Starr-Edwards mitral valve-48 years till redo surgery, with over 54 years of patient survival after primary mitral valve replacement.

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.

[Comment] The challenges of planetary mental health in the COVID-19 era.

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.

Cardiocutaneous fistula 15 years postcardiac surgery: A real challenge.

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.

The challenge of simultaneous major aortic surgery and pectus excavatum repair in a patient with Ehlers-Danlos type IV syndrome.

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.

Metabolic syndrome and the skin: a more than superficial association. Reviewing the association between skin diseases and metabolic syndrome and a clinical decision algorithm for high risk patients.

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 < 40 mg/dl (men)/< 50 mg/dl (women), blood pressure > 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.

Insights into the epidemiology, aetiology and associations of infraspinatus atrophy in overhead athletes: a systematic review.

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.

Dominant vs. non-dominant shoulder morphology in volleyball players and associations with shoulder pain and spike speed.

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. 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. 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. 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.

The volleyball athlete's shoulder: biomechanical adaptations and injury associations.

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.

Coronary endarterectomy: The current state of knowledge.

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.

Surgical perspectives in the management of atrial fibrillation.

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.

Assessment of vacuum-assisted closure therapy on the wound healing process in cardiac surgery.

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.

Blunt Thoracic Aortic Injuries: New Perspectives in Management.

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.

Effects of combined vitamin D--calcium supplements on the cardiovascular system: should we be cautious?

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.

Advances in the treatment of blunt thoracic aortic injuries.

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.

Coronary arteriovenous fistulae: a review.

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.

What type of valve is most appropriate for osteogenesis imperfecta patients?

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.