Review of mitral valve insufficiency: repair or replacement

Machine Learning Prediction Models for Mitral Valve Repairability and Mitral Regurgitation Recurrence in Patients Undergoing Surgical Mitral Valve Repair

Background: Mitral valve regurgitation (MR) is the most common valvular heart disease and current variables associated with MR recurrence are still controversial. We aim to develop a machine learning-based prognostic model to predict causes of mitral valve (MV) repair failure and MR recurrence. Methods: 1000 patients who underwent MV repair at our institution between 2008 and 2018 were enrolled. Patients were followed longitudinally for up to three years. Clinical and echocardiographic data were included in the analysis. Endpoints were MV repair surgical failure with consequent MV replacement or moderate/severe MR (>2+) recurrence at one-month and moderate/severe MR recurrence after three years. Results: 817 patients (DS1) had an echocardiographic examination at one-month while 295 (DS2) also had one at three years. Data were randomly divided into training (DS1: n = 654; DS2: n = 206) and validation (DS1: n = 164; DS2 n = 89) cohorts. For intra-operative or early MV repair failure assessment, the best area under the curve (AUC) was 0.75 and the complexity of mitral valve prolapse was the main predictor. In predicting moderate/severe recurrent MR at three years, the best AUC was 0.92 and residual MR at six months was the most important predictor. Conclusions: Machine learning algorithms may improve prognosis after MV repair procedure, thus improving indications for correct candidate selection for MV surgical repair.

[Echocardiographic emergency diagnostics]

Echocardiography is a non-invasive, versatile imaging modality for the diagnostics and monitoring of life-threatening cardiac diseases. This article summarizes the currently valid recommendations on emergency echocardiography of the German Cardiac Society and the European Association of Cardiovascular Imaging and provides practical guidance for their implementation in emergency medicine. Echocardiography is especially important for the diagnostics of acute coronary syndrome and its potential complications, of pulmonary embolism and endocarditis as well as the differential diagnosis of patients in shock and in emergencies. A domain of increasing importance in echocardiography is the treatment monitoring of patients supported by modern cardiac assist devices.

Can We Predict Failure of Mitral Valve Repair?

Objective: To identify echocardiographic and surgical risk factors for failure after mitral valve repair. Methods: We identified a total of 77 consecutive patients from our institutional mitral valve surgery database who required redo mitral valve surgery due to recurrence of mitral regurgitation after primary mitral valve repair. A control group of 138 patients who had a stable echocardiographic long-term result was included based on propensity score matching. Systematic analysis of echocardiographic parameters was performed before primary surgery; after mitral valve repair and prior to redo surgery. Risk factor analysis was performed using multivariate Cox regression model. Results: Redo surgery was associated with the presence of pulmonary hypertension ≥ 50 mmHg (p = 0.02), a mean transmitral gradient > 5 mmHg (p = 0.001), left ventricular ejection fraction ≤ 45% (p = 0.05) before surgery and mitral regurgitation ≥moderate at time of discharge (p = 0.002) in the whole cohort. Patients with functional mitral valve regurgitation had a higher tendency to undergo redo surgery if preoperative left ventricular end-diastolic diameter exceeded 65 mm (p = 0.043) and if postoperative tenting height exceeded 6 mm (p = 0.018). Low ejection fraction was not significantly associated with the need for redo mitral valve surgery in the functional subgroup. Conclusions: Recurrent mitral regurgitation is still a valuable problem and is associated with relevant perioperative mortality. Patients with severe mitral regurgitation should undergo early mitral valve repair surgery as long as systolic pulmonary artery pressure is low, left ventricular ejection fraction is preserved, and LVEED is deceeds 65 mm.

Chordal replacement versus quadrangular resection in degenerative posterior mitral leaflet repair

Background

As an alternative to quadrangular resection (QR), little is known of the potential of chordal replacement (CR) for treating posterior mitral leaflet (PML) prolapse when comparing these two techniques. This study aimed to assess mid- to long-term outcomes of CR versus QR for isolated degenerative PML (idPML) repair.

Methods

We reviewed 112 consecutive patients using CR or QR for idPML repair from 4/2010 to 12/2015. Outcomes were compared before and after propensity score matching.

Results

CR was more used through the minimally invasive approach (CR 59.4% vs. QR 9.4%, P<0.001). At discharge mitral regurgitation (MR) was successfully rectified to a mild or less degree in both groups (CR P<0.001, QR P<0.001; between groups: P=0.337). Group CR showed much shorter postoperative time (CR 9.9±4.0 vs. QR 14.0±8.3 days, P<0.004) and higher event-free survival rate between matched patients [56 months, CR 85.7% vs. QR 30.8%, P (log-rank) =0.017], however QR showed better freedom from above-mild recurrent MR (MR ≥2.5+) during follow-up [60 months, CR 50.2% vs. QR 96.3%, P (log-rank) =0.061]. Cox regression analysis might suggest that CR technique was a risk factor for recurrent MR [CR over QR, hazard ratio (HR) 2.149; 95% CI: 0.974-4.744; P=0.058; adjusted for surgical approach, gender, age, preoperative MR and ejection factor (EF)].

Conclusions

CR is more often used with the minimally invasive approach with less complications and shorter hospital stay. Nonetheless, CR is associated with recurrent MR development over time. Retaining of MV competence after CR demands attention and further investigation.

Information-Derived Mechanistic Hypotheses for Structural Cardiotoxicity

Adverse events resulting from drug therapy can be a cause of drug withdrawal, reduced and or restricted clinical use, as well as a major economic burden for society. To increase the safety of new drugs, there is a need to better understand the mechanisms causing the adverse events. One way to derive new mechanistic hypotheses is by linking data on drug adverse events with the drugs' biological targets. In this study, we have used data mining techniques and mutual information statistical approaches to find associations between reported adverse events collected from the FDA Adverse Event Reporting System and assay outcomes from ToxCast, with the aim to generate mechanistic hypotheses related to structural cardiotoxicity (morphological damage to cardiomyocytes and/or loss of viability). Our workflow identified 22 adverse event-assay outcome associations. From these associations, 10 implicated targets could be substantiated with evidence from previous studies reported in the literature. For two of the identified targets, we also describe a more detailed mechanism, forming putative adverse outcome pathways associated with structural cardiotoxicity. Our study also highlights the difficulties deriving these type of associations from the very limited amount of data available.

A comprehensive pipeline for multi-resolution modeling of the mitral valve: Validation, computational efficiency, and predictive capability

Multiple studies have demonstrated that the pathological geometries unique to each patient can affect the durability of mitral valve (MV) repairs. While computational modeling of the MV is a promising approach to improve the surgical outcomes, the complex MV geometry precludes use of simplified models. Moreover, the lack of complete in vivo geometric information presents significant challenges in the development of patient-specific computational models. There is thus a need to determine the level of detail necessary for predictive MV models. To address this issue, we have developed a novel pipeline for building attribute-rich computational models of MV with varying fidelity directly from the in vitro imaging data. The approach combines high-resolution geometric information from loaded and unloaded states to achieve a high level of anatomic detail, followed by mapping and parametric embedding of tissue attributes to build a high-resolution, attribute-rich computational models. Subsequent lower resolution models were then developed and evaluated by comparing the displacements and surface strains to those extracted from the imaging data. We then identified the critical levels of fidelity for building predictive MV models in the dilated and repaired states. We demonstrated that a model with a feature size of about 5 mm and mesh size of about 1 mm was sufficient to predict the overall MV shape, stress, and strain distributions with high accuracy. However, we also noted that more detailed models were found to be needed to simulate microstructural events. We conclude that the developed pipeline enables sufficiently complex models for biomechanical simulations of MV in normal, dilated, repaired states.

Surgical Treatment of Ischemic Mitral Regurgitation: Valve Repair Versus Replacement

PURPOSE OF REVIEW

Ischemic mitral regurgitation (MR), which occurs in about 20-30% patients with a prior myocardial infarction, is associated with worsening heart failure and an increase in cardiovascular mortality. It should be treated surgically if certain hemodynamic severity criteria are met and in patients who continue to experience symptoms of heart failure despite optimal medical therapy. However, current guidelines do not suggest which of the available approaches to mitral valve surgery-mitral valve (MV) repair or replacement (MVR) is superior for this indication. While MV repair is reported to confer improved survival, MVR may provide higher rates of freedom from recurrent MR. This article attempts to provide the reader with a comprehensive review and comparison of current techniques of mitral valve surgery in patients with severe ischemic MR.

RECENT FINDINGS

The first randomized trial to compare MV repair versus MVR in patients with severe ischemic MR, the Cardiothoracic Surgical Trials Network (CTSN) trial, was recently concluded and reported no significant difference in the primary outcome of left ventricular end systolic volume index between the two approaches at either 1- or 2-year follow-ups. Data comparing approaches of MV repair and MVR for ischemic MR is largely limited to small, non-randomized retrospective trials. The only randomized trial data to examine this issue suggested no difference in mortality with either MVR or MV repair; however, MVR was shown to be consistently associated with higher rates of MR recurrence. Certain echocardiographic features have been reported to predict poor outcomes with MVR and may help refine the selection of the surgical approach in the individual patient.

Current Discoveries and Interventions for Barlow's Disease

Mitral valve prolapse is a common valve pathology. One particular type of mitral valve prolapse that can be difficult to treat is Barlow's disease. This review serves to give insight on the current discoveries and therapeutic interventions of Barlow's disease.

Features of rheumatic mitral valves and a grading system to identify suitable repair cases in China

Background

We aimed to assess the pathological characteristics of rheumatic mitral valve disease in Chinese patients and formulate a pathological grading system to identify cases suitable for rheumatic mitral valve repair (rMVP).

Methods

Nearly 5 years of follow-up data on patients who underwent rMVP were analysed. A Kaplan-Meier survival curve for freedom from reoperation and valve failure was constructed. A pathological grading system of rheumatic mitral valve lesions (PGSRMVL) was developed based on the pathological characteristics of rheumatic mitral valve disease and tested by receiver operating characteristics (ROCs) curve analysis. Predictors of endpoints for rheumatic repair were analysed.

Results

From January 2012 to June 2016, 179 patients underwent rMVP in our centre. The mean follow-up duration was 24±14 months. A left atrial anterior and posterior diameter >60 mm was an independent predictor for the 16 endpoints [hazard ratio (HR) =3.884, P=0.029]. Between 2015 and 2016, 126 consecutive pathological characteristics of rheumatic mitral valve were evaluated (61 and 65 repair and replacement cases, respectively). The ROCs area under the curve was 0.891 for the correlation between the pathological score and successful repair (cut-off point, 17.5; sensitivity, 78%; specificity, 85.2%). Seven lesions had higher ratios in the replacement group than the repair group. Commissural fusion/calcification and main chordae tendineae fusion/calcification were the most common severe pathological lesions.

Conclusions

The main pathological characteristics of rheumatic mitral valve disease in Chinese patients are commissure and sub-valvular apparatus lesions. Most patients can be appropriately treated via commissurotomy and leaflet thinning. Severe calcification of the commissure and sub-valvular apparatus can considerably decrease the odds of a successful repair. The median follow-up results of rheumatic mitral repair are considered satisfactory for the pathological characteristics in Chinese patients.

Mitral valve repair for ischemic mitral regurgitation: lessons from the Cardiothoracic Surgical Trials Network randomized study

Approximately 30% to 50% of patients will develop ischemic mitral regurgitation (MR) after a myocardial infarction, which is a result of progressive left ventricular remodeling and dysfunction of the subvalvular apparatus, and portends a poor long-term prognosis. Surgical treatment is centered on mitral valve repair utilizing a restrictive annuloplasty, or valve replacement with preservation of the subvalvular apparatus. In the recent Cardiothoracic Surgical Trials Network (CSTN) study, patients with severe ischemic MR were randomized to mitral valve repair with a restrictive annuloplasty versus chordal-sparing valve replacement, and concomitant coronary artery bypass grafting, if indicated. At 2-year follow-up, mitral valve repair was associated with a significantly higher incidence of moderate or greater recurrent MR and heart failure, with no difference in the indices of left ventricular reverse remodeling, as compared with valve replacement. The current appraisal aims to provide insight into the CSTN trial results, and discusses the evidence supporting a pathophysiologic-guided repair strategy incorporating combined annuloplasty and subvalvular repair techniques to optimize the outcomes of mitral valve repair in ischemic MR.

Early Results of a Novel Mitral Valve Repair Procedure: The Interpapillary Polytetrafluoroethylene Bridge Formation

BACKGROUND

Surgical repair of ischemic mitral regurgitation (IMR) associated with chordal rupture in patients with ischemic cardiomyopathy is challenging as it aims to correct several structural pathologies at once. There are ongoing studies evaluating multiple approaches, however long term results are still scarce.

METHODS AND RESULTS

19 patients with IMR underwent mitral valve repair with interpapillary polytetrafluoroethylene (PTFE) bridge and neochordae formation at the Zala County Teaching Hospital. Concomitant coronary artery bypass grafting was performed in all patients. Post-procedural Transesophageal Echocardiogram (TEE) showed no mitral regurgitation (MR) in eighteen (94.7%) patients, with a leaflet coaptation mean height of 8 ± 3 mm. No operative mortality was observed. At the follow up (mean 17.7 ± 4.6 months; range 9 to 24 months), 17 (89%) patients showed no leakage and 2 had regurgitation grade ≤1, with documented NYHA functional class I or II in all patients.

CONCLUSION

This retrospective study presents the first results of a novel surgical approach to treating ischemic mitral regurgitation. The interpapillary PTFE bridge formation is a safe and feasible surgical procedure that is reproducible, time sparing and effectively eliminates mitral valve regurgitation with promising long-term results.

Automated fastener versus manually tied knots in minimally invasive mitral valve repair: impact on operation time and short- term results

Background

This study compares the influence of two different annuloplasty attachment suture applications, namely the use of an automated fastener versus manually tied knots using a traditional knot pusher, on total operation time, on cardiopulmonary-bypass time and on cross-clamp time, and on short-term outcome.

Methods

Sixty patients underwent isolated minimally invasive mitral valve repair in Carpentier Type-II mitral disease with implantation of an annuloplasty ring in combination with correction of the prolapsing leaflet using artificial chords. The first 30 patients after implementation of a novel automated fastener were compared with the last 30 patients corrected with a traditional knot pusher. No significant differences with regard to demographic data (age, gender, NYHA class, ejection fraction, BMI, cardiovascular risk factors) between the two groups were found. All patients received isolated mitral valve repair in the first run. Bretschneider HTK was used for cardioplegic cardiac arrest in all patients.

Results

Transesophageal and transthoracic echocardiography at the end of operation and at discharge revealed no (n = 25), trace (n = 28) or mild (n = 7) residual regurgitation with no evidence of ring dehiscence and without any significant clinical differences between the groups. Cross-clamp, cardiopulmonary-bypass and total- operation time were significantly reduced in the automated fastener group compared to the group using a traditional knot pusher (87.1 ± 17.9 vs. 101.3 ± 17.8; p < 0.01, 138.1 ± 25.6 vs. 152.7 ± 24.9; p < 0.05, and 203.9 ± 31.02 vs. 223.8 ± 29.01; p < 0.01, respectively).

Conclusion

Our short-term results indicate a safe, reliable and fast application of the novel automated fastener device in combination with significant time savings in cardioplegic arrest and cardiopulmonary bypass.

Targeted laser ablation of the zebrafish larval heart induces models of heart block, valvular regurgitation, and outflow tract obstruction

Mammalian models of cardiac disease have provided unique and important insights into human disease but have become increasingly challenging to produce. The zebrafish could provide inexpensive high-throughput models of cardiac injury and repair. We used a highly targeted laser, synchronized to fire at specific phases of the cardiac cycle, to induce regional injury to the ventricle, atrioventricular (AV) cushion, and bulbus arteriosus (BA). We assessed the impact of laser injury on hearts of zebrafish early larvae at 72 h postfertilization, to different regions, recording the effects on ejection fraction (EF), heart rate (HR), and blood flow at 2 and 24 h postinjury (hpi). Laser injury to the apex, midzone, and outflow regions of the ventricle resulted in reductions of the ventricle EF at 2 hpi with full recovery of function by 24 hpi. Laser injury to the ventricle, close to the AV cushion, was more likely to cause bradycardia and atrial-ventricular dysfunction, suggestive of an electrical conduction block. At 2 hpi, direct injury to the AV cushion resulted in marked regurgitation of blood from the ventricle to the atrium. Laser injury to the BA caused temporary outflow tract obstruction with cessation of ventricle contraction and circulation. Despite such damage, 80% of embryos showed complete recovery of the HR and function within 24 h of laser injury. Precision laser injury to key structures in the zebrafish developing heart provides a range of potentially useful models of hemodynamic overload, injury, and repair.

The long-term outcomes of physiologic repair for ccTGA (congenitally corrected transposition of the great arteries)

PURPOSE

The short-term outcome of physiologic repair for congenitally corrected transposition of the great arteries (ccTGA) is generally considered favorable; however, the long-term outcome is the greatest problem, especially with regard to right ventricular (RV) function and tricuspid regurgitation (TR). Although tricuspid valve replacement (TVR) appears to be a realistic choice for treating severe TR, determining the timing of TVR may be difficult.

METHODS

We carried out a retrospective analysis of the long-term outcomes of physiologic repair for ccTGA focusing on patients with TVR. The study involved 23 patients after physiologic repair 10 or more years prior. There were 9 TVR cases in 5 pediatric patients (before age 18) and 4 adult patients.

RESULTS

There were two late deaths; however, there was no case related with cardiac events. Overall survival at 10 and 20 years were 95.5 and 90.2 %, respectively, and 7 of 8 patients after TVR were NYHA class I or II. No patient has presented postoperative complications in the form of bleeding or embolism after TVR with mechanical valve.

CONCLUSIONS

An analysis of the results of physiologic repair for ccTGA showed that the long-term outcome was overall favorable. To maintain RV function, early TVR may be a reasonable option, even in the management of patients during childhood.

Minimally invasive procedures

Minimally invasive procedures, which include laparoscopic surgery, use state-of-the-art technology to reduce the damage to human tissue when performing surgery. Minimally invasive procedures require small "ports" from which the surgeon inserts thin tubes called trocars. Carbon dioxide gas may be used to inflate the area, creating a space between the internal organs and the skin. Then a miniature camera (usually a laparoscope or endoscope) is placed through one of the trocars so the surgical team can view the procedure as a magnified image on video monitors in the operating room. Specialized equipment is inserted through the trocars based on the type of surgery. There are some advanced minimally invasive surgical procedures that can be performed almost exclusively through a single point of entry-meaning only one small incision, like the "uniport" video-assisted thoracoscopic surgery (VATS). Not only do these procedures usually provide equivalent outcomes to traditional "open" surgery (which sometimes require a large incision), but minimally invasive procedures (using small incisions) may offer significant benefits as well: (I) faster recovery; (II) the patient remains for less days hospitalized; (III) less scarring and (IV) less pain. In our current mini review we will present the minimally invasive procedures for thoracic surgery.

Pneumothorax: an up to date "introduction"

The pneumothorax is an abnormal collection of air or gas in the pleural space that separates the lung from the chest wall. Like pleural effusion where a large abnormal concentration of fluid (>100 mL) is liquid buildup in that space, pneumothorax may interfere with normal breathing. A medical term that it is used is the collapsed lung, although that term may also refer to atelectasis. There are two major types of pneumothorax; there is one that occurs without an apparent cause and in the absence of significant lung disease, while the so called; "secondary" pneumothorax occurs in the presence of existing lung pathology. In a minority of cases, the amount of air in the chest increases markedly when a one-way valve is formed by an area of damaged tissue, leading to a third type of pneumothorax, called "tensioned".

Heimlich valve and pneumothorax

The Heimlich valve is a small one-way valve used for chest drainage that empties into a flexible collection device and prevents return of gases or fluids into the pleural space. The Heimlich valve is less than 13 cm (5 inches) long and facilitates patient ambulation. Currently there are several systems in the market. It can be used in many patients instead of a traditional water seal drainage system. The Heimlich chest drainage valve was developed so that the process of draining the pleural cavity could be accomplished in a safe, relatively simple, and efficient manner. This valve system has replaced the cumbersome underwater drainage bottle system. Moreover; the Heimlich valve system connects to chest tubing and allows fluid and air to pass in one direction only. This system functions in any position, and it does not ever need to be clamped, a regulated suction can be attached to it if necessary. The valve drains into a plastic bag that can be held at any level, allowing the patient undergoing chest drainage to be ambulatory simply by carrying the bag. In the current mini review we will present the Heimlich valve system and method of insertion.

Pneumothorax as a complication of central venous catheter insertion

The central venous catheter (CVC) is a catheter placed into a large vein in the neck [internal jugular vein (IJV)], chest (subclavian vein or axillary vein) or groin (femoral vein). There are several situations that require the insertion of a CVC mainly to administer medications or fluids, obtain blood tests (specifically the "central venous oxygen saturation"), and measure central venous pressure. CVC usually remain in place for a longer period of time than other venous access devices. There are situations according to the drug administration or length of stay of the catheter that specific systems are indicated such as; a Hickman line, a peripherally inserted central catheter (PICC) line or a Port-a-Cath may be considered because of their smaller infection risk. Sterile technique is highly important here, as a line may serve as a port of entry for pathogenic organisms, and the line itself may become infected with organisms such as Staphylococcus aureus and coagulase-negative Staphylococci. In the current review we will present the complication of pneumothorax after CVC insertion.

Pacemaker insertion

A pacemaker (PM) (or artificial PM, so as not to be confused with the heart's natural PM) is a medical device that uses electrical impulses, delivered by electrodes contracting the heart muscles, to regulate the beating of the heart. The primary purpose of this device is to maintain an adequate heart rate, either because the heart's natural PM is not fast enough, or there is a block in the heart's electrical conduction system. Modern PMs are externally programmable and allow the cardiologist to select the optimum pacing modes for individual patients. Some combine a PM and defibrillator in a single implantable device. PMs can be temporary or permanent. Temporary PMs are used to treat short-term heart problems, such as a slow heartbeat that's caused by a heart attack, heart surgery, or an overdose of medicine. Permanent PMs are used to control long-term heart rhythm problems. A PM can relieve some arrhythmia symptoms, such as fatigue and fainting. A PM also can help a person who has abnormal HRs resume a more active lifestyle. In the current mini review we will focus on the insertion of a PM and the possible pneumothorax that can be caused.

Pneumothorax from diagnosis to treatment, hands on course: Part II

Pneumothorax is a situation where air is inserted in the pleural space that separates the lung from the chest wall. Pneumothorax can be primary or secondary. There is also a third type called; tensioned. Based on the concentration of air and type of pneumothorax the proper treatment has to be selected. There are cases where the concentration is minimal and observation is enough and more severe cases where surgery is required. Currently there are many techniques used for the biopsy of lung lesions. The bronchoscope (forceps, fine needle aspiration), fine needle aspiration under computed tomography scan and endobronchial ultrasound (EBUS) are commonly used. However, all these techniques have in common a possible side effect; pneumothorax. In our current issue we will focus on the different minimally invasive techniques of pneumothorax management. Moreover, a presentation will be made for several systems that are being used for air or fluid aspiration.

Chest drainage systems in use

A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air in the case of pneumothorax or fluid such as in the case of pleural effusion, blood, chyle, or pus when empyema occurs from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter. Insertion of chest tubes is widely performed by radiologists, pulmonary physicians and thoracic surgeons. Large catheters or small catheters are used based on each situation that the medical doctor encounters. In the current review we will focus on the chest drain systems that are in use.

Video-assisted thoracic surgery and pneumothorax

Video-assisted thoracoscopic surgery (VATS) is a type of thoracic surgery performed using a small video camera that is introduced into the patient's chest via a scope. It is considered a minimally invasive technique where the surgeon is able to view the instruments that are being used along with the anatomy on which the surgeon is operating. The camera and instruments are inserted through separate holes in the chest wall also known as "ports", depending on the patient and problem there are surgeries with one port "uniport", two or three ports. These small ports have the advantage that fewer infections are observed. This allows for a faster recovery. Traditionally, thoracic surgery performed for diagnosis or treatment of chest conditions has required access to the chest through thoracotomy or sternotomy incisions. Vats minimally invasive technique has replaced in many cases thoracotomy or sternotomy. In our current review we will present this technique in detail.

Semi-Fowler vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis

BACKGROUND AND OBJECTIVE

The aim of this study is to compare usefulness of Semi-Fowler position vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis.

MATERIALS AND METHODS

From January 2009 to January 2010, 263 consecutive patients with palmar and axillar hyperhidrosis underwent thoracoscopic sympathectomy Th2-Th4. Patients were divided into two groups: group A (n=133) underwent thoracoscopic sympathectomy through lateral decubitus using double lumen endotracheal intubation, and group B (n=130) underwent thoracoscopic sympathectomy through Semi-Fowler supine position (semi sitting with arm abducted) using single lumen endotracheal intubation without insufflation of CO2, but with short apnea period. All operations were performed through two 5 mm operating ports, videothoracoscopic camera 0° and endoscopic ultrasound activated harmonic scalpel.

RESULTS

There were 107 males and 156 females with median age 30.31±8.35 years. Two groups were comparable in gender, age, severity of sweating. All operations were successfully performed with no complications or perioperative morbidity. For group A average operation time for both sides was 31.2±3.87 min and for group B average time was 14.19±4.98 min. In group B apnea period per one lung lasts 2.86±1.15 min and during that period observed saturation was 92.65%±5.66% without significant cardiorespiratory disturbances. Pleural drains were taken off on operation table after forced manually lung reexpansion. Patients were discharged from hospital for few hours, after the operation and radiologic confirmation of complete lung reexpansion.

CONCLUSIONS

Based on this data (shorter operating time, lack of incomplete lung collapse, insignificant apnea and better reexpansion of lungs) we concluded that thoracoscopic sympathectomy through Semi-Fowler supine position is highly effective and easy to perform for primary hyperhidrosis.

Open thoracotomy for pneumothorax

A thoracotomy is an incision into the pleural space of the chest. It is performed by surgeons (or emergency physicians under certain circumstances) to gain access to the thoracic organs, most commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine. This surgical procedure is a major surgical maneuver it is the first step in many thoracic surgeries including lobectomy or pneumonectomy for lung cancer and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation, rigid bronchoscope can be also used if necessary. Thoracotomies are thought to be one of the most difficult surgical incisions to deal with post-operatively, because they are extremely painful and the pain can prevent the patient from breathing effectively, leading to atelectasis or pneumonia. In the current review we will present the steps of this procedure.

Barotrauma and pneumothorax

Barotrauma is physical damage to body tissues caused by a difference in pressure between a gas space inside, or in contact with the body, and the surrounding fluid. This situation typically occurs when the organism is exposed to a significant change in ambient pressure, such as when a scuba diver, a free-diver or an airplane passenger ascends or descends, or during uncontrolled decompression of a pressure vessel, but it can also happen by a shock wave. Whales and dolphins are also vulnerable to barotrauma if exposed to rapid and excessive changes in diving pressures. In the current review we will focus on barotraumas from definition to treatment.

Pleura space anatomy

The pleural cavity is the potential space between the two pleurae (visceral and parietal) of the lungs. The pleurae are serous membranes which fold back onto themselves to form a two-layered membranous structure. The thin space between the two pleural layers is known as the pleural cavity and normally contains a small amount of pleural fluid. There are two layers; the outer pleura (parietal pleura) is attached to the chest wall and the inner pleura (visceral pleura) covers the lungs and adjoining structures, via blood vessels, bronchi and nerves. The parietal pleurae are highly sensitive to pain, while the visceral pleura are not, due to its lack of sensory innervation. In the current review we will present the anatomy of the pleural space.

Physiology of the pleural space

The pleural cavity is created between the 4(th) and 7(th) week of embryologic development. These embryonic components of visceral and parietal pleurae develop different anatomic characteristics with regard to vascular, lymphatic, and nervous supply. There are two layers: a superficial mesothelial cell layer facing the pleural space and an underlying connective tissue layer. The pleura might present inflammatory response and maintenance of the pleural fluid is observed. The latter function is especially important in the mechanical coupling of the lung and chest wall. Fluid is filtered into the pleural space according to the net hydrostatic oncotic pressure gradient. It flows downward along a vertical pressure gradient, presumably determined by hydrostatic pressure and resistance to viscous flow. There also may be a net movement of fluid from the costal pleura to the mediastinal and interlobar regions. In these areas, pleural fluid is resorbed primarily through lymphatic stomata on the parietal pleural surface. In the current review we will present the physiology of the pleural space in a step by step manner.

Postoperative pain management

Postoperative pain is a very important issue for several patients. Indifferent of the surgery type or method, pain management is very necessary. The relief from suffering leads to early mobilization, less hospital stay, reduced hospital costs, and increased patient satisfaction. An individual approach should be applied for pain control, rather than a fix dose or drugs. Additionally, medical, psychological, and physical condition, age, level of fear or anxiety, surgical procedure, personal preference, and response to agents given should be taken into account. The major goal in the management of postoperative pain is minimizing the dose of medications to lessen side effects while still providing adequate analgesia. Again a multidisciplinary team approach should be pursued planning and formulating a plan for pain relief, particularly in complicated patients, such as those who have medical comorbidities. These patients might appear increase for analgesia-related complications or side effects.

Approach of the treatment for pneumothorax

Pneumothorax can occur in several situations such as; chronic obstructive pulmonary disease (COPD) where emphysema is observed or due to a biopsy for malignancy suspicion. In any case it is a dangerous situation that requires immediate attention and treatment. Pneumothorax can be divided in primary and secondary. Staging of pneumothorax is also very important. In our current editorial we summarize etiology and treatment of pneumothorax from a panel of pulmonary physicians, oncologists and thoracic surgeons.

Bronchoscopic interventions for severe COPD

Chronic obstructive pulmonary disease (COPD) causes severe handicap among smokers. Most patients have to remain under continuous oxygen therapy at home. Moreover, respiratory infections are very common among these patients and vaccination is obligatory against influenza. Emphysema and bronchiectasis are observed with computed tomography (CT) and in several situations these parenchymal damages are responsible for pneumothorax in one case and pseudomonas aeroginosa infection. Novel mini-invasive techniques are used currently for emphysema treatments which are described extensively throughout our current work.

Pneumothorax in sarcoidosis

While sarcoidosis is a relatively common but often underdiagnosed disease, pneumothorax appears to be a rare clinical event observed mostly at the late stages of the disease course. The precise underlying mechanism of such complication is unclear and probably involves the formation of bullae due to bronchial obstruction and retraction-collapse of distracted lung tissue. Thoracoscopic bullectomy represent the preferred treatment option for recurrent pneumothoraces. The administration of corticosteroids for the treatment of pulmonary sarcoidosis may have a protecting effect for such recurrences, but remains a controversial issue.

Human immunodeficiency virus infection and pneumothorax

Pneumothorax is a serious and relatively frequent complication of human immunodeficiency virus (HIV) infection that may associate with increased morbidity and mortality and may prove difficult to manage, especially in patients with acquired immunodeficiency syndrome (AIDS).

Acute respiratory distress syndrome and pneumothorax

Acute respiratory distress syndrome (ARDS) can occur during the treatment of several diseases and in several interventional procedures as a complication. It is a difficult situation to handle and special care should be applied to the patients. Mechanical ventilation is used for these patients and several parameters are changed constantly until compliance is achieved. However, a complication that is observed during the application of positive airway pressure is pneumothorax. In our current work we will present definition and causes of pneumothorax in the setting of intensive care unit (ICU). We will identify differences and similarities of this situation and present treatment options.

Unusual causes of pneumothorax

Pneumothorax is divided to primary and secondary. It is a situation that requires immediate treatment, otherwise it could have severe health consequences. Pneumothorax can be treated either by thoracic surgeons, or pulmonary physicians. In our current work, we will focus on unusual cases of pneumothorax. We will provide the etiology and treatment for each case, also a discussion will be made for each situation.

The role for medical thoracoscopy in pneumothorax

Pneumothorax is a life threatening situation that requires fast treatment. There are two major classifications: Primary and Secondary. Staging of pneumothorax is also very important for treatment. Treatment of pneumont can be performed either from thoracic surgeons, or pulmonary physicians. In our current work we provide up-to-date information regarding pneumothorax classification, staging and treatment from the point of view of expert pulmonary physicians.

Pneumothorax in cystic fibrosis

Pneumothorax is recognized as a common and life-threatening complication in cystic fibrosis (CF) patients, especially in those who are infected with P. aeruginosa, B. cepacia or Aspergillus, need enteral feeding, are diagnosed as suffering from allergic bronchopulmonary aspergillosis (ABPA), developed massive hemoptysis, and their respiratory function is seriously compromised. Structural impairment and altered airflow dynamics in the lungs of CF patients are considered as the main predisposing factors, but also inhaled medications and non-invasive positive pressure ventilation (NIPPV) could increase the risk of pneumothorax. Clinical presentation could range from dramatic to very mild. Management of spontaneous pneumothorax occurring to patients with CF is essentially similar to that for non-CF patients. Therapeutic options include intercostal tube drainage, video-assisted thoracoscopic surgery (VATS), and medical or surgical pleurodesis. Pneumothorax increases both short- and long-term morbidity and mortality in CF patients and causes significant deterioration of their quality of life.

Tube thoracostomy; chest tube implantation and follow up

Pneumothorax is an urgent medical situation that requires urgent treatment. We can divide this entity based on the etiology to primary and secondary. Chest tube implantation can be performed either in the upper chest wall or lower. Both thoracic surgeons and pulmonary physicians can place a chest tube with minimal invasive techniques. In our current work, we will demonstrate chest tube implantation to locations, methodology and tools.

Pneumothorax after transbronchial needle biopsy

Currently there several diagnostic techniques that re used by radiologists and pulmonary physicians for lung cancer diagnostics. In several cases pneumothorax (PNTX) is induced and immediate action is needed. Both radiologists and pulmonary physicians can insert a chest tube for symptom relief. However; only pulmonary physicians and thoracic surgeons can provide a permanent solution for the patient. The final solution would be for a patient to undergo surgery for a final solution. In our current work we will provide all those diagnostic cases where PNTX is induced and treatment from the point of view of expert radiologists and pulmonary physicians.

Transbronchial lung biopsy and pneumothorax

Mini-interventional procedures are used in the everyday clinical practice by pulmonary physicians and radiologists. Fine needle aspiration and biopsy forceps are the tools mostly used. During these procedures pneumothorax can occur and immediate treatment is necessary. In our current work, we will focus on minimal invasive techniques for biopsy and pneumothorax treatment.

Catamenial pneumothorax

Catamenial pneumothorax (CP) is the most common form of thoracic endometriosis syndrome, which also includes catamenial hemothorax, catamenial hemoptysis, catamenial hemopneumothorax and endometriosis lung nodules, as well as some exceptional presentations. Usually onset of lung collapse is less than 72 hours after menstruation. Most commonly occurs in women aged 30-40 years, but has been diagnosed in young girls as early as 10 years of age and post menopausal women (exclusively in women of menstrual age) most with a history of pelvic endometriosis. Diagnosis can be hinted by high recurrence rates of lung collapse in a woman of reproductive age with endometriosis. Moreover; CA-125 is elevated. Video-assisted thoracoscopy or medical thoracoscopy is used for confirmation. In our current work we will present all aspects of CP from diagnosis to treatment.

Penetrating trauma

Pneumothorax occurs when air enters the pleural space. Currently there is increasing incidence of road traffic accidents, increasing awareness of healthcare leading to more advanced diagnostic procedures, and increasing number of admissions in intensive care units are responsible for traumatic (non iatrogenic and iatrogenic) pneumothorax. Pneumothorax has a clinical spectrum from asymptomatic patient to life-threatening situations. Diagnosis is usually made by clinical examination and imaging techniques. In our current work we focus on the treatment of penetrating trauma.

Pneumothorax: observation

Pneumothorax based on the cause, it can be divided into two large categories; primary and secondary. The staging of pneumothorax plays a crucial role for treatment. Currently both thoracic surgeons and pulmonary physicians can handle efficiently treatment. Pulmonary physicians with the minimally medical thoracoscopy while thoracic surgeons with a more extensive intervention. Experience defines the outcome in most situations and not the method. In our current work we will present data regarding the observation of pneumothorax from a panel of experts.

Pneumothorax: from definition to diagnosis and treatment

Pneumothorax is an urgent situation that has to be treated immediately upon diagnosis. Pneumothorax is divided to primary and secondary. A primary pneumothorax is considered the one that occurs without an apparent cause and in the absence of significant lung disease. On the other hand secondary pneumothorax occurs in the presence of existing lung pathology. There is the case where an amount of air in the chest increases markedly and a one-way valve is formed leading to a tension pneumothorax. Unless reversed by effective treatment, this situation can progress and cause death. Pneumothorax can be caused by physical trauma to the chest or as a complication of medical or surgical intervention (biopsy). Symptoms typically include chest pain and shortness of breath. Diagnosis of a pneumothorax requires a chest X-ray or computed tomography (CT) scan. Small spontaneous pneumothoraces typically resolve without treatment and require only monitoring. In our current special issue we will present the definition, diagnosis and treatment of pneumothorax from different experts in the field, different countries and present different methods of treatment.

Mitral Regurgitation - A Multidisciplinary Challenge

Mitral regurgitation is an increasing valvular disease that represents a difficult management challenge. Surgical treatment for degenerative mitral regurgitation is the standard of care treatment. Percutaneous therapies have emerged rapidly over the past years as an option for treatment of mitral regurgitation for selected, predominantly high-risk patients. Catheter-based devices mimic these surgical approaches with less procedural risk. Mitraclip® implantation mimics the surgical edge-to-edge leaflet repair technique, reducing the regurgitant area. We review the increasing evidence with the Mitraclip device reported to date.