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Significant unprotected left main (ULM) disease is the highest-risk coronary artery lesion, carries high morbidity and mortality related to a large amount of myocardium supplied, and should undergo prompt revascularization. Among recent randomized controlled trials (RCTs), NOBLE failed to demonstrate non-inferiority of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). However, all the other RCTs have shown comparable outcomes. While CABG is associated with higher stroke rates at 30 days and 1 year, PCI is associated with increased spontaneous myocardial infarction (MI) events and the need for repeat revascularization. Furthermore, the benefit of CABG is more evident with the increased complexity of coronary artery disease. In current European and American guidelines, CABG is the standard of care for ULM disease. PCI is considered a reasonable alternative in selected patients (2a B-NR). There is still a great need for carefully designed RCTs with longer follow-up times to validate the role of recent technological and pharmacological regimens.

This comprehensive review aims to delineate the prevailing non-cardiac thoracic injuries occurring in urban environments following initial on-site treatment and subsequent admission to hospital emergency departments. Our study involved a rigorous search within the PubMed database, employing key phrases and their combinations, including "thoracic injury," "thoracic trauma," "haemothorax," "lung contusion," "traumatic pneumothorax," "rib fractures," and "flail chest." We focused on original research articles and reviews. Non-cardiac thoracic injuries exhibit a high prevalence, often affecting poly-trauma patients, and contributing to up to 35% of polytrauma-related fatalities. Furthermore, severe thoracic injuries can result in a substantial 5% mortality rate. This review provides insights into clinical entities such as lung contusion, traumatic haemothorax, pneumothorax, rib fractures, and sternal fractures. Thoracic injuries represent a frequent and significant clinical concern for emergency department physicians and thoracic surgeons, warranting thorough understanding and timely intervention.

The perioperative management of patients undergoing mediastinal mass operations presents a persistent challenge across multiple clinical specialties. General anesthesia administration further increases the risk of perioperative cardiorespiratory decompensation. The interdisciplinary team plays a crucial role in ensuring a safe perioperative period. However, due to the rarity and variability of mediastinal mass syndromes, specific management protocols are lacking. This review aims to outline the multitude of challenges and pitfalls encountered during perioperative management in patients with the mediastinal mass syndrome. We describe diagnostic evaluation, preoperative optimization, intraoperative considerations, and postoperative care strategies, emphasizing the paramount significance of a multidisciplinary approach and personalized treatment plans. Preoperative multidisciplinary discussions, meticulous anesthetic management, and well-established protocols for emergency situations are pivotal to ensuring patient safety. Healthcare providers involved in the care of patients with mediastinal mass syndrome must grasp these challenges and pitfalls, enabling them to deliver safe and effective perioperative management.

Mediastinal tumors encompass a diverse range of malignancies, originating within or spreading to the mediastinum. The administration of radiotherapy within the anatomical confines of the mediastinum presents unique challenges owing to the close proximity of critical organs, including the heart, lungs, esophagus, and spinal cord. However, recent progress in imaging techniques, treatment modalities, and our understanding of tumor biology has significantly contributed to the development of effective and safe therapeutic strategies for mediastinal diseases. This review article aims to explore the latest innovations in radiotherapy and their practical applications in the management of mediastinal tumors, with a primary focus on lymphomas, thymomas, and thymic carcinomas. By examining these advancements, we seek to provide valuable insights into the current state of the art in radiotherapy for mediastinal malignancies, ultimately fostering improved patient outcomes and clinical decision-making.

Valve-in-Valve (ViV) procedures for failed surgical bioprostheses are becoming increasingly common. We present a case of a 73-year-old male patient with significant comorbidities who underwent a primary transcatheter aortic valve implantation (TAVI) with an Evolut 29 mm (Medtronic, Minneapolis, MN, USA) valve. This TAVI-prosthesis implantation failed due to the inability to fix the valve at the appropriate height to achieve an optimal hemodynamic result. The valve had to be snared and pulled into an adequate position and was then fixed by an implantation of another TAVI-prosthesis (29 mm Sapien S3, Edwards Lifesciences, Irvine, CA, USA) with optimal final result. The patient was discharged after significant clinical improvement and without further complications.

Low-dose computed tomography is being used for lung cancer screening in high-risk groups. Detecting lung cancer at an early stage improves the chance of optimal treatment and increases overall survival. This article compares segmentectomy vs. lobectomy as surgical options, in the case of stage I non-small cell lung carcinoma, ideally IA. To compare the 2 previously referred strategies, data were collected from articles (40 studies were reviewed), reviews, and systematic analyses in PubMed Central, as well as reviewing recent literature. Segmentectomy could be an equal alternative to lobectomy in early-stage NSCLC (tumour < 2 cm). It could be preferred for patients with a low cardiopulmonary reserve, who struggle to survive a lobectomy. As far as early-stage NSCLC is concerned, anatomic segmentectomy is an acceptable procedure in a selective group of patients. For better tumour and stage classification, a systematic lymph node dissection should be performed.

The mediastinum constitutes an area of special surgical interest due to important anatomical relationships and histopathologic variability of mediastinal primary and metastatic tumours. Mediastinum was considered inaccessible until the end of the 19th century. For many decades the diagnosis of mediastinal disease relied solely upon clinical presentation, and the mainstay of treatment was medical therapy. The advancements in radiology and intraoperative ventilatory support facilitated the improvement of certain diagnostic and therapeutic approaches to mediastinal disease.

Minimally invasive thoracic techniques often need to be converted to open thoracotomy. Thoracotomy is associated with severe postoperative pain in 50% of the patients, and this situation can be maintained for a prolonged period. Many efforts have been made to avoid this complication. We propose an easy and fast thoracotomy closure technique to avoid nerve entrapment at the time of chest closure suitable for cases of conversion to thoracotomy after a minimally invasive attempt. The proposed method effectively avoids interference with the intercostal nerve, which remains intact and restores the anatomy of the intercostal space. Efforts to decrease postoperative pain are vital. Thoracic surgeons are the principal health professionals able to deal with operative factors and postoperative pain management. We believe that the use of this easy and fast technique can facilitate excellent anatomic repositioning of the ribs alongside nerve sparing.

Malignant primary cardiac tumors are rare, with atrial myxoma and rhabdomyosarcoma the common types in adult and pediatric populations respectively. Rhabdomyosarcomas are rare and are usually located in the atria; they present with symptomatology dependent on their location. A 63-year-old woman presented with the symptomatology of dyspnea, cough, and palpitations and was diagnosed with biatrial primary cardiac rhabdomyosarcoma, which required excision. The postoperative course was uneventful and the patient was discharged on the 5th postoperative day. Postoperative cardiac functional tests revealed an ejection fraction of 60%, consistent with the preoperative value, and no mitral valve dysfunction. Biatrial rhabdomyosarcomas are extremely rare, with only 3 cases reported, including ours, reported in the literature, to the best of our knowledge. Transthoracic echocardiogram is useful in the diagnosis. They require surgical excision along with chemotherapy or radiotherapy. Their prognosis is poor, with a median survival of almost one year. Primary biatrial rhabdomyosarcoma is an extremely rare diagnosis that can present with symptomatology based on the location, size, and number of masses. There is no consensus on how to manage them due to the scarcity of cases, but they are managed as single rhabdomyosarcomas. The majority require surgical excision, with subsequent chemotherapy or radiotherapy. The prognosis is very poor, with the majority of the patients not surviving longer than one year.

Background: Postoperative air leak (PAL) is a frequent and potentially serious complication following thoracic surgery, characterized by the persistent escape of air from the lung into the pleural space. It is associated with extended hospitalizations, increased morbidity, and elevated healthcare costs. Understanding the mechanisms, risk factors, and effective management strategies for PAL is crucial in improving surgical outcomes. Aim: This review seeks to synthesize all known data concerning PAL, including its etiology, risk factors, diagnostic approaches, and the range of available treatments from conservative measures to surgical interventions, with a special focus on the use of autologous plasma. Materials and Methods: A comprehensive literature search of databases such as PubMed, Cochrane Library, and Google Scholar was conducted for studies and reviews published on PAL following thoracic surgery. The selection criteria aimed to include articles that provided insights into the incidence, mechanisms, risk assessment, diagnostic methods, and treatment options for PAL. Special attention was given to studies detailing the use of autologous plasma in managing this complication. Results: PAL is influenced by a variety of patient-related, surgical, and perioperative factors. Diagnosis primarily relies on clinical observation and imaging, with severity assessments guiding management decisions. Conservative treatments, including chest tube management and physiotherapy, serve as the initial approach, while persistent leaks may necessitate surgical intervention. Autologous plasma has emerged as a promising treatment, offering a novel mechanism for enhancing pleural healing and reducing air leak duration, although evidence is still evolving. Conclusions: Effective management of PAL requires a multifaceted approach tailored to the individual patient’s needs and the specifics of their condition. Beyond the traditional treatment approaches, innovative treatment modalities offer the potential to improve outcomes for patients experiencing PAL after thoracic surgery. Further research is needed to optimize treatment protocols and integrate new therapies into clinical practice.

Lung cancer is one of the leading causes of cancer-related deaths worldwide. Superior vena cava syndrome (SVCS) is a rare but potentially life-threatening complication of lung cancer, occurring in approximately 5–10% of cases. There are difficulties in the process of surgical treatment of SVC infiltrated by lung tumors but the contribution of technological evolution and innovation is promising. At the same time, the amelioration of survival rates of patients subjected to surgical treatment is equally promising. The reported outcomes of surgical treatment for SVC invasion due to lung tumors vary depending on the extent of the tumor and the patient’s overall health status. However, studies clearly suggest that surgical treatment can improve survival and quality of life in selected patients. The literature review showed that the surgical approach to lung cancer invading the SVC constitutes the most indispensable treatment which helps to achieve the long-term survival of patients.

Background: Older patients with malignancies are more comorbid than younger ones and are usually undertreated only because of their age. The aim of this study is to investigate the safety of open anatomical lung resections for lung cancer in elderly patients. Methods: We retrospectively analyzed all patients who underwent lung resection for lung cancer in our institution and categorized them into two groups: the elderly group (≥70 years old) and the control (p = 0.037), higher differentiated tumors (12.6% vs. 6.4%, p = 0.014), and at an earlier stage (stage I: 55.6% for elderly vs. 36.6%, p = 0.002). Elderly patients were more vulnerable to postoperative pneumonia (3.7% vs. 0.8%, p = 0.034), lung atelectasis (7.4% vs. 2.9%, p = 0.040), and pleural empyema (3.2% vs. 0%, p = 0.042), however, with no increased 30-day-mortality (5.2% for elderly vs. 2.7%, p = 0.168). Survival was comparable in both groups (43.4 vs. 45.3 months, p = 0.579). Conclusions: Elderly patients should not be excluded from open major lung resections as the survival benefit is not reduced in selected patients.

Background: Resection of lung metastases with curative intention in selected patients is associated with prolonged survival. Laser–assisted resection of lung metastases results in complete resection of a high number of lung metastases, while preserving lung parenchyma. However, data concerning laser lung resections are scarce and contradictory. The aim of this study was to conduct a systematic review to evaluate the utility of laser-assisted pulmonary metastasectomy. Methods: An electronic search in MEDLINE (via PubMed), complemented by manual searches in article references, was conducted to identify eligible studies. Results: Fourteen studies with a total of 1196 patients were included in this metanalysis. Laser-assisted surgery (LAS) for lung metastases is a safe procedure with a postoperative morbidity up to 24.2% and almost zero mortality. LAS resulted in the resection of a high number of lung metastases with reduction of the lung parenchyma loss in comparison with conventional resection methods. Survival was similar between LAS and conventional resections. Conclusion: LAS allows radical lung-parenchyma saving resection of a high number of lung metastases with similar survival to conventional methods.

Background: There is growing evidence that supports the use of chest ultrasound (CUS) versus conventional chest X-ray (CXR) in order to diagnose postoperative complications. However, data regarding its use after thoracic surgery are scarce and contradictory. The aim of this study was to conduct a systematic review to evaluate the accuracy of CUS after thoracic surgery. Methods: An electronic search in MEDLINE (via PubMed), complemented by manual searches in article references, was conducted to identify eligible studies. Results: Six studies with a total of 789 patients were included in this meta-analysis. Performing CXR decreased in up to 61.6% of cases, with the main reasons for performing CXR being massive subcutaneous emphysema or complex hydrothorax. Agreement between CUS and routine-based therapeutic options was, in some studies, up to 97%. Conclusions: The selectively postoperative use of CUS may reduce the number of routinely performed CXR. However, if CUS findings are inconclusive, further radiological examinations are obligatory.

Background: Postoperative myocardial dysfunction following cardiac surgery is a relatively common occurrence. Levosimendan, a calcium sensitizer and inotropic drug, has shown potential in improving outcomes for patients with low preoperative ejection fraction (EF) and myocardial dysfunction after cardiac surgery. This study aims to evaluate the efficacy of levosimendan in optimizing the surgical outcome for such patients. Methods: A retrospective analysis was conducted on 314 patients with preoperative severe heart failure who underwent cardiac surgery. Among them, 184 patients received perioperative adjunctive therapy with levosimendan, while a comparable group of 130 patients received conventional treatment. Results: The use of levosimendan demonstrated several advantages in postoperative outcomes. It significantly improved short- and long-term survival rates after cardiac surgery, enhanced hemodynamic stability, reduced the requirement for inotropic support, and facilitated faster weaning from ventilator support. Patients who received levosimendan reported reduced angina and dyspnea symptoms, as well as fewer postoperative arrhythmias. Furthermore, levosimendan helped minimize myocardial injury inevitable after cardiac surgery. The levosimendan group also exhibited a notable reduction in hospital readmissions. Conclusions: This study provides evidence of several benefits associated with the perioperative use of levosimendan. However, further prospective randomized studies are warranted to standardize and comprehensively document the other perioperative therapies, in order to validate these findings and establish stronger conclusions.

Background: Renal dysfunction and impaired organ perfusion are common concerns following cardiac surgery. Levosimendan, a calcium sensitizer inotropic drug, is investigated in this study for its potential to improve postoperative renal function and organ perfusion in patients with low preoperative ejection fraction and severe myocardial dysfunction after cardiac surgery. Methods: A retrospective analysis was conducted on 314 patients with preoperative heart failure who underwent cardiac surgery. Among them, 184 patients received perioperative adjunctive therapy with levosimendan, while 130 patients with similar characteristics received conventional treatment. Results: The perioperative administration of levosimendan resulted in a significantly lower need for renal replacement therapy (p < 0.001) and improvements in the serum creatinine levels, glomerular filtration rate, and creatinine clearance. Similarly, the C-reactive protein levels, blood pH, and lactic acid levels showed comparable improvements. Conclusions: The use of levosimendan was associated with a significant enhancement in postoperative renal function and a reduction in the need for renal replacement therapy. Furthermore, it resulted in a decrease in the extent of organ malperfusion. Postoperative inflammatory reactions and metabolic balance also exhibited improvements.

(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.

Pulmonary embolism due to hydatid cysts is a very rare pathology. A 55-year-old male was transferred to our hospital due to respiratory failure, as a result of left pulmonary artery obstruction by cystic lesions. His medical history included multiple operations for abdominal echinococcosis. He was urgently operated for the extraction of the proximal hydatid cysts with the use of cardiopulmonary bypass with an excellent outcome and six months later through a right thoracotomy for the distal right pulmonary artery, the cysts were extracted. Meanwhile, he followed additional medication treatment with albendazole, preoperatively as well as postoperatively. Today, 5 years later, he has no evidence of hydatidosis recurrence.

Elastofibroma is a rare benign, soft-tissue slow-growing tumor seen predominantly in elderly females. We present such a case in a 46-year-old female. She presented with gradually increasing soft tissue swelling of 8×6 cm in the right inferior subscapular region. MRI showed a large intramuscular lesion with atypia. She underwent excisional biopsy and the histopathology and immunochemistry showed elastofibroma. We present this rare case to emphasize the important role of the diagnostic tools. A definitive diagnosis helps to avoid unnecessary wide and radical resection.

Solitary Fibrous Tumor of the Pleura (SFTP) is a rare tumor of the pleura. Worldwide about 800 patients diagnosed with this oncological entity have been described in the existing literature. We report our center's 13 year experience. During this time three patients suffering from this rare disease have been treated in our department. All patients were asymptomatic and their diagnosis was initially triggered by a random finding in a routine chest x-ray. The diagnosis was set preoperatively through a needle biopsy under computer tomography (CT) guidance. The tumors were resected surgically though video-assisted thoracoscopic surgery (VATS) or thoracotomy. Because of the lack of specific guidelines due to the rarity of the disease a long-term, systematic follow-up was recommended and performed. Parallel an overview of the diagnostic and therapeutic procedures of the rare tumor is made.

Pneumomediastinum is a rare clinical entity that concerns the clinicians in the emergency department. We present a case of a patient with spontaneous pneumomediastinum (Hamman's syndrome) that presented to our hospital's emergency department with cervical subcutaneous emphysema. A conservative treatment with observation was performed. The patient after 24 hours of observation was discharged with a suggested follow-up. Keywords: Hamman's syndrome, Pneumomediastinum, Emphysema, Dyspnea

Pulmonary embolism is a common clinical entity related to high mortality. About 200,000 to 300,000 patients die every year due to pulmonary embolism. The purpose of this article is to describe a case of a patient who on the second postoperative day after undergoing thromboembolectomy of the left femoral artery, manifested a massive pulmonary embolism. Due to cardiorespiratory collapse a combined treatment via extracorporeal life support (ECLS) and parallel catheter thrombolysis was decided and performed. By cardiorespiratory improvement and final stabilization the patient was successfully weaned from ECLS and the system was successfully removed. After a reasonable postoperative time the patient was dismissed in good overall condition. Keywords: Pulmonary embolism, Extracorporeal membrane oxygenation, Thrombolysis, Catheter thrombolysis

We present a rare case of a 74 year old female with unruptured aneurysm of the left coronary sinus of Valsalva accompanied with patent foramen ovale and atrial fibrillation. This rare combination was detected during diagnostics for a cardiac etiology stroke. The left coronary sinus of Valsalva was reconstructed using an autologous pericardial patch, the left atrial appendage closed, left atrial ablation performed with cooled radiofrequency and the patent foramen ovale sutured directly. The patient was dismissed on the 12th postoperative day after having an uncomplicated postoperative course.

Deep accidental hypothermia is an unusual clinical entity in developed countries. We report a case of a 30 year old male Caucasian patient with accidental severe hypothermia who was transferred to the emergency department of our hospital after prolonged exposure in the urban city's night environment cold as a result of alcohol and drugs abuse. The patient was found unconscious in the first early hours from onlookers. The time that the patient remained unconscious is unknown. During the transfer to the hospital because of cardiac arrest cardiopulmonary resuscitation began. In the emergency department an extracorporeal life support system (ECLS) was implanted under cardiopulmonary resuscitation in order to achieve hemodynamic stabilization and rapid and safe rewarming. The patient's rewarming lasted 6 hours. The patient was extubated the next day. Keywords: Hypothermia, Resuscitation, ECMO, Cardiac arrest

Abstract Sclerosing mediastinitis (SM), previously named chronic fibrosing mediastinitis, is an inflammatory process that in its end-stage results to sclerosis around the mediastinal structures. SM is quite rare and has been correlated with inflammatory and autoimmune diseases, as well as malignancy. SM may either present in a mild form, with minor symptoms and a benign course or in a more aggressive form with severe pulmonary hypertension and subsequent higher morbidity and mortality. The diagnosis of SM may be difficult and quite challenging, as symptoms depend on the mediastinal structure that is mainly involved; quite often the superior vena cava. However, practically any mediastinal structure may be involved by the fibrotic process, such as the central airways, as well as the pulmonary arteries and veins, leading to obstruction or total occlusion. The latter may be impossible to undergo proper surgical excision of the lesion, and is considered to be a real challenge to the surgeon. We herein report a case of SM that presented with arterial and venous compression. The imaging appearance was that of unilateral pulmonary edema, associated with lung collapse. The case is supplemented by a non-systematic review of the relevant literature.