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Objectives: Conventional treatment for type A aortic dissection includes replacement of the ascending aorta with an open distal anastomosis in the hemiarch position. The frozen elephant trunk (FET) is a hybrid technique that extends the repair to the descending thoracic aorta. The goal is to improve resolution of malperfusion syndrome and to induce positive aortic remodelling and reduce the need for reintervention on the downstream aorta. We aim to summarize the data on the short and long-term outcomes of this technique., Methods: A thorough search of the literature was conducted isolating all articles dealing with aortic remodelling after the use of FET in case of type A acute aortic dissection. Keywords 'aortic dissection', 'frozen elephant trunk', 'aortic remodelling' and 'false lumen thrombosis' were used. Data for type B and chronic aortic dissections were excluded., Results: FET use favourably influences aortic remodelling. The main advantages lie in the exclusion of distal entry tears in either the aortic arch or descending aorta thus restoring antegrade blood flow in the true lumen and inducing false lumen thrombosis. False lumen thrombosis is not only induced at the level of the stent deployment but also lower in the distal descending aorta. Moreover, it offers an adequate landing zone in the mid-descending aorta for second-stage endovascular or open surgical aortic repair, if needed., Conclusions: FET can be advantageous in the treatment of acute type A aortic dissection dealing with extended aortic pathology., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Coronary artery anomalies are a diverse group of congenital disorders presenting with highly variable clinical manifestations. The anomalous origin of left circumflex artery from the right coronary sinus following a retro-aortic trajectory is a well-recognized anatomic variation. Despite its benign course, it can prove lethal in association with valvular surgery. When single aortic valve replacement or combined with mitral valve replacement is performed, the aberrant coronary vessel may be compressed by or between the prosthetic rings triggering postoperative lateral myocardial ischemia. If left untreated, the patient is at risk of sudden death or myocardial infarction with its detrimental complications. Skeletonization and mobilization of the aberrant coronary artery is the most widely accepted intervention, but valve downsizing or concomitant surgical or transcatheter revascularization have also been described. However, large series are lacking from the literature. Therefore, no guidelines exist. This study is a thorough review of the literature concerning the aforementioned anomaly in association with valvular surgery., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The aim of this study was to compare mean maximum ascending aortic diameter at the time of acute aortic dissection with the current surgical threshold for elective ascending aortic operations on non-syndromic thoracic aortic aneurysms., Material and Methods: All consecutive non-syndromic adult patients admitted for acute type A aortic dissection in a single tertiary centre were prospectively enrolled from April 2020 to March 2021. The primary endpoint was the difference between mean maximum aortic diameter at the time of dissection and the 5.5 cm threshold for elective repair. Secondary endpoints included 30-day/in-hospital mortality, aortic length and comparison with normal controls, length/height ratio index, "actual" preoperative Euroscore II and "predicted" Euroscore II if electively operated., Results: Among 31 patients ageing 67.3±12.03 years on average, mean maximum aortic diameter at the time of dissection was 5.13±0.66 cm, significantly lower than the guidelines-derived surgical threshold of 5.5 cm (p=0.004). Mean aortic length was 11±1.47 cm, also significantly longer compared normal controls reported in the literature (p<0.001). The 30-day/in-hospital mortality was 35.5%. Mean length/height ratio index was 6.18±0.76 cm/m. Finally, mean "actual" preoperative Euroscore II was 10.43±4.07 which was significantly higher than the 1.47±0.57 "predicted" Euroscore II (p<0.05)., Conclusions: The maximum aortic diameter at the time of acute type A aortic dissection of non-syndromic cases was significantly lower than the current recommendation for elective repair. Lowering of the current diameter-based surgical threshold of 5.5 cm may be profitable in terms of prevention, but further investigations should be undertaken. Length-based thresholds could also add to timely aortic dissection prevention., (Copyright © 2022 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

The impairment of intracellular calcium homeostasis plays an essential role during ischemia-reperfusion injury. Calcium release from sarcoplasmic reticulum which is triggered by myocardial ischemia is mainly mediated by ryanodine receptors. Dantrolene sodium is a ryanodine receptor antagonist. The objective of the present study was to evaluate the in-vivo impact of dantrolene sodium on myocardial ischemia-reperfusion injury in swine models. An in vivo, experimental trial comparing 10 experimental animals which received dantrolene sodium with 9 control swine models was conducted. Their left anterior descending coronary artery was temporarily occluded for 75 minutes via a vessel tourniquet, which was then released. Myocardial reperfusion was allowed for 24 hours. Dantrolene was administered at the onset of the reperfusion period and levels of troponin, creatine phosphokinase and creatine kinase myocardial band between the two groups were compared. Additionally, various other hemodynamic parameters and left ventricular morphology and function were examined. There were significantly lower values of troponin, creatine phosphokinase and creatine kinase myocardial band in the dantrolene group indicating less ischemia-reperfusion injury. Moreover, the postischemic cardiac index was also greater in the dantrolene group, whereas viable myocardium was also better preserved. In conclusion, the in vivo cardioprotective role of dantrolene sodium against ischemia-reperfusion injury in swine models was indicated in this study. Therefore, dantrolene sodium administration could be a promising treatment against ischemia-reperfusion injury in humans. However, large randomized clinical studies should be firstly carried out to prove this hypothesis., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Venous thromboembolism clinically presents as deep venous thrombosis or acute pulmonary embolism and is globally recognized as the third most frequent acute cardiovascular syndrome after myocardial infarction and stroke. Although pulmonary embolism does not typically cause severe pulmonary hypertension in the acute setting, thrombus organization and fibrosis can lead to stenosis or obliteration of pulmonary arteries in a minority of patients, which in turn result in severe pulmonary hypertension and right heart failure. This disease is labeled chronic thromboembolic pulmonary hypertension and can occur after a single episode or multiple ones of pulmonary embolism. The cornerstone of pulmonary embolism treatment is medical therapy, whereas systemic thrombolytic therapy has to be considered for patients with hemodynamic instability. Given the current acceptable short-term surgical mortality, the potential of first-line surgical embolectomy as an alternative to medical thrombolysis has gained momentum as far as pulmonary embolism treatment is concerned. In contrast to pulmonary embolism, bilateral complete pulmonary endarterectomy under short deep hypothermic circulatory arrest intervals is the treatment of choice against chronic thromboembolic pulmonary hypertension, given patients' operability. Pulmonary endarterectomy is suggested in every operable patient when the operation is offered by an experienced multidisciplinary team, including at least one experienced surgeon. Surgical embolectomy should also be limited to large institutions since it also requires an experienced heart team. This review concerns a thorough discussion regarding surgical treatment of pulmonary embolism and chronic thromboembolic pulmonary hypertension. Eligibility criteria, operation-related complications and postoperative outcomes are discussed in detail., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Aortic valve replacement is the treatment of choice concerning aortic valve disease. Excellent short- and long-term clinical results are reported. Patients referred for aortic valve replacement are getting older and older, so bioprosthetic valves play a more central role worldwide. However, patient comorbidities are also increased more often rendering patients unsuitable for open conventional aortic valve replacement. As a result, transcatheter aortic valve implantation has become the treatment of choice in patients at very high surgical risk. However, the percutaneous technique is related to major disadvantages provided that the diseased native valve is left in place. Its durability is also uncertain. More recently, sutureless Perceval S valve bioprosthesis has gained ground in the field of aortic stenosis therapy filling the gap between conventional aortic valve replacement and transcatheter approach. Excellent hemodynamic and clinical results are reported. Its deployment is performed under direct view and ischemic and overall operative times are significantly decreased. Five-year follow-up results are also optimal. However, the "Achilles' heel" of sutureless technology is increased rates of postoperative permanent pacemaker implantation requirement compared to conventional approach. The incidence of this complication varies in literature. Patient-related factors such as preoperative conduction disorders, older age and short membranous septum are predictors of postoperative pacemaker requirement. However, several technical modifications regarding manufacturer recommendations can be adopted to mitigate this complication. Appropriate annular decalcification, higher guiding sutures placement, reduced balloon pressure and duration and avoiding of oversizing can contribute to prevent from this complication.

Background and Aim of the Study: HAART 300 is an internal geometric annuloplasty ring. The safety and efficacy of this novel device in aortic valve (AV) repair in a single referral center are reported., Methods: Twenty patients with trileaflet AV insufficiency with ascending aorta and/or aortic root enlargement were included. Subannular implantation was performed to correct annular dilatation, whereas concomitant leaflet repair was performed whenever required. All but two patients also received ascending aorta replacement, whereas selective sinus replacement was performed in all but five patients., Results: Follow-up was for a maximum of 3.8 years and a mean of 2.2 years. Mean age was 54.2 years old. Moderate to severe preoperative AV insufficiency was noted in 75% of patients, whereas 70% of them had an ascending aorta over 45 mm. One patient was lost from follow-up. Overall mortality as well as major complication rates were zero. Early postoperatively, no more than mild AV regurgitation was detected, whereas only one patient appeared with moderate AV regurgitation during our 2.2-year follow-up. New York Heart Association class was also significantly lower compared to preoperative values and valve gradients remained low at last follow-up., Conclusions: Geometric ring annuloplasty is a safe and effective valve sparing approach to deal with AV insufficiency contributing to overall root reconstruction. Short-term results are excellent rendering this easily reproducible and versatile method very attractive., (© 2021 Wiley Periodicals LLC.)

Discrete subaortic stenosis (DSS) is a type of left ventricular outflow tract obstruction whereas double-chambered right ventricle is a form of right ventricular outflow tract obstruction. Both of these cardiac malformations share lots of similar characteristics which classify them as acquired developmental heart diseases despite their congenital anatomical substrate. Both of them are frequently associated to ventricular septal defects. The initial stimulus in their pathogenetic process is anatomical abnormalities or variations. Subsequently, a hemodynamic process is triggered finally leading to an abnormal subaortic fibroproliferative process with regard to DSS or to hypertrophy of ectopic muscles as far as double-chambered right ventricle is concerned. In many cases, these pathologies are developed secondarily to surgical management of other congenital or acquired heart defects. Moreover, high recurrence rates after initial successful surgical therapy, particularly regarding DSS, have been described. Finally, an interesting coexistence of DSS and double-chambered aortic ventricle has also been reported in some cases., (© 2021 Wiley Periodicals LLC.)

Objectives: As thoracic aortic aneurysm disease continues to cause significant morbidity and mortality in the general population, the cardiovascular community continues the search for the golden threshold of elective surgical replacement of the ascending aorta., Methods: Thoracic aortic aneurysm is a common disease, classified within the 20 most common causes of death in patients over 65 years old. Once aortic complications like dissection or rupture occur, they can prove fatal. Prophylactic surgical replacement of the ascending aorta remains the mainstay of treatment to prevent these complications. Current American and European guidelines agree that the threshold for the diameter for elective replacement of the ascending aorta in non-syndromic, asymptomatic aneurysmal disease is 5.5 cm. Overall, aortic dissection is related to poor prognosis, thus making early intervention paramount., Results: There is a critical size above which the risk of dissection or rupture becomes extremely high. However, a significant post-dissection increase in diameter is reported, thus rendering the predissection aortic diameter well below the current threshold for elective surgical replacement of the ascending aorta. Moreover, it is widely reported that the majority of acute aortic dissections would not meet the criteria for prophylactic surgery prior to dissection. Additionally, elective surgical ascending aortic replacement in the current era shows a significantly improved risk-benefit ratio, which justifies a more aggressive approach in the management of aortic aneurysmal disease., Conclusions: As a result, there is a lot of discussion in the literature about the requirement of a leftward shifting of the surgical threshold for elective aortic replacement., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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., (© 2020 Wiley Periodicals, Inc.)

Long-term survival of patients submitted to a Fontan procedure is reduced because of arrhythmias. Late post-Fontan ventricular tachycardia is extremely rare, but it can be fatal. Consequently, the implantation of an implantable cardioverter defibrillator may be required. The implantation of such a device after a Fontan operation can be rather difficult due to anatomic reasons that exclude transvenous approach. Epicardial ICD implantation is a treatment option for these patients. Transatrial approach, shock ICD coils placement in azygos vein or directly in the pericardium are possible alternatives. We hereby present a successful epicardial implantable cardioverter defibrillator implantation in a post-Fontan 39-year-old man suffering from ventricular tachycardia., Competing Interests: None

Objective: Native and aortic graft infections are rare, but they represent one of the most life threatening complications of vascular surgery. Several materials and surgical approaches have been developed so far. Among them, cryopreserved allografts have been proposed as a treatment option. A systematic review and meta-analysis was conducted to investigate the role of cryopreserved allografts for arterial reconstruction after aorto-iliac infection., Methods: The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Patient baseline characteristics were investigated, along with 30 outcomes after use of cryopreserved arterial allografts for reconstruction after aorto-iliac infection. Pooled proportions with 95% CIs of outcome rates were calculated., Results: A total of 31 studies, including 1,377 patients, finally participated in the meta-analysis. Among the early outcomes, 30 day mortality was 14.91% (95% CI 11.78-18.31). Peri-anastomotic rupture/allograft disruption rate was 5.90% (95% CI 2.77-9.88), while pooled aneurysmal degeneration/allograft dilatation was 4.99% (95% CI 1.60-9.68). A pooled rate of 3.11% (95% CI 1.60-4.98) was estimated for pseudoaneurysm formation after the use of cryopreserved arterial allografts, while the allograft thrombotic/stenotic complication rate and peri-anastomotic infection were 12.19% (95% CI 7.90-17.15) and 3.32% (95% CI 1.90-5.03), respectively. Mortality during follow up was 19.24% (95% CI 11.97-27.58), while allograft related mortality during follow up was 3.58% (95% CI 1.56-6.15). A pooled allograft related re-operation rate was estimated at 24.87% (95% CI 17.89-32.51)., Conclusions: The use of cryopreserved allograft seems to be a safe and durable option with acceptable outcomes for treatment of aorto-iliac infection., (Copyright © 2019 European Society for Vascular Surgery. All rights reserved.)

Background: Conventional open total arch replacement is the treatment of choice for surgical aortic arch pathologies. However, it is a two-stage procedure related to high cumulative and interval mortality rates. Hybrid type III aortic arch reconstruction, the so-called "frozen elephant trunk" is a one-stage alternative approach., Methods: A meta-analysis and detailed review of the literature published from January 2013 until December 2016, concerning frozen elephant trunk hybrid approach was conducted and data for morbidity and mortality rates were extracted., Results: Among 989 patients included, the pooled 30-day or in-hospital mortality rate was 5.04% (95%CI=1.13-10.74), stroke rate was 2.38% (95%CI=0.13-6.30), and the irreversible paraplegia due to spinal cord injury rate was 0.63% (95%CI=0.00-2.73). Finally, the pooled cumulative survival at 1year was remarkably high (86.7%, 95%CI=81.08-92.90)., Conclusions: Frozen elephant trunk is a safe alternative to conventional elephant trunk repair for extensive aortic arch pathologies with acceptable short- and mid-term results, avoiding the interval mortality hazard., (Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

There are few cases in the literature reporting dysphagia caused by oesophageal compression by the aorta due to acute or chronic aortic pathology. This type of dysphagia is called dysphagia aortica. Thoracic endovascular aortic repair is nowadays the treatment of choice for anatomically suitable patients experiencing complicated Type B aortic dissection. Oesophageal necrosis is a rare but fatal complication following thoracic endovascular aortic repair. Extrinsic oesophageal compression by the thrombosed aneurysmal sac, a mediastinal haematoma or extensive thrombosis in the false lumen of a dissected aorta and acute vascular occlusion of the oesophageal supply are possible mechanisms. When oesophageal necrosis is suspected, endoscopic examination and computed tomography imaging should be performed repeatedly. Oesophagoscopy will confirm the diagnosis revealing a black, diffusely necrotic and ulcerated oesophageal mucosa. It is critical to intervene before full-thickness oesophageal wall necrosis and mediastinitis occur. Guidelines are absent because of the rarity of this complication. Moreover, lack of a large series does not permit the establishment of guidelines either. However, oesophagectomy of the impaired oesophagus is the only chance for survival. Unfortunately, survival rates are disappointing. Prevention and awareness is the cornerstone of success. Early endoscopic examination when oesophageal necrosis is suspected due to even minimal symptoms will detect this fatal menace on time.

Introduction: Conventional open total arch replacement is the treatment of choice for surgical aortic arch pathologies. However, it is an invasive procedure, requiring cardiopulmonary bypass and deep hypothermic circulatory arrest leading to significant morbidity and mortality rates. Hybrid aortic arch debranching procedures without (type I) or with (type II) ascending aorta replacement seek to limit operative, bypass, and circulatory arrest times by making the arch repair procedure simpler and shorter., Material and Methods: A meta-analysis and detailed review of the literature published from January 2013 until December 2016, concerning hybrid aortic arch debranching procedures was conducted and data for morbidity and mortality rates were extracted., Results: As far as type I hybrid aortic arch reconstruction is concerned, among the 122 patients included, the pooled endoleak rate was 10.78% (95%CI=1.94-23.40), 30-day or in-hospital mortality was 3.89% (95%CI=0.324-9.78), stroke rate was 3.79% (95%CI=0.25-9.77) and weighted permanent paraplegia rate was 2.4%. In terms of type II hybrid approach, among 40 patients, endoleak rate was 12.5%, 30-day or in-hospital mortality rate was 5.3%, stroke rate was 2.5%, no permanent paraplegia was noticed and late mortality rate was 12.5%., Conclusions: Hybrid aortic arch debranching procedures are a safe alternative to open repair with acceptable short- and mid-term results. They extend the envelope of intervention in aortic arch pathologies, particularly in high-risk patients who are suboptimal candidates for open surgery., (Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

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.

Objective: Conventional open surgery encompassing cardiopulmonary bypass has been traditionally used for the treatment of ascending aorta diseases. However, more than one in five of these patients will be finally considered unfit for open repair. We conducted a systematic review and meta-analysis to investigate the role of thoracic endovascular aortic repair (TEVAR) for aortic diseases limited to the ascending aorta., Methods: The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We investigated patients' baseline characteristics along with early (30 days/in-hospital stay) and late (beyond 30 days/in-hospital stay) outcomes after TEVAR limited to the ascending aorta and not involving the arch vessels. Separate analyses for case reports and case series were conducted, and pooled proportions with 95% confidence intervals (CIs) of outcome rates were calculated., Results: Approximately 67% of the patients had a prior cardiac operation. TEVAR was performed mainly for acute or chronic Stanford type A dissection (49%) or pseudoaneurysm (28%). The device was usually delivered through the femoral artery (67%), and rapid ventricular pacing was used in nearly half of the patients. Technical success of the method was 95.5% (95% CI, 87.8-99.8). Among the early outcomes, conversion to open repair was 0.7% (95% CI, 0.1-4.8), whereas mortality was 2.9% (95% CI, 0.02-8.6). We estimated a pooled rate of 1.8% (95% CI, 0.1-7.0) for neurologic events (stroke or transient ischemic attack) and 0.8% (95% CI, 0.1-5.6) for myocardial infarction. Late endoleak was recorded in 16.4% (95% CI, 8.2-26.0), and 4.4% (95% CI, 0.1-12.4) of the population died in the postoperative period. Finally, reoperation was recorded in 8.9% (95% CI, 3.1-16.4) of the study sample., Conclusions: TEVAR in the ascending aorta seems to be safe and feasible for selected patients with various aortic diseases, although larger studies are required., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Extracorporeal circulation has led to a great development in cardiovascular surgery during the last five decades. Its time-proven efficacy and safety have made on-pump coronary artery bypass grafting (CABG) the gold standard method of surgical revascularization. However, coronary revascularization on cardiopulmonary bypass and the accompanying aortic manipulation are related to plenty of deleterious complications. Therefore, off-pump CABG surgery was established to avoid complications. Nevertheless, despite the initial enthusiasm on this technique, only 20% of myocardial revascularization procedures worldwide are performed off-pump. Not only are off-pump cardiac procedures more technically difficult but also they do not provide better results in terms of graft patency, completeness of revascularization, repeat revascularization requirement, cost, and quality of life. Completeness of revascularization and anastomotic quality should not be compromised to avoid cardiopulmonary bypass.

Background: The aim of this study was to evaluate the safety and efficacy of medical thoracoscopy through a single port [single-port medical thoracoscopy (S-MT)] for the treatment of empyema thoracis in its early stages., Methods: We performed a retrospective analysis reviewing the medical records of 84 patients referred for empyema and treated by medical thoracoscopy at our Thoracic Departments from January 2001 until November 2014. S-MT was performed under local anesthesia with neuroleptoanalgesia and spontaneous breathing using a single 1-cm incision for debridement and lavage of the pleural cavity., Results: A total of 84 patients underwent S-MT for pleural empyema stage I (9 patients, 10.7%) or II (75 patients, 89.3%). Median age was 61.8 years (range, 18 to 84 y). Male to female ratio was 3.76. Surgery was performed 5 to 26 days after the onset of symptoms. Macroscopically complete debridement of the pleural cavity was achieved in 71 patients (84.5% of cases). The rest 15.5% of cases required video-assisted thoracoscopic surgery or open decortication due to trapped-lung syndrome. Median operation time was 45 minutes (range, 30 to 94 min). No intraoperative complications occurred. In-hospital mortality was zero, whereas in-hospital morbidity rate was 16.7%. Median hospital stay was 7.8 days (range, 3 to 18 days). Recurrence rate was 4.8% as 4 patients experienced a relapse of empyema., Conclusion: It seems that S-MT is a minimally invasive, safe and effective procedure for the treatment of pleural empyema with very good results in early stages of the disease and reduced time of hospital stay.

A hybrid strategy, firstly performed in the 1990s, is a combination of tools available only in the catheterization laboratory with those available only in the operating room in order to minimize surgical morbidity and face with any cardiovascular lesion. The continuous evolution of stent technology along with the adoption of minimally invasive surgical approaches, make hybrid approaches an attractive alternative to standard surgical or transcatheter techniques for any given set of cardiovascular lesions. Examples include hybrid coronary revascularization, when an open surgical anastomosis of the left internal mammary artery to the left anterior descending coronary artery is performed along with stent implantation in non-left anterior descending coronary vessels, open heart valve surgery combined with percutaneous coronary interventions to coronary lesions, hybrid aortic arch debranching combined with endovascular grafting for thoracic aortic aneurysms, hybrid endocardial and epicardial atrial fibrillation procedures, and carotid artery stenting along with coronary artery bypass grafting. The cornerstone of success for all of these methods is the productive collaboration between cardiac surgeons and interventional cardiologists. The indications and patient selection of these procedures are still to be defined. However, high-risk patients have already been shown to benefit from hybrid approaches., (Copyright © 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Coronary artery bypass grafting surgery effectively relieves signs and symptoms of myocardial ischemia. The left internal thoracic artery (LITA) graft is the gold standard having 90-95% patency rate at 10 years, whereas only 50% of saphenous vein (SV) grafts are patent at 10 years. However, there is a novel "no touch" technique in order to harvest an SV complete with its cushion of surrounding tissue, thus maintaining its endothelium-intact. Significantly superior short- and long-term graft patency rates comparable to LITA grafts can be achieved. Consequently, the SV may be revived as an important conduit in coronary artery bypass surgery.

For over 40 years, the left internal thoracic artery has been used as the gold standard for myocardial revascularization and anastomosis over the left anterior descending artery due to its excellent patency rates. However, the right internal thoracic artery behaves in the same manner as the left, also having excellent long-term patency. Hence, no patient should be deprived of the benefits of total arterial revascularization allowed by the bilateral use of both internal thoracic arteries., (Copyright © 2016 Hellenic Cardiological Society. Published by Elsevier B.V. All rights reserved.)

Cold heart protection via cardioplegia administration, limits the amount of oxygen demand. Systemic normothermia with warm cardioplegia was introduced due to the abundance of detrimental effects of hypothermia. A temperature of 32-33°C in combination with tepid blood cardioplegia of the same temperature appears to be protective enough for both; heart and brain. Reduction of nitric oxide (NO) concentration is in part responsible for myocardial injury after the cardioplegic cardiac arrest. Restoration of NO balance with exogenous NO supplementation has been shown useful to prevent inflammation and apoptosis. In this article, we discuss the "deleterious" effects of the oxidative stress of the extracorporeal circulation and the up-to-date theories of "ideal'' myocardial protection.

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.)

Radial artery (RA) is the most popular arterial graft after the left internal thoracic artery in both low- and high-risk patients undergoing coronary artery bypass grafting. Various arterial grafts such as the right internal thoracic artery, the right gastroepiploic artery, and the inferior epigastric artery have also gained ground over the past 30 years because of the intimal hyperplasia and atherosclerosis of the saphenous vein leading to late graft occlusion. In this review article we would like to present the utility of the RA as a graft, focused mainly on its structural and biological characteristics., (Copyright © 2013 Japanese College of Cardiology. Published by Elsevier Ltd. 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.)

Hepatic hydrothorax is a complication of liver cirrhosis. Several invasive therapeutic approaches have been performed such as thoracentesis, video-assisted thoracic surgery and repair of the diaphragmatic defects with debatable results. Medical thoracoscopy is a minimally invasive and effective technique with challenging applications that has not been thoroughly used in the treatment of hepatic hydrothorax. We hereby present the case of a hepatic hydrothorax complicated by thoracic empyema in a 38-year-old patient with alcoholic cirrhosis that was treated with medical thoracoscopy and talc pleurodesis., (© JSCR.)

Short periods of ischaemia consecutive to reperfusion periods before a sustained ischaemic condition, the so-called ischaemic preconditioning (IP), aim to protect myocardial cells against prolonged ischaemia. IP appears as a considerable endogenous cardioprotective mechanism decreasing the infarct size after total occlusion in either experimental models or humans. Angina periods before an acute coronary syndrome limit the myocardial infarction being protective for the myocardium. Our report aims to review the international bibliography of the IP during off-pump coronary artery bypass grafting.

Vasa vasorum (VV) are microscopic vases that perfuse the vessel's wall; arteries and veins. Many recent researches support the opinion that VV have a significant role in aortic pathology. The VV, or 'the vessels of the vessels', form a network of microvessels that lie in the adventitia and penetrate the outer media of the host vessel wall. Although the importance of the VV in providing nutritional support is not well known, obstruction of blood flow through these vessels has been implicated in the pathogenesis of many cardiovascular diseases such as aortic intramural hematoma, aortic aneurysm, and acute or chronic aortic dissection. Although the proliferation of VV due to atherogenic stimuli is controversial, experimental and clinical studies strongly suggest the potential of VV in vascular proliferative disorders. It seems that the rupture of VV is implicated in intramural hematoma, which can develop in acute aortic dissection. In this review article, we would like to stress the anatomy and mainly the pathophysiology, and the implication of VV in the acute and chronic aortic pathologies., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

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.)