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A new class-A force-balance accelerometer (FBA) is designed, simulated, and evaluated. The focus of this work was to design a low-cost but high-performance instrument. The FBA has output voltage proportional to ground acceleration, flat response from direct current to 200 Hz, output range ± 10 V differential (40Vpp, peak-to-peak) and sensitivity 2.5 V/g, which provides a ± 4g range. Unlike other well-established designs with rotational pendulum systems and single-coil actuators that present partially nonlinear performance, the proposed design is based on a linear motion spring-mass mechanism with two parallel leaf springs and a double symmetrical magnet-coil force actuator. This architecture ensures that the displacement transducer’s response is linear and that an acting force on the seismic mass is not disturbed by any cross-axial motion. This force depends on displacement only, as imposed by the electronic control circuit, which is implemented on a small high-density printed circuit board (PCB) mounted on top of the mechanical construction. The plates of the variable capacitance displacement transducer consist of ordinary PCBs for cost efficiency. The coils of the force actuator are placed on each side of the moving plate of the capacitive transducer and the magnets are placed on the aluminum rigid frame of the device. The central moving plate of the variable capacitor and the attached force actuator coils, along with some extra aluminum mass, consist the accelerometer’s seismic mass. The performance of the accelerometer is evaluated in terms of earthquake data records and in comparison of its response with that of a commercial FBA with corresponding specifications. The instrument’s self-noise was also measured over a long period of operation and proved to comply with typical FBA application requirements and commercial product standards.

We report a male patient who underwent successful redo cardiac surgery in 2014; tricuspid valve repair and redo mitral valve replacement of a Starr–Edwards mitral valve implanted 48 years previously. Six years after the redo operation, the patient remains well and therefore has an impressive over 54 years of survival following mitral valve replacement surgery.

Late Cardiocutaneous Fistula (CF) is an uncommon but potentially serious postoperative complication of cardiac surgery. We present the successful treatment of a 58-year-old female who developed a CF extending from the left ventricular apex into the left breast related to mitral valve replacement 15 years ago.

A unique case of a patient with Ehlers-Danlos type IV syndrome was referred with aortic root aneurysm and previous cosmetic primary repair of pectus excavatum (PE) through a solid silicone onlay prosthesis. The patient underwent successful removal of the silicone prosthesis and one-stage ascending aortic root replacement with concomitant Nuss procedure for repair of the PE.

As the focus of the COVID-19 crisis is gradually taken away from emergency healthcare needs, increased attention is warranted on the psychological impact of the pandemic on a global level. Existing guidance on managing the COVID-19 related distress needs to be better informed by upcoming larger-scale research. Applying e-Health can be useful in dealing with the immediate psychological needs, while developing strategies to identify vulnerable populations and shifting the provision of mental health and social care to community services need to be prioritised when looking at the future. Focusing on global mental health during this universal crisis is an opportunity for promoting a more compassionate and less discriminating society.

Infraspinatus atrophy (IA) is much more prevalent in overhead sports compared with the general population. Its exact aetiology in this group of athletes remains unclear and definitive associations with pathology and performance have not yet been reached. The aim of this systematic review is to present the evidence on IA in overhead athletes focussing on the proposed mechanisms of suprascapular neuropathy and its associations with shoulder pathology and performance. A thorough literature search via Medline, EMBASE and Scopus was performed. From the nine articles identified, the majority of authors propose suprascapular nerve (SN) injury at the spinoglenoid notch; however, the suprascapular notch has also been suggested as a potential site of injury. With regard to the exact mechanism of suprascapular neuropathy, the majority of authors propose repeated traction of the nerve during extreme shoulder abduction and horizontal adduction and/or eccentric contractions of the infraspinatus. In the limited relevant literature, convincing links between IA and performance or shoulder pathology have not been identified. IA in overhead sports is most likely of multi-factorial aetiology. Important questions about IA and its significance in overhead sports remain unanswered and more biomechanical and prospective studies are warranted to provide further insights into this athletic injury.

In volleyball, the dominant shoulder of the athlete undergoes biomechanical and morphological adaptations; however, definitive conclusions about their exact nature, aetiology, purpose and associations with shoulder injury have not been reached. We present a systematic review of the existing literature describing biomechanical adaptations in the dominant shoulders of volleyball players and factors that may predispose to shoulder pain/injury. A thorough literature search via Medline, EMBASE and SCOPUS was conducted for original studies of volleyball players and 15 eligible articles were identified. Assessment of study quality was performed using the STROBE statement. The reviewed literature supports the existence of a glenohumeral internal rotation deficit (GIRD) and a possible (and less pronounced) external rotation gain in the dominant vs. the non-dominant shoulder of volleyball athletes. Unlike other overhead sports, the GIRD in volleyball athletes appears to be anatomical as a response to the repetitive overhead movements and not to be associated with shoulder pain/injury. Additionally, the dominant shoulder exhibits muscular imbalance, which appears to be a significant risk factor for shoulder pain. Strengthening of the external rotators should be used alongside shoulder stretching and joint mobilisations, core strengthening and optimisation of spike technique as part of injury management and prevention programmes.

There is ongoing scientific interest regarding comorbidities associated with the metabolic syndrome (MeTS). MeTS comprises a combination of parameters that predispose individuals to the development of type 2 diabetes and cardiovascular disease (CVD). Three or more of the following criteria are necessary: fasting glucose > 110 mg/dl (5.6 mmol/l), hypertriglyceridemia > 150 mg/dl (1.7 mmol/l), HDL levels 130/85 mmHg, waist circumference (values for Mediterranean populations > 94 cm (men)/> 89 cm (women). In this review we attempted to summarize relevant data by searching dermatological literature regarding associations between various skin conditions and MeTS. A multitude of studies was retrieved and a further goal of the present article is to present plausible mechanistic connections. The severity of skin conditions like psoriasis has been linked with MeTS. Parameters of MeTS like insulin resistance are present in patients with early onset androgenic alopecia, hidradenitis suppurativa acne and rosacea. Since MeTS can lead to CVD and type 2 diabetes early detection of patients would be very important. Also therapeutic intervention on MeTS could lead to improvement on the severity of skin conditions. This reciprocal relationship between skin diseases and MeTS in our opinion holds great interest for further investigation.

Blunt thoracic aortic injuries, even though rare in incidence, carry significant mortality rates and their management still remains challenging. There have been major shifts in diagnosing and treating these injuries in the last 5 decades, which proved to be beneficial in terms of mortality and complications. Endovascular repair has been increasingly used for definitive treatment and its outcomes appear to be at least equally safe and effective as those of open repair. We present a balanced review of the relevant literature regarding the most appropriate approach and definitive treatment of these pathological entities. Based on the studies analyzed, endovascular repair is increasingly being established as the choice of treatment, however, the conventional open surgical approach still remains a safe method for severe injuries; the mortality, complication rates and proven longterm results of the latter are continuously improving. Additionally, delayed repair, where appropriate, seems to be a safe option with very low mortality rates. Despite the encouraging short and midterm outcomes reported, endovascular treatment needs to be assessed in the longterm for more accurate conclusions to be drawn about its durability and safety.

Blunt thoracic aortic injuries (BTAIs) present a great challenge because of their potentially fatal outcomes. Recent advancements in their management have proved to be beneficial in terms of various parameters, including mortality and complications. Endovascular repair is now the treatment of choice in most centres and is continuously replacing the traditional open surgical method. We present a mini-review of the most recent relevant literature that briefly describes the major shifts in the diagnosis and treatment of BTAIs and compares the outcomes of the conventional surgical approach to those of the endovascular method for the definitive repair of these injuries. Although both the reviewed literature and the most recently published guidelines are in support of the use of the endovascular approach, as short and midterm results are promising, its long-term outcomes still remain in question.

Postoperative deep sternal wound infection (DSWI) is a serious complication in cardiac surgery (1–5% of patients) with high mortality and morbidity rates. Vacuum-assisted closure (VAC) therapy has shown promising results in terms of wound healing process, postoperative hospital length of stay and lower in-hospital costs. The aim of our retrospective study is to report the outcome of patients with DSWI treated with VAC therapy and to assess the effect of contributory risk factors. Data of 52 patients who have been treated with VAC therapy in a single institution (study period: September 2003–March 2012) were collected electronically through PAtient Tracking System PATS and statistically analysed using SPSS version 20. Of the 52 patients (35 M: 17 F), 88·5% (n = 46) were solely treated with VAC therapy and 11·5% (n = 6) had additional plastic surgical intervention. Follow-up was complete (mean 33·8 months) with an overall mortality rate of 26·9% (n = 14) of whom 50% (n = 7) died in hospital. No death was related to VAC complications. Patient outcomes were affected by pre-operative, intra-operative and postoperative risk factors. Logistic EUROscore, postoperative hospital length of stay, advanced age, chronic obstructive pulmonary disease (COPD) and long-term corticosteroid treatment appear to be significant contributing factors in the long-term survival of patients treated with VAC therapy.

Despite the growing body of evidence on the potential effects of calcium and vitamin D as monotherapies on different cardiovascular (CV) parameters, the combined supplementation with calcium and vitamin D (CaD), which is most frequently encountered in clinical practice, has not received the attention it deserves. A literature search was conducted via EMBASE and Medline and identified 14 randomised controlled trials (RCTs) and 2 meta-analyses reporting on effects of combined supplementation with CaD on CV events, CV death, blood pressure, lipids, glucose metabolism and weight. Overall, the existing evidence does not support beneficial properties of supplementation with CaD on the CV system, nor does it suggest that a re-appraisal of the use of CaD is necessary due to adverse effects, although increased risk of CV events has been reported by some authors. The guidelines for the use of CaD supplementation need not change until well-conducted RCTs that have CV effects as primary outcomes and adjust for major confounders indicate otherwise.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was in osteogenesis imperfecta (OI) patients with valve disease undergoing valve replacement which type of valve (bioprosthetic or mechanical) is most appropriate in terms of safety, complications and survival. Altogether more than 77 papers were found as a result of the reported search, of which 43 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Previous review articles have presented case reports up to 2009. As all published data are based on case reports, we conducted a more detailed analysis that included the aforementioned series, reports that were missed prior to 2009 and all published data from 2009 to October 2013. Our analysis identified 43 OI patients. Mechanical valves were used in the majority of cases (31 patients), bioprosthetic valves in 10 patients and homografts in 2 patients. We conclude that based on the best available evidence, it appears that bioprosthetic valves have had better outcomes (mortality rate 10%) and a lower valve-related complication rate (0%) compared with mechanical valves (mortality rate 16.1%, complication rate 16.1%), even though differences were not statistically significant. Although the existing evidence is solely based on case reports of a relatively small number, we would suggest the use of bioprosthetic valves in OI patients with valve disease, as they appear to be safer according to our analysis. Moreover, considering the surgical difficulties related to the friability and weakness of the tissues in terms of suture lines and implantation of the valve as well as the high risk of perioperative bleeding which can be related to tissue friability, capillary fragility and platelet dysfunction followed by the risk of major traumatic fractures and a possible risk of aortic dissection in the future, the bioprosthetic valves seem to be safer taking into account the avoidance of lifelong anticoagulation and its secondary bleeding complications.

Coronary arteriovenous fistulae are a coronary anomaly, presenting in 0.002% of the general population. Their etiology can be congenital or acquired. We present a review of recent literature related to their epidemiology, etiology, pathophysiology, clinical presentation, diagnostic approach, and therapeutic management.

Osteogenesis imperfecta (OI) is a heritable disorder of the connective tissue. Cardiovascular involvement is rare, related mainly to aortic valve regurgitation. Open-heart surgery in these patients is associated with increased morbidity and mortality rates as a result of tissue friability and bone brittleness as well as platelet dysfunction. We present a patient with OI who underwent successful aortic valve replacement with a mini-sternotomy approach.

Background: The aims of our study were to compare the dominant (DOM) and non-dominant (NDOM) shoulders of high-level volleyball athletes and identify possible associations of shoulder adaptations with spike speed (SS) and shoulder pathology.\ud Materials-Methods: A total of 22 male volleyball players from two teams participating in the first division of the Cypriot championship underwent clinical shoulder tests and simple measurements around their shoulder girdle joints bilaterally. SS was measured with the use of a sports speed radar.\ud Results: Compared with the NDOM side, the DOM scapula was more lateralised, the DOM dorsal capsule demonstrated greater laxity, the DOM dorsal muscles stretching ability was compromised, and the DOM pectoralis muscle was more lengthened. Players with present or past DOM shoulder pain demonstrated greater laxity in their DOM dorsal capsule, tightening of their DOM inferior capsule, and lower SS compared with those without shoulder pain. Dorsal capsule measurements bilaterally were significant predictors of SS. None of the shoulder measurements was associated with team roles or infraspinatus atrophy, while scapular lateralisation was more pronounced with increasing years of experience, and scapular antetilting was greater with increasing age.\ud Conclusions: Adaptations of the DOM shoulder may be linked to pathology and performance. We describe simple shoulder measurements that may have the potential to predict chronic shoulder injury and become part of injury prevention programmes. Detailed biomechanical and large prospective studies are warranted to assess the validity of our findings and reach more definitive conclusions.

Optimal thromboprophylaxis following bioprosthetic aortic valve replacement (AVR) remains controversial. The main objective, which is the effective prevention of central nervous or peripheral embolic events, especially in the early postoperative period, will have to be weighed against the haemorrhagic risk that is associated with the utilization of different antithrombotic regimes. Most governing bodies in cardiovascular medicine have issued recommendations on thromboprophylaxis after the surgical implantation of aortic bioprostheses. However, the level of evidence to support these recommendations remains low, largely due to the inherent limitations of conducting appropriately randomized and adequately powered clinical research in this area. It is apparent from the recent surveys and large registries that there is a great variability in antithrombotic practice at an institutional or individual-clinician level reflecting this controversy and the lack of robust evidence. While organizational, financial or conceptual limitations could hinder the conduct and availability of conclusive research on optimal thromboprophylaxis after aortic bioprosthesis, it is imperative that all evidence is presented in a systematic way in order to assist the decision-making for the modern clinician. In this review, we provide an outline of the current recommendations for thromboprophylaxis, followed by a comprehensive and analytical presentation of all comparative studies examining anticoagulation vs. antiplatelet therapy after bioprosthetic AVR.

Objective: Prospective randomised study comparing patients with atrial fibrillation (AF) of more than 6 months duration after mitral valve surgery plus biatrial modified radiofrequency Maze procedure using Medtronic Cardioblate System (Cardioblate group, n = 24) vs mitral valve surgery plus intensive rhythm control strategy (control group, n = 25). Methods: Patients were blinded to randomisation. Preoperatively, at discharge, and at 3-month and 1 -year follow-up, echocardiography, quality of life assessments and ECGs were done. In both groups, sinus rhythm (SR) restoration was attempted by intra- and postoperative DC cardioversion and class III antiarrhythmic medication. All patients received warfarin. Amiodarone and warfarin was considered for discontinuation after 3 months in SR, 24-h Holter or event monitor excluding AF. Results: Both groups underwent mitral valve replacement or repair (Cardioblate vs control: 16:8 vs 10:15), had similar gender (male: 33% vs 56%), age (66 ± 8 years vs 68 ± 9 years), additional aortic valve replacement (7 vs 6 patients), tricuspid annuloplasty (13 vs 13 patients), and CABG (10 vs 16 patients). There was 0% operative mortality, 0% postoperative cerebrovascular accidents, but 2 late deaths in the control group. At discharge, 3-and 12-month follow-up, more patients in the Cardioblate group returned to normal SR compared to control (29%, 57% and 75% vs 20%, 43% and 39%; p = 0.030). Return of functional atrial contraction in patients in SR at 1 year was comparable between groups (63% vs 89%, NS), and more likely in non-rheumatic pathology and preoperative AF of shorter duration. The effectiveness of atrial contraction was 36 ± 14% vs 43 ± 18% of transmitral flow and there was no difference between groups. Amiodarone treatment decreased more in Cardioblate group over time (92%, 55% and 29% vs 52%, 52% and 21%; p = 0.003), whereas warfarin decrease was comparable (100%, 100% and 71% vs 100%, 95% and 82%; NS). Conclusions: Radiofrequency Maze ablation additional to mitral valve surgery resulted in a higher SR conversion rate (75%), despite control group treatment with intensive rhythm control strategy having a higher SR conversion rate (39%) compared to literature (∼25%). Maze ablation resulted in normalisation of atrial function in 63% of patients converted to SR.

Coronary cameral fistula, a rare acyanotic congenital or acquired anomaly that involves a large communication between one of the coronary arteries and a cardiac chamber, is the most important hemodynamically significant coronary artery abnormality. This case report is the first description of the combination of double coronary artery cameral fistulas associated with pulmonary hypertension and congestive heart failure and complicated by mitral and tricuspid regurgitation, patent foramen ovale, and chronic atrial fibrillation.

Coronary artery endarterectomy (CE) is a procedure performed adjunctive to coronary artery bypass grafting in patients with diffuse coronary artery disease (CAD). This review was conducted in order to assess the safety of the procedure, the associated complications as well as short- and long-term patient outcomes. A literature search was performed via Pubmed, and 50 articles were included in the review based on our inclusion and exclusion criteria. The mortality and morbidity rates were found to be acceptable in a highly selected group of patients. Therefore, CE may have an important role to play in the surgical management of patients with complicated CAD and should be incorporated to the armamentarium of the cardiologist and the cardiac surgeon following careful consideration by a multi-disciplinary approach.

We report the diagnosis and surgical management of the interesting case of a patient with a gastrointestinal stromal tumour (GIST).

We present the successful management of an interesting case of a single-stage combined mitral valve repair plus repair of the pectus excavatum with a Nuss bar.

Pulmonary chondromatous (or chondroid) hamartomas are common benign tumours of the lung and may be either parenchymal or endobronchial. The latter are only rarely encountered and have a variation in their clinical presentation related to the endobronchial obstructive lesion, including atelectasis, pneumonia, hemoptysis. If not diagnosed early and treated properly, endobronchial hamartomas can cause irreversible lung damage. We present a review of the recent English literature over the diagnostic approach and management of pulmonary endobronchial chondromatous hamartomas.

Pulmonary artery sarcoma is a known but rare tumor with poor prognosis. It is a challenging diagnostic dilemma, as the main complaint of these patients is progressive dyspnea. Dyspnea is a common symptom in cardiorespiratory disease and therefore a high index of suspicion is necessary to make the diagnosis early and proceed with surgery and radiotherapy and/or chemotherapy. We report a case of primary pulmonary artery sarcoma that presented initially with weight loss, shortness of breath, palpitations, and dysphagia.

Professor Archibald Cochrane (1909–1988) is considered to be the originator of the idea of evidence-based medicine in our era. With his landmark book ‘Effectiveness and Efficiency: Random Reflections on Health services’ he managed to inspire and positively influence the medical society with respect to the proper assessment of reliable evidence for the provision of the best medical care. His vision combined with his scientific achievements can be considered as the foundation of the Cochrane Collaboration; named after him in recognition of and gratitude for his pioneering work. We present the highlights of his adventurous and vibrant personal and academic life in an attempt to honour his contribution to shaping modern medical research.

Coronary artery perforation is a known complication of percutaneous coronary intervention and potentially life threatening. Normally, these perforations are small and localized. We report the successful surgical management of a coronary artery perforation following stent insertion with extrusion of an 8-cm endarterectomy length of the circumflex coronary artery with a brief review of the recent literature.

We read with great interest the best evidence topic by Yap et al. regarding the best bioprosthesis for aortic valve replacement [1]. We would like to present the results of our relative prospective multicentre randomized study. The aim of the study was to compare the haemodynamic performance and the sizing characteristics of the Medtronic Mosaic Ultra porcine and Carpentier-Edwards Perimount Magna bovine pericardial bioprosthetic stented aortic valve in relation to the patient's true aortic annulus size [2]. After the aortic valve excision, the annulus was measured by blinded sizers prior to the randomization of 141 patients (Ultra, n = 72; Magna, n = 69) [2]. The median patient age was 75 years, and 89% of the patients had aortic valve stenosis. A good left ventricular function was present in 75% of patients, and the EuroSCORE-predicted mortality was equal to 9%. Concomitant procedures (coronary artery bypass grafting, mitral/tricuspid valve repair, septal myectomy, modified maze procedure with radiofrequency) were performed in 61% of patients. The in-hospital mortality was 3%, and at six months postoperatively, 96% of the patients were in NYHA class I/II, with no inter-group differences. The mean 'true aortic annulus' size was 23.0 ± 1.4 mm for the Ultra valve, and 22.6 ± 1.8 mm for the Magna valve (P = not significant). The implanted labeled valve size was > or = 23 mm for 83% of Ultra valves, and for 52% of Magna valves (P 70 years [2,4]. The results of in vitro studies have also suggested that the Perimount Magna ThermaFix anticalcification treatment may be inferior to the Mosaic Ultra anti-calcification, and would result in an earlier reversal of the initially favorable Magna gradients [5]. Conflict of interest: none declared

I read with interest and a lot of attention the article by Birgand et al. regarding the results of their quasi-experimental single-centre prospective cohort study related to the efficacy of gentamicin-impregnated collagen sponges in preventing deep sternal wound infections in high-risk cardiac surgery patients [1]. I would greatly appreciate it, if the authors could explain the relation of their first reference by Barennes et al. to their very well presented data [2]. According to the International Committee of Medical Journal Editors, readers should be provided with direct references to original research work whenever possible. There is no need for large numbers of references. Small numbers of references to key or pivotal original articles often provide the appropriate volume of information [3]. In addition, citation errors sometimes appear in the published version of articles inadvertently [3]. Conflict of interest: none declared

We read with great interest the manuscript by Yano et al. regarding the surgical treartment of a mycotic aneurysm of ascending aorta [1]. We agree with the authors that the surgical repair of mycotic aortic aneurysms (extensive debridement of infected tissues, irrigation of the operative field with saline solution or antiseptic fluid and in situ reconstruction of the aorta) combined with wrapping of the prosthetic graft with pedicled omentum and administration of long-term antibiotics for prevention of the recurrence of infection is an acceptable mode of treatment [1]. Rifampicin-bonded prosthetic grafts can offer very good mid-term results. Uchida et al., in their retrospective study of 23 patients with mycotic aneurysms (6in thoracic aorta, 8 in thoracoabdominal aorta and 9 in abdominal aorta), who treated with in situ replacement of aorta with these grafts (plus omental pedicle grafts) found out that the overall survival at 5 years and freedom from aortic events was 95% and 86%, respectively. One patient died in the hospital due to recurrence of infection and another one required reoperation in another site of the aorta [2]. In addition, cryopreserved arterial homografts can be considered the treatment of choice and is our preferred option. Vogt et al., in their retrospective study of 19 patients with mycotic aneurysms (9/19) or infected grafts (10/19), in the thoracic (7/19) or abdominal aorta (12/19), apart from 16.2% mortality (1 early and 2 late deaths) didn't report on any recurrence of infection, homograft problems or anastomotic aneurysms in a mean follow-up period of 18.6 ± 13 months [3]. Silver-coated Dacron grafts compared to cryopreserved arterial homografts are reportable safe and present no significant difference in the treatment of infected abdominal aorta (in early mortality and mid-term survival) [4]. During the last years there is an increased use of thoracic endovascular stents and this modality of treatment has to be considered in the management of the complex cases, but with a higher incidence of recurrent infection. Patel et al., in their retrospective study of 20 patients with endovascular stenting of infected aortic pathological cases including 4 with infected grafts (10 aortobronchial fistulae, 2 aorto-oesophageal fistulae, 1 aortocutaneous fistula and 7 mycotic aneurysms) had an in-hospital mortality of 15%. Arch repair was needed in 8 patients, total descending, in 6 patients. Three patients underwent hybrid thoracic endovascular repair or debranching procedures. Mean Kaplan-Meier survival was 39.0 months. Late mortality was seen in 13 patients (history of immunosuppression and concurrent malignancy in 4 and 5 patients respectively) with 3 related to recurrent infection of thoracic aorta [tendency for recurrence when endovascular stent was performed in an infected graft (p = 0.08)]. At last imaging follow-up, 14 patients had a healed aorta [5]. In conclusion, conventional surgical treatment (with cryopreserved homografts or mycotic resistant prosthetic grafts or omental wrapping) is still the treatment of choice. However, knowing and understanding its limitations, the consideration of endovascular treatment in challenging, high-risk patients may offer acceptable results. Conflict of interest: none declared

We read with interest the manuscript by Wu and Chen and we would like to comment on the surgical complications of intracardiac pacemaker implantation [1]. The use of permanent pacemakers (PPM) and implantable cardioverter-defibrillators (ICD) is increasing due to the expansion of indications and aging of the population. As a consequence, cardiologists and cardiothoracic surgeons have to deal with a broad spectrum of complications, which are sometimes under-estimated and life-threatening. The surgical complications of PPM and ICD may occur during the immediate or early post-operative period and can be related to venous access process (pneumothorax, hemothorax, air embolism, haematoma, arterial puncture, wound healing problems, infection, pain), to the pacemaker lead (cardiac perforation, tamponade, malposition or dislodgement of the lead), or to the generator device. In addition, other complicationed that may occur during the late post-operative period are related to infections, thrombosis, endocarditis, pulmonary embolism, superior vena cava (SVC) syndrome (due to thrombus formation and/or fibrosis of the pacing wires within the SVC) and pericarditis [2-5]. Ostovan and Aslani have reported on the successful treatment of massive pulmonary air embolism during a PPM implantation with air suctioning by the guide catheter inserted into main pulmonary artery via the left femoral vein. Treatment for air embolisms includes oxygen treatment, haemodynamic support and prevention of further air entry in the systemic circulation. The left lateral decubitus position can prevent the air obstruction of the pulmonary outflow tract (air can be moved toward the right ventricular apex) [2]. Aggarwal et al. found no difference in the incidence of intraoperative and early postoperative complications (up to two months after implantation) between single and dual chamber pacing systems [3]. Sohail et al., in their retrospective review of 189 patients with pacemaker related infections, found out that the most common clinical presentations were generator pocket infection (69%) and device-related endocarditis (23%). The leading pathogens were Coagulase-negative Staphylococci and Staphylococcus aureus, in 42% and 29% of cases, respectively. There was a broad spectrum of related complications such us septic arthritis, sternal or vetebral or femoral osteomyelitis, and abscesses in lung, spleen, liver, brain and perinephric area. Twenty-two (11.6%) patients had thrombosis of the subclavian vein or superior vena cava and 6 of them developed clinical manifestations of pulmonary embolism. Ninety-eight percent of patients underwent complete device removal combined with antibiotic treatment and 96% of patients were treated successfully [4]. Nineteen patients had lead extraction via a median sternotomy and the rest underwent percutaneous lead extraction. Interventional complications were more common in patients with a history of multiple device-related procedures and were related to tricuspid valve failure, laceration of subclavian vein, hemothorax, haematoma, fracture of lead tip, ventriculotomy and bleeding [4]. Right atrial thrombosis and pulmonary embolism are infrequent complications (0.6%-3.5%) and its therapeutic modalities include anticoagulation, thrombolysis and or surgery [5]. In conclusion, the knowledge of all potential complications of the PPM/ICD and its multidisciplinary approach is very important for its prevention and definitive treatment. Conflict of interest: none declared

We read with interest the article by Thekkudan and associates regarding the tricuspid valve chordal rupture due to blunt injury and we agree with their comment that the timing of the surgical intervention in the heart valve depends on the patient's general clinical condition [1]. Cardiac valvular injuries are quite uncommon after blunt thoracic trauma and the tricuspid valve is perhaps the more vulnerable because of the proximity of the right ventricle to the sternum [2]. Bailey et al. have highlighted that even a moderate blunt chest injury can provoke a significant injury of cardiac valves [2]. The major causes of injury are related to motor vehicle accidents followed by falls from one or more stories, falls off a horse or bus and compressed air explosions [2, 3]. Van Son et al. have reported on their experience with the surgical management of thirteen patients with tricuspid insufficiency due to blunt chest trauma (twelve cases were related to motor vehicle accidents and one to an explosion of a tank of compressed air). The median duration between trauma and surgical treatment was 17 years (range, 1 month to 37 years) and the primary cause of tricuspid insufficiency was flail of the anterior leaflet because of chordae tendinea rupture (n = 9), rupture of anterior papillary muscle (n = 3), or tear in the anterior leaflet (n= 1). In one patient, the septal leaflet was missing and in another it was retracted and adherent to the ventricular septum. Eight patients underwent tricuspid valve replacement and four tricuspid valve repair. No early or late deaths occurred at a median follow-up of 12 years [3]. Choi and Kim have reported on the successful management of simultaneous rupture of mitral and tricuspid valve with left ventricular rupture due to blunt chest injury. Their brief review of the relevant literature found that only eight patients had simultaneous rupture of the atrioventricular valves [4]. The diagnostic and therapeutic approach is a real challenge for these complex cases. When cardiac trauma is suspected after blunt chest trauma, transthoracic echocardiography can facilitate its appropriate management. However, the atrioventricular valve rupture can be missed due to cardiac tamponade and resultant ventricular collapse or due to other significant thoracic injuries [4]. In controversial cases or in extremely unstable patients transesophageal echocardiography (preoperative and/or intraoperative) can establish the definitive diagnosis [2]. Post-traumatic tricuspid and mitral valve repair has to be considered very carefully because these patients are haemodynamically unstable and there are anatomic valvular difficulties such as myocardial contusion, focal endocardial ischaemia, friable endocardium and necrotic papillary muscle. Because the right heart is a low-pressure system and the septomarginal trabecula is thick, the ruptured anterior papillary muscle can be reattached to its primary position with the use of the native chordae or neochordae with pledgeted sutures [1, 4]. In conclusion, the experience of valve repair in blunt chest trauma is limited however, especially for the tricuspid valve this therapeutic modality can be effective.

We read with interest the article by Andreetti et al. regarding the treatment of post-pneumonectomy bronchopleural fistula (PPBPF) by self-expandable stent and we agree that this modality can be in the armamentarium of cardiothoracic surgeons [1]. PPBPF is one of the most serious and lethal complications in thoracic surgery. There are well-known predisposing factors related to this devastating postoperative complication such as extensive bronchial devascularization, right-sided pneumonectomy, long residual bronchial stump, neoadjuvant or adjuvant chemotherapy, regional radiotherapy, diabetes mellitus, steroid therapy, prolonged mechanical ventilation, history of smoking, pre-existing empyema, incomplete resection of cancer at the bronchial margins, decreased albumin levels (less than 3.5 mg/dL), male gender, and technique of bronchial stump closure [2, 3]. From the beginning of thoracic surgery, many different methods have been used to prevent the development of PPBPF [2, 3]. Pedicled pericardial flap or pericardial fat pad, pleura, intercostal muscle, diaphragm, and azygos vein (for right pneumonectomy) have been used as an additional coverage of bronchial stub wound with very good results [2, 3]. Brewer et al. in 1953 were the first ones who reported on their experimental and clinical work on the use of pedicled pericardial fat graft for reinforcement of bronchial closure in patients with pulmonary resection [4]. Taghavi et al. in 2005, in their retrospective study of 96 patients who underwent pneumonectomy (89.2% for primary lung cancer) and had covered bronchial stump with a pedicled pericardial flap, did not notice any evidence of PPBPF during the perioperative and postoperative period (mean follow up 15 ± 21.2 months) [2]. Sfyridis et al. in 2007, in their prospective randomised trial of 70 patients with diabetes mellitus who underwent pneumonectomy and were randomised to have their bronchial stump covered with an intercostal muscle flap or not; found that the group with the covered bronchial stump had a lower incidence of PPBPF (0% versus 8.8%; p = 0.02) and of empyema (0% versus 7.4%; p = 0.05) compared with the group not covered, at a mean follow-up of 18 ± 9.2 months [3]. Endobronchial valves have also been used to good effect in patients with persistent pulmonary air leaks (refractory to other therapy) secondary to alveolopleural fistula and to bronchopleural fistula as well [5]. In conclusion, in high risk patients the consideration of an effective method for covered bronchial stump for the prevention of the development of PPBLF is very important. Therefore, the multidisciplinary approach for the ideal treatment of patients with PBPF should be on an individual basis and is of paramount importance. Conflict of Interest: None declared

We would like to comment on the case report by Kim and colleagues concerning the surgical treatment of a gastrointestinal stromal tumour in the posterior mediastinum [1]. Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract (5000 new cases per year in the United States) [2]. They can be found in patients with a median age of 60 y, with frequent occurrence (70%) in the muscular wall of the stomach, followed by small bowel (10-20%), oesophagus, omentum, mesentery and retroperitoneum [2,3]. GISTs can range from small benign tumours to sarcomas at all sites of occurrence. Tumours that have metastasized at presentation have a very poor prognosis. The 5-year survival in patients with malignant GISTs is less than 40% [2]. There are three key prognostic factors: mitotic rate, tumour size, and site. Tumours that are small (=2 cm) and show mitotic activity not exceeding 5 mitoses per 50 high-power fields, have an excellent prognosis. This prognosis probably is independent of site, although this has not been shown specifically for all sites. In the stomach, most epithelioid GISTs are benign. However, we have to bear in mind that a small proportion of tumours apparently lacking mitotic activity do metastasize [2,3]. GISTs in association with paragangliomas and pulmonary chondromas constitute the Carney triad. In fact, the ‘Carney triad’ is a multiple neoplasia syndrome affecting mostly females. This syndrome - or Carney complex - predisposes to a variety of tumours including adrenocortical adenomas (unilateral or bilateral) that are usually non-functioning [2,4]. Carney and Stratakis, in 2002, distinguished the inherited GISTs with paraganglioma syndrome from the Carney triad as an autosomal dominant condition in adult patients. This condition has been called Carney-Stratakis syndrome [5]. These two syndromes, even though quite rare, have entered the realm of multiple endocrine neoplasias in the last years. Carney-Stratakis syndrome is probably more frequent and may be prevalent amongst patients with GISTs that are negative for KIT/PDGFRA mutations [2]. A high index of suspicion is required by surgeons who are dealing with patients with isolated or sporadic GISTs or paragangliomas. They have to be aware of the Carney and Carney-Stratakis syndromes. A multidisciplinary diagnostic approach regarding the medical and family history of the patients is of paramount importance (especially in the younger patient with KIT or PDFGRA mutation-negative GISTs) [2]. Conflict of Interest: None declared

Bhagwat and colleagues have reported on the successful surgical treatment of a patient with primary pulmonary artery sarcoma [1]. We would like to share our experience relating to a 62 year female and to add a brief comment as well [2]. We reported on a patient with primary pulmonary artery sarcoma presenting initially with weight loss, shortness of breath, palpitations, and dysphagia. The diagnostic approach consisted of echocardiography, CT scan, MRI and coronary angiogram, and the differential diagnosis included pulmonary emboli, chronic thromboembolic disease and pulmonary artery tumour. The patient underwent exploratory median sternotomy under cardiopulmonary bypass (CPB), logistic EuroSCORE 6%, and the entire tumour was resected with an extensive tumour endarterectomy. However, as a fibrotic area in the right ventricle was left, this was considered to be a palliative procedure and the patient was referred for chemotherapy and radiotherapy [2]. Pulmonary artery sarcoma presents a diagnostic challenge, as the main presenting complaint of patients is progressive dyspnoea. Dyspnoea is a quite common symptom in diseases of the heart and lungs and therefore a high index of suspicion is necessary to make the diagnosis early, and to proceed with surgery and radiotherapy and/or chemotherapy [2]. Since 1923, when the first case was described, until 2006, no more than 210-220 cases have been reported [2]. Pulmonary artery sarcomas arise from pluripotent intimal cells. They are most frequently located within the pulmonary trunk, spreading into the proximal and distal pulmonary arteries. Typical onset age is 45-55 years, with reported age ranging from 13 to 86 years and a female to male ratio equal to 2:1. Due to the rarity of these tumours, they are often initially misdiagnosed as chronic thromboembolic disease leading to unnecessary anticoagulation of affected patients [2]. Preoperative histological diagnosis is generally not possible although, rarely, biopsy may be obtained via CT-guided transthoracic aspiration or, alternatively, via transvenous catheter suction biopsy with pulmonary angioscopy, as well as by transbronchial biopsy [2]. Endarterectomy via median sternotomy and CPB, with dissection of the intima and most of the media, may result in complete tumour removal and is the most commonly used and widely acceptable surgical strategy. Although in unilateral disease it is possible to attempt a pneumonectomy, in bilateral disease it seems to be of limited value [2]. Alternative surgical methods include total excision of pulmonary trunk with reconstruction, and heart and lung transplantation for unresectable tumours [3,4]. Palliative treatment includes debulking of the tumour, endovascular stent or bypass procedure [2,5]. The prognosis is poor: without surgery survival is 1.5 months. The median survival has been significantly improved with radical surgical resection and multimodality treatment [1,2]. Surgical treatment remains the cornerstone of management, offering definite diagnosis, improvement of symptoms and the best outcome. However, if curative resection is not possible, palliative resection still provides good symptom relief and can improve survival [2]. A high index of suspicion for early diagnosis is the key to successful treatment and prolonged survival for these patients presenting with no specific symptoms. Conflict of Interest: None declared

Memetoglu and Kalkan, in their well-written manuscript have reported on the successful percutaneous treatment of an aneurysm in a patient with Behcet's disease [1]. We agree with the consideration of a percutaneous therapeutic modality instead of conventional surgical treatment for the management of aneurysms in Behcet's disease and would like to add a brief comment from a historical perspective. In 1956, the ophthalmologist Feigenbaum highlighted the first description of Behcet's syndrome by Hippocrates of Kos [2,3]. According to Feigenbaum, Hippocrates wrote in his third “Epidemion” book; case 7, “But there were also other fevers, as it will be described. Many had their mouths affected with aphthous ulcerations. There were also many defluxions about the genital parts, and ulcerations, boils (phymata), externally and internally about the groins. Watery ophthalmies of a chronic character, with pains; fungous excrescences of the eyelids, externally and internally, called fici, which destroyed the sight of many persons…”[2,3]. Zouboulis and Keitel, in their well-documented historical review, showed that the Greek ophthalmologist Benediktos Adamantiades (1875-1962) brought the ocular signs, genital ulcers and the arthritis in connection with a single disease [3]. On 15th of November 1930, Adamantiades presented a case report entitled “A case of relapsing iritis with hypopyon” at the annual meeting of the Medical Association of Athens and this presentation was published in the Proceedings of the Medical Society of Athens [3,4]. The case report was related to a 20 year old male, whose first clinical symptoms were edema and ulcerations of his left leg with a primary diagnosis of thrombophlebitis. In a two years follow-up, the patient developed recurrent iritis with hypopyon in both eyes, resulting in blindness and atrophy of the optic nerve, scrotal ulcers, oral aphthous ulcers, and sterile arthritis of both knees. The last three signs were recurrent and the bacterial cultures of the knees and eyes were negative [3,4]. Adamantiades went on to publish this case report in the French journal Annales d'Oculistique in 1931 [5]. In 1946, Adamantiades reported on two further patients and defined thrombophlebitis as a fourth sign of the disease [3]. In 1953, he presented the first classification of the disease and proposed the first diagnostic criteria and in 1958, his last work regarding its neurologic complications [3] was published. On 11th of May 1937, Hulsi (Hulusi) Behcet (1889-1948) presented a case report of a 34 year old female with a seven-year history of recurrent oral aphthous ulcers, genital ulcers, and ocular lesions at a meeting of the Dermatological Association of Istanbul [3]. This case report with the addition of a similar one was published in 1937 [3]. Behcet published three more manuscripts from 1938 to 1940, drawing medical attention [3]. He was aware of the publications by Adamantiades and included these in his references. Even though the current World Health Organization/ICD-10 standard is Behcet's disease, we believe that the term Adamantiades-Behcet's disease honors both first describers (in the modern era) for their contributions [3]. Conflict of Interest: None declared

Rare Sugars: Applications and Enzymatic Production Medical professionals such as doctors, nurses and paramedics often use headlight to examine or to perform surgical intervention in the patients. However, there are concerns related to its use such as comfort for the user, mobility and asepsis for the cable, availability, and cost effectiveness. The concept of a retrofitted 1-watt sports headlight (adjusted on magnifying loupes) would give quick access to a light source, be available and reliable at any place, save vital funds and would be environmentally friendly as the battery can be replaced.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and a huge public health burden associated with significant morbidity and mortality. For decades an increasing number of patients have undergone surgical treatment of AF, mainly during concomitant cardiac surgery. This has sparked a drive for conducting further studies and researching this field. With the cornerstone Cox-Maze III “cut and sew” procedure being technically challenging, the focus in current literature has turned towards less invasive techniques. The introduction of ablative devices has revolutionised the surgical management of AF, moving away from the traditional surgical lesions. The hybrid procedure, a combination of catheter and surgical ablation is another promising new technique aiming to improve outcomes. Despite the increasing number of studies looking at various aspects of the surgical management of AF, the literature would benefit from more uniformly conducted randomised control trials.

We present a rare case of bacterial endocarditis of the aortic valve complicated by intracranial haemorrhage, splenic and renal infarcts. Aortic valve replacement was complicated by delayed splenic rupture. The successful surgical management of this case is described as well as a review of the literature.

We have read the article by O'Sullivan et al. and we would like to add a comment on the complications of this pathological entity [1]. Aortic coarctation (AC) carries an incidence of 4 per 10 000 live births (5-8% of all congenital heart disease) and it can occur in association with patent ductus arteriosus, ventricular septal defect, bicuspid aortic valve (present in nearly two-thirds of patients with coarctation), concomitant hypoplastic aortic arch as well as parachute mitral valve stenosis, circle of Willis cerebral aneurysms and other congenital heart diseases (transposition of the great vessels, Taussig-Bing anomaly, hypoplastic left heart syndrome etc). Finally, AC is the commonest cardiac anomaly present in females with Turner syndrome [2, 3]. More importantly, the mean survival without treatment is 35 years and the vast majority of patients (90%) die before their 50s [2]. The choice of treatment has to be decided by a multi disciplinary team meeting with relevant specialists (Recommendation Class I, Level of Evidence C) [3]. Despite successful outcomes of its surgical treatment, late survival is compromised. For patients who are operated at a mean age of 16 years, the 10-, 20- and 30-year survival rates are 91%, 84% and 72% respectively [2]. Late complications can be subdivided into 8 categories namely: (i) re-coarctation, (ii) aortic aneurysm formation/aortic dissection, (iii) related to coexisting bicuspid aortic valve, (iv) endocarditis, (v) premature coronary atherosclerosis, (vi) strokes secondary to cerebrovascular aneurysms, (vii) systemic hypertension, and (viii) aortobronchial or aorto-oesophageal fistulas [2]. Re-coarctation is usually treated with primary balloon angioplasty with or without stent or surgical intervention. The probability of re-coarctation after surgery may be as high as 44% in neonates and 11% in older children, while adults carry a much lower risk (0-9%) [2]. About 9% of surgically-treated patients can develop aneurysms or pseudoaneurysms while those treated with balloon dilatation carry a much higher risk (20%) [2]. Those with coexisting bicuspid aortic valves are at an additional risk of developing aortic root dilatation [2]. Endocarditis can occur at the site of repair or at the coexisting bicuspid aortic valve and antibiotic prophylaxis is recommended subsequently according to the American Heart Association Guidelines [2, 3]. Premature atherosclerosis is usually the commonest cause of late death (25-37% of cases), leading to an increased risk of myocardial infarction and sudden death [2]. Circle of Willis aneurysms are present in 3-5% of patients and may cause cerebral haemorrhages even in normotensive individuals [2]. Systemic hypertension is found in 20-40% of patients followed-up 10 to 20 years after treatment and it represents a big challenge for the screening of either pregnant women or those with exercise-induced hypertension [2]. Aortobronchial fistulas are a rare though lethal complication and they can be safely managed with TEVAR [1, 2, 4]. All patients with treated AC should have lifelong close follow-up (at least yearly - Recommendation Class I, Level of Evidence C), magnetic imaging resonance/computed tomography should be repeated at intervals of 5 years at least (depending on anatomic findings) and management of blood pressure (Recommendation Class I, Level of Evidence B) and other risk factors should be applied [1, 3].