: stage 1-5, IIA-21, IIB-17, III-3. The pathology of the thymus showed: hyperplasia-26, atrophy-8, thymoma B1 and B2 type-9, thymoma B3 type (well differentiated thymic carcinoma)-3. The patients were evaluated 39-166 (mean 91.87 +/- 38.38) months after thymectomy. At the end of the follow-up period, the patients were classified as follows: group A: complete stable remission, group B: pharmacological remission + minimal manifestations + improvement + deterioration. Paraffin sections of thymic tissue were subjected to: a) immunohistochemistry (bax, bcl-2, caspase-3 protein); b) in situ hybridization (bax, bcl-2 mRNA); and c) TUNEL-stain (apoptotic cells). Bax to bcl-2 mRNA and protein ratio was determined for each sample by dividing the % bax (+) cells by the % bcl-2 (+) cells., Results: Follow-up data were available for 39/46 patients: 13/39 patients belonged to group A and 26/39 to group B. The Bax/Bcl-2 mRNA and protein ratios were increased towards advanced disease stages (+370% for mRNA and +391% for protein, from MG stage I to stage III). These ratios were correlated with caspase-3 expression (r = 0.782 and 0.583, p < 0.01) and apoptosis (r = 0.591 and 0.358 p < 0.01 and p < 0.05). All the 13 cases in group A had a Bax/Bcl-2 ratio < 1 (mean +/- SD: 0.58 +/- 0.04 for mRNA and 0.62 +/- 0.03 for protein), whereas all the 26 cases of group B had a ratio > 1 (1.47 +/- 0.07 for mRNA and 1.52 +/- 0.18 for protein). The Kaplan-Meier survival curve showed higher, free of disease, survival in group A (p = 0.0082). Cox regression analysis revealed that the Bax/Bcl-2 ratio was an independent prognostic factor, however the p-value was marginally significant (95% CI: 1.078-44.073, p = 0.041)., Conclusion: This study has demonstrated that in patients with MG who underwent thymectomy: a) the Bax/Bcl-2 ratio may up-regulate caspase-3 expression and modulate apoptosis associated with progress of the disease; b) the Bax/Bcl-2 ratio < 1 was associated with complete stable remission after thymectomy; and c) Bax/Bcl-2 ratio was an independent predictive marker for therapeutic response after thymectomy.

Background: The transplanted lung suffers ischemia-reperfusion injury and many efforts have been made to improve preservation. The aim of this study was to compare the effectiveness of intracellular high-potassium Belzer solution versus extracellular Celsior in 24-hour lung preservation., Material/methods: Sixteen pigs weighing 25.1-28.1 kg underwent single, left-lung allotransplantation. Sixteen other pigs were donors of the left lung. Heart and lungs were retrieved from the donors using single-flush perfusion by a randomly selected solution that was also used for cold storage (4 degrees C) for 24 hrs. Biopsies were taken from the right lung before storage, after the preservation, and finally three hours following transplantation. The observation period lasted three hours following transplantation., Results: Pulmonary artery pressure and pulmonary vascular resistance were significantly higher in the Belzer group (p<0.05), while the pO2/FiO2 ratio was much higher in the Celsior group (p<0.05). Compliance was reduced approximately equally in both groups. Histology showed less edema, atelectasis, and hemorrhagic infiltration in the Celsior group than in the Belzer group, which developed more interstitial thickening and presented more leukocyte infiltration and desquamation of alveoli cells., Conclusions: According to hemodynamic, respiratory, and histological data, the extra-cellular solution Celsior offers improved prolonged preservation compared with Belzer.

Background: The lobar torsion after lung surgery is a rare complication with an incidence of 0.09 to 0.4 %. It may occur after twisting of the bronchovascular pedicle of the remaining lobe after lobectomy, usually on the right side. The 180-degree rotation of the pedicle produces an acute obstruction of the lobar bronchus (atelectasis) and of the lobar vessels as well. Without prompt treatment it progresses to lobar ischemia, pulmonary infarction and finally fatal gangrene., Case Presentation: A 62 years old female patient was admitted for surgical treatment of lung cancer. She underwent elective left lower lobectomy for squamous cell carcinoma (pT2 N0). The operation was unremarkable, and the patient was extubated in the operating room. After eight hours the patient established decrease of pO(2) and chest x-ray showed atelectasis of the lower lobe. To establish diagnosis, bronchoscopy was performed, demonstrating obstructed left lobar bronchus. The patient was re-intubated, and admitted to the operating room where reopening of the thoracotomy was performed. Lobar torsion was diagnosed, with the diaphragmatic surface of the upper lobe facing in an anterosuperior orientation. A completion pneumonectomy was performed. At the end of the procedure the patient developed a right pupil dilatation, presumably due to a cerebral embolism. A subsequent brain angio-CT scan established the diagnosis. She died at the intensive care unit 26 days later., Conclusion: The thoracic surgeon should suspect this rare early postoperative complication after any thoracic operation in every patient with atelectasis of the neighboring lobe. High index of suspicion and prompt diagnosis may prevent catastrophic consequences, such as, infarction or gangrene of the pulmonary lobe. During thoracic operations, especially whenever the lung or lobe hilum is full mobilized, fixation of the remaining lobe may prevent this life threatening complication.

Rhabdomyomas are benign tumors in which at least some cells are differentiated as skeletal muscle cells with cytoplasmic cross-striations. Extracardiac adult rhabdomyoma is an extremely uncommon benign neoplasm that usually involves the head and neck region. Rare cases have been reported to involve other sites of the body including mediastinum. We report the fourth case of mediastinal adult rhabdomyoma.

Objective: Atrial natriuretic peptide (ANP) plasma levels are increased in patients with valvular heart disease. The present study investigates possible changes after mitral or aortic valve replacement (MVR, AVR)., Methods: In this prospective study, ANP plasma levels were measured in 11 patients undergoing MVR for mitral stenosis, in 11 patients undergoing AVR for aortic valve stenosis, and in 6 patients without heart disease undergoing thoracotomy for lung resection (control group). Blood samples were collected preoperatively (1 day before), during, and 8 days after the operation by serial blood sampling and were determined by radioimmunoassay method. ANP values were correlated with the duration of cardiopulmonary bypass (CPB), the aortic cross-clamping time, and the left atrial filling pressures., Results: ANP plasma levels were increased in all patients with valvular heart disease preoperatively and did not change during anesthesia or CPB; nor were they correlated with CPB duration or atrial filling pressures. The left atriotomy did not alter ANP plasma levels. The intracardiac surgical manipulations as well as CPB did not influence the ANP secretion intraoperatively and during the first postoperative week. Patients who underwent lung resection showed no change of ANP plasma levels perioperatively., Conclusion: ANP levels are not altered during and 1 week after valve replacement and, therefore, do not reflect hemodynamic changes perioperatively.