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Flail chest is a life-threatening clinical entity which can be complicated by respiratory insufficiency. Paradoxical motion of a part of chest wall is the basic cause to put the blame on. Consequently, stabilization of the chest wall is occasionally of paramount importance to achieve early extubation in a patient with post-trauma respiratory insufficiency. Hereby, a simple, low-cost, harmless and effective approach of external stabilization is presented. [ABSTRACT FROM AUTHOR]

Right-sided infective endocarditis (RSIE) accounts for 5–10% of all cases of infective endocarditis and is predominantly encountered among injecting drug users (IDUs). RSIE diagnosis requires a high index of suspicion as respiratory symptoms predominate. Prognosis of isolated RSIE is favourable, and most cases (70–80%) resolve following antibiotic administration. Surgical intervention is indicated in patients with persistent infection that does not respond to antibiotic therapy, recurrent pulmonary emboli, intractable heart failure and if the size of a vegetation increases or persists at >1 cm. Techniques can be divided into ‘prosthetic’ (valve replacement or prosthetic annular implantation) or ‘non-prosthetic’ ones (Kay's or De Vega's annuloplasty, bicuspidalization or valvectomy). In IDUs who run a high risk of complications, vegetectomy and valve repair, avoiding artificial material should be considered as the first line of surgical management as is associated with better late survival. [ABSTRACT FROM AUTHOR]

Antiphospholipid syndrome (APLS) is a rare syndrome mainly characterized by several hyper-coagulable complications and therefore, implicated in the operated cardiac surgery patient. APLS comprises clinical features such as arterial or venous thromboses, valve disease, coronary artery disease, intracardiac thrombus formation, pulmonary hypertension and dilated cardiomyopathy. The most commonly affected valve is the mitral, followed by the aortic and tricuspid valve. For APLS diagnosis essential is the detection of so-called antiphospholipid antibodies (aPL) as anticardiolipin antibodies (aCL) or lupus anticoagulant (LA). Minor alterations in the anticoagulation, infection, and surgical stress may trigger widespread thrombosis. The incidence of thrombosis is highest during the following perioperative periods: preoperatively during the withdrawal of warfarin, postoperatively during the period of hypercoagulability despite warfarin or heparin therapy, or postoperatively before adequate anticoagulation achievement. Cardiac valvular pathology includes irregular thickening of the valve leaflets due to deposition of immune complexes that may lead to vegetations and valve dysfunction; a significant risk factor for stroke. Patients with APLS are at increased risk for thrombosis and adequate anticoagulation is of vital importance during cardiopulmonary bypass (CPB). A successful outcome requires multidisciplinary management in order to prevent thrombotic or bleeding complications and to manage perioperative anticoagulation. More work and reporting on anticoagulation management and adjuvant therapy in patients with APLS during extracorporeal circulation are necessary. [ABSTRACT FROM AUTHOR]

Preoperative medication by inhibitors of angiotensin-converting enzyme (ACE) in coronary artery patients predisposes to vasoplegic shock early after coronary artery bypass grafting. Although in the majority of the cases this shock is mild, in some of them it appears as a situation, "intractable" to high-catecholamine dose medication. In this study we examined the possible role of prophylactic infusion of low-dose vasopressin, during and for the four hours post-bypass after cardiopulmonary bypass, in an effort to prevent this syndrome. In addition, we studied the influence of infused vasopressin on the hemodynamics of the patients, as well as on the postoperative urine-output and blood-loss. In our study 50 patients undergoing coronary artery bypass grafting were included in a blindrandomized basis. Two main criteria were used for the eligibility of patients for coronary artery bypass grafting: ejection fraction between 30-40%, and patients receiving ACE inhibitors, at least for four weeks preoperatively. The patients were randomly divided in two groups, the group A who were infused with 0.03 IU/min vasopressin and the group B who were infused with normal saline intraoperativelly and for the 4 postoperative hours. Measurements of mean artery pressure (MAP), central venous pressure (CVP), systemic vascular resistance (SVR), ejection fracture (EF), heart rate (HR), mean pulmonary artery pressure (MPAP), cardiac index (CI) and pulmonary vascular resistance (PVR) were performed before, during, and after the operation. The requirements of catecholamine support, the urine-output, the blood-loss, and the requirements in blood, plasma and platelets for the first 24 hours were included in the data collected. The incidence of vasodilatory shock was significantly lower (8% vs 20%) in group A and B respectively (p = 0,042). Generally, the mortality was 12%, exclusively deriving from group B. Postoperatively, significant higher values of MAP, CVP, SVR and EF were recorded in the patients of group A, compared to those of group B. In group A norepinephrine was necessary in fewer patients (p = 0.002) and with a lower mean dose (p = 0.0001), additive infusion of epinephrine was needed in fewer patients (p = 0.001), while both were infused for a significant shorter infusion-period (p = 0.0001). Vasopressin administration (for group A) was associated with a higher 24 hour diuresis) (0.0001). In conclusion, low-dose of infused vasopressin during cardiopulmonary bypass and for the next 4 hours is beneficial for its postoperative hemodynamic profile, reduces the doses of requirements of catecholamines and contributes to prevention of the postcardiotomy vasoplegic shock in the patient with low ejection fraction who is receiving ACE preoperatively. [ABSTRACT FROM AUTHOR]

Background: Although mediastinal tumors compressing or invading the superior vena cava represent the major causes of the superior vena cava syndrome, benign processes may also be involved in the pathogenesis of this medical emergency. One of the rarest benign causes is a pseudoaneurysm developing in patients previously having heart surgery. Case report: We present the case of a large pseudoaneurysm of the ascending aorta, five years after primary surgery, with a significant compression of the right mediastinal venous system causing superior vena cava syndrome, detected at chest CT angiography. Perioperative findings showed two rush out points both coming from the distal aortic suture line which was performed five years ago. The patient underwent reoperation under circulatory arrest facilitating safe exploration and repair of the distal anastomotic leaks Conclusion: Enhanced chest CT should be always undertaken in all patients with superior vena cava syndrome, especially in those previously having cardiac or aortic surgery to correctly evaluate the presence of a pseudoaneurysm. Mass effect to the superior vena cava makes necessary an open surgical treatment of the pseudoaneurysm so as to concurrently resolve the right mediastinal venous system's compression. Surgery should be performed in terms of safe approach to avoid exsanguination and cerebral malperfusion. [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]

“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. [Copyright &y& Elsevier]

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. [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]

A response from the authors of the article "Right-sided infective endocarditis: surgical management" in the 2012 issue is presented.

The article describes the clinical case illustrating the possible consequence if thoracocentesis will be conducted based on X-ray without the computed tomography (CT) of the chest. The case concerns an 85-year-old female who complained of dyspnea. Her chest X-ray showed pleural effusion on the right side, suggestive of a thoracocentesis and chest tube placement.

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]

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]

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]

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]

Background The adverse effects of myocardial ischemia and reperfusion during cardiopulmonary bypass (CPB) have been thoroughly described. Lazaroid U-74389G, a 21 aminosteroid, has been shown to attenuate ischemia and reperfusion injury and improve recovery in a variety of experimental models. Methods Sixteen male swine were randomly divided in two groups. All animals underwent 45 min of ischemic cardioplegic arrest, with U-74389G addition to the standard cardioplegic solution, whereas controls underwent the same procedure without U-74389G. Creatine kinase-MB isoenzyme (CK-MB) and cardiac troponin T levels were measured immediately before CPB (time point 0), during the ischemic period (time point 1) and 30 (time point 2), 60 (time point 3), and 120 (time point 4) min after reperfusion. Myocardial biopsies were obtained at time points 0 and 4. Results CK-MB levels (in U/L) at time points 0-4 were 205 (186-235) versus 219 (196-269; P = 0.72), 215 (167-248) versus 253 (193-339; P = 0.23), 234 (198-255) versus 338 (249-441; P = 0.02), 244 (217-272) versus 354 (269-496; P = 0.01), and 285 (230-321) versus 439 (432-530; P < 0.01) in lazaroid-treated animals versus controls, respectively. Cardiac troponin T levels (in ng/L) at time points 0-4 were 58 (26-287) versus 237 (26-395; P = 0.72), 129 (61-405) versus 265 (145-525; P = 0.23), 261 (123-467) versus 474 (427-1604; P = 0.04), 417 (204-750) versus 841 (584-1818; P = 0.11), and 643 (353-1259) versus 1600 (1378-2313; P < 0.01), respectively. Necrosis grades at time point 4 were 0.0 (0.0-1.0) versus 1.5 (1.0-2.0; P < 0.01) in lazaroid-treated animals versus controls, respectively. Conclusions The present study, in addition to reconfirming the well-described adverse effects of CPB, demonstrates the efficacy of the newer generation lazaroid U-74389G in alleviating these effects. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Adipose tissue is considered an endocrine organ, producing bioactive peptides, called adipokines. Adipokines produced by periadventitial fat have been implicated in the pathogenesis of vascular disease, including atherosclerosis. Adiponectin has established antiatherogenic actions, while the role of T-cadherin as an adiponectin receptor is not fully elucidated. The apelinergic system, consisting of apelin and its APJ receptor, is a mediator of various cardiovascular functions and may also be involved in the atherosclerotic process. We investigated the protein expression of adiponectin, T-cadherin, apelin and APJ in human aortas, coronary vessels, and the respective periadventitial adipose tissue and correlated their expression with the presence of atherosclerosis and clinical parameters. Methods: Immunohistochemistry for adiponectin, T-cadherin, apelin, and APJ was performed on human aortic and coronary artery samples including the periadventitial adipose tissue. Aortic and coronary atherosclerotic lesions were assessed using the american heart association (AHA) classification. Results: Adiponectin immunostaining, of varied intensity, was detected only in adipocytes, while T-cadherin was localized to vascular smooth muscle cells (VSMCs) and endothelial cells. Apelin immunostaining was detected in adipocytes, VSMCs, endothelial cells, and foam cells in atherosclerotic lesions, while APJ was found in VSMCs and endothelia. Periadventitial adiponectin and VSMC T-cadherin expression were negatively correlated with atherosclerosis in both sites, as was VSMC apelin expression. Several other — depot specific — associations were observed. Conclusions: Our results suggest a possible role for T-cadherin as a mediator of antiatherogenic adiponectin actions, while they support the putative antiatherogenic profile for apelin and its APJ receptor in human arteries. Further research is absolutely necessary to confirm these notions. Summary: Periadventitial adipose tissue adipokines are implicated in vascular physiology and pathology. Adiponectin/T-cadherin and apelin/APJ immunoreactivity is detected in human aortas and coronary arteries. Adiponectin/T-cadherin and apelin/APJ expression patterns were found to be inversely associated with human aortic and coronary atherosclerosis. [Copyright &y& Elsevier]

Abstract: Background: Airway trauma is a life threatening condition requiring prompt diagnosis and management. We present our experience focusing on the diagnosis, airway management and treatment. Material and methods: This is a retrospective analysis of 25 patients treated for tracheal or bronchial injury within a 12 year period. Data collected included: mechanism and sites of injury, associated injuries, clinical presentation, indications for surgical management, treatment and outcome. Results: There were 15 traumatic injuries (blunt/penetrating, 10/5 patients) and 10 post-intubation perforations. The most common findings included subcutaneous emphysema, pneumomediastinum and pneumothorax. Endotracheal intubation was carried out under bronchoscopic guidance. Tracheostomy was performed in one patient. Most injuries were located at the trachea/carina. Surgical treatment was undertaken in 22 patients. In 13 of them, all with traumatic injuries, the surgical treatment was decided on the basis of the clinical and radiological findings. The decision for surgery in post-intubation injuries was based on the proximity of the injuries to the carina (2 patients), the suspicion of an unsafe airway (1 patient) and the present of posterior tracheal wall perforations>2cm (2 patients). The surgical approach for the repair was dictated by the location of the injury. There was a single case of perioperative mortality in the subgroup of patients with traumatic injuries. Conclusions: Surgical primary repair represents the treatment of choice in airway injuries with the approach depending on the specific site of the lesion. Therefore we consider valuable the division of the tracheobronchial tree in 4 zones. [Copyright &y& Elsevier]