Publications by authors named "Nikolaos A Papakonstantinou"

42 Publications

A modern approach to aortic valve insufficiency: Aortic root restoration via HAART 300 internal annuloplasty ring.

J Card Surg 2021 Aug 27. Epub 2021 Aug 27.

3rd Cardiac Surgery Department, Onassis Cardiac Surgery Center, Athens, Greece.

Background And Aim Of The Study: HAART 300 is an internal geometric annuloplasty ring. The safety and efficacy of this novel device in aortic valve (AV) repair in a single referral center are reported.

Methods: Twenty patients with trileaflet AV insufficiency with ascending aorta and/or aortic root enlargement were included. Subannular implantation was performed to correct annular dilatation, whereas concomitant leaflet repair was performed whenever required. All but two patients also received ascending aorta replacement, whereas selective sinus replacement was performed in all but five patients.

Results: Follow-up was for a maximum of 3.8 years and a mean of 2.2 years. Mean age was 54.2 years old. Moderate to severe preoperative AV insufficiency was noted in 75% of patients, whereas 70% of them had an ascending aorta over 45 mm. One patient was lost from follow-up. Overall mortality as well as major complication rates were zero. Early postoperatively, no more than mild AV regurgitation was detected, whereas only one patient appeared with moderate AV regurgitation during our 2.2-year follow-up. New York Heart Association class was also significantly lower compared to preoperative values and valve gradients remained low at last follow-up.

Conclusions: Geometric ring annuloplasty is a safe and effective valve sparing approach to deal with AV insufficiency contributing to overall root reconstruction. Short-term results are excellent rendering this easily reproducible and versatile method very attractive.
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http://dx.doi.org/10.1111/jocs.15947DOI Listing
August 2021

External flail chest stabilization; The simple, low-cost way.

J Cardiovasc Thorac Res 2021 28;13(2):174-175. Epub 2020 Nov 28.

Cardiothoracic Surgery Department, University Hospital of Ioannina, School of Medicine, Ioannina, Greece.

Flail chest is a life-threatening clinical entity which can be complicated by respiratory insufficiency. Paradoxical motion of a part of chest wall is the basic cause to put the blame on. Consequently, stabilization of the chest wall is occasionally of paramount importance to achieve early extubation in a patient with post-trauma respiratory insufficiency. Hereby, a simple, low cost, harmless and effective approach of external stabilization is presented.
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http://dx.doi.org/10.34172/jcvtr.2020.58DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302900PMC
November 2020

Perceval S valve empire: healing the Achilles' heel of sutureless aortic valves.

J Cardiovasc Surg (Torino) 2021 May 20. Epub 2021 May 20.

Cardiothoracic Surgery Department, General Hospital of Athens Evangelismos', Athens, Greece.

Aortic valve replacement is the treatment of choice concerning aortic valve disease. Excellent short- and longterm clinical results are reported. Patients referred for aortic valve replacement are getting older and older, so bioprosthetic valves play a more central role worldwide. However, patient comorbidities are also increased more often rendering patients unsuitable for open conventional aortic valve replacement. As a result, transcatheter aortic valve implantation has become the treatment of choice in patients at very high surgical risk. However, the percutaneous technique is related to major disadvantages provided that the diseased native valve is left in place. Its durability is also uncertain. More recently, sutureless Perceval S valve bioprosthesis has gained ground in the field of aortic stenosis therapy filling the gap between conventional aortic valve replacement and transcatheter approach. Excellent haemodynamic and clinical results are reported. Its deployment is performed under direct view and ischemic and overall operative times are significantly decreased. Five-year follow-up results are also optimal. However, the "Achilles' heel" of sutureless technology is increased rates of postoperative permanent pacemaker implantation requirement compared to conventional approach. The incidence of this complication varies in literature. Patient-related factors such as preoperative conduction disorders, older age and short membranous septum are predictors of postoperative pacemaker requirement. However, several technical modifications with regard to manufacturer recommendations can be adopted to mitigate this complication. Appropriate annular decalcification, higher guiding sutures placement, reduced balloon pressure and duration and avoiding of oversizing can contribute to prevent from this complication.
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http://dx.doi.org/10.23736/S0021-9509.21.11608-8DOI Listing
May 2021

Congenital, acquired, or both? The only two congenitally based, acquired heart diseases.

J Card Surg 2021 Aug 28;36(8):2850-2856. Epub 2021 Apr 28.

Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece.

Discrete subaortic stenosis (DSS) is a type of left ventricular outflow tract obstruction whereas double-chambered right ventricle is a form of right ventricular outflow tract obstruction. Both of these cardiac malformations share lots of similar characteristics which classify them as acquired developmental heart diseases despite their congenital anatomical substrate. Both of them are frequently associated to ventricular septal defects. The initial stimulus in their pathogenetic process is anatomical abnormalities or variations. Subsequently, a hemodynamic process is triggered finally leading to an abnormal subaortic fibroproliferative process with regard to DSS or to hypertrophy of ectopic muscles as far as double-chambered right ventricle is concerned. In many cases, these pathologies are developed secondarily to surgical management of other congenital or acquired heart defects. Moreover, high recurrence rates after initial successful surgical therapy, particularly regarding DSS, have been described. Finally, an interesting coexistence of DSS and double-chambered aortic ventricle has also been reported in some cases.
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http://dx.doi.org/10.1111/jocs.15588DOI Listing
August 2021

Aortocoronary saphenous vein graft aneurysm misdiagnosed as aortic arch aneurysm.

Ann Card Anaesth 2021 Apr-Jun;24(2):247-249

Department of Radiolgy. Interventional Radiology Unit. General Hospital of Athens Evangelismos, Greece.

Coronary artery bypass grafting is the mainstay of revascularization worldwide. However, the most widely used saphenous vein grafts are related to a number of late sequelae. Aortocoronary saphenous vein graft aneurysms mainly diagnosed incidentally are one of these complications. Although rare, given the fatal risk of rupture if left untreated, management either with percutaneous intervention or open redo surgery should be considered. However, no guidelines are established in current scarce literature. Hereby, we present the successful percutaneous management of a huge saphenous vein graft aneurysm via coiling, avoiding the risks of repeat sternotomy.
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http://dx.doi.org/10.4103/aca.ACA_74_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8253034PMC
April 2021

Reply to Roberto et al.

Eur J Cardiothorac Surg 2021 07;60(1):208

Cardiovascular and Thoracic Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece.

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http://dx.doi.org/10.1093/ejcts/ezab088DOI Listing
July 2021

Reply to Acharya et al.

Eur J Cardiothorac Surg 2021 07;60(1):204-205

Cardiovascular and Thoracic Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece.

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http://dx.doi.org/10.1093/ejcts/ezab002DOI Listing
July 2021

Dantrolene Induces Mitigation of Myocardial Ischemia-Reperfusion Injury by Ryanodine Receptor Inhibition.

Semin Thorac Cardiovasc Surg 2021 Jan 15. Epub 2021 Jan 15.

1st Department of Critical Care Medicine, General Hospital of Athens "Evangelismos'', School of Medicine, National and Kapodistrian University of Athens, Greece.

The impairment of intracellular calcium homeostasis plays an essential role during ischemia-reperfusion injury. Calcium release from sarcoplasmic reticulum which is triggered by myocardial ischemia is mainly mediated by ryanodine receptors. Dantrolene sodium is a ryanodine receptor antagonist. The objective of the present study was to evaluate the in-vivo impact of dantrolene sodium on myocardial ischemia-reperfusion injury in swine models. An in vivo, experimental trial comparing 10 experimental animals which received dantrolene sodium with 9 control swine models was conducted. Their left anterior descending coronary artery was temporarily occluded for 75 minutes via a vessel tourniquet, which was then released. Myocardial reperfusion was allowed for 24 hours. Dantrolene was administered at the onset of the reperfusion period and levels of troponin, creatine phosphokinase and creatine kinase myocardial band between the two groups were compared. Additionally, various other hemodynamic parameters and left ventricular morphology and function were examined. There were significantly lower values of troponin, creatine phosphokinase and creatine kinase myocardial band in the dantrolene group indicating less ischemia-reperfusion injury. Moreover, the postischemic cardiac index was also greater in the dantrolene group, whereas viable myocardium was also better preserved. In conclusion, the in vivo cardioprotective role of dantrolene sodium against ischemia-reperfusion injury in swine models was indicated in this study. Therefore, dantrolene sodium administration could be a promising treatment against ischemia-reperfusion injury in humans. However, large randomized clinical studies should be firstly carried out to prove this hypothesis.
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http://dx.doi.org/10.1053/j.semtcvs.2021.01.004DOI Listing
January 2021

Elective replacement of the ascending aorta: is the 5.5-cm threshold appropriate? The insidious, small aorta.

Eur J Cardiothorac Surg 2021 04;59(3):554-561

Cardiovascular and Thoracic Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece.

Objectives: As thoracic aortic aneurysm disease continues to cause significant morbidity and mortality in the general population, the cardiovascular community continues the search for the golden threshold of elective surgical replacement of the ascending aorta.

Methods: Thoracic aortic aneurysm is a common disease, classified within the 20 most common causes of death in patients over 65 years old. Once aortic complications like dissection or rupture occur, they can prove fatal. Prophylactic surgical replacement of the ascending aorta remains the mainstay of treatment to prevent these complications. Current American and European guidelines agree that the threshold for the diameter for elective replacement of the ascending aorta in non-syndromic, asymptomatic aneurysmal disease is 5.5 cm. Overall, aortic dissection is related to poor prognosis, thus making early intervention paramount.

Results: There is a critical size above which the risk of dissection or rupture becomes extremely high. However, a significant post-dissection increase in diameter is reported, thus rendering the predissection aortic diameter well below the current threshold for elective surgical replacement of the ascending aorta. Moreover, it is widely reported that the majority of acute aortic dissections would not meet the criteria for prophylactic surgery prior to dissection. Additionally, elective surgical ascending aortic replacement in the current era shows a significantly improved risk-benefit ratio, which justifies a more aggressive approach in the management of aortic aneurysmal disease.

Conclusions: As a result, there is a lot of discussion in the literature about the requirement of a leftward shifting of the surgical threshold for elective aortic replacement.
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http://dx.doi.org/10.1093/ejcts/ezaa387DOI Listing
April 2021

SARS-CoV-2, COVID-19 pandemic, "coronawar"… oops; something was forgotten. Cardiovascular disease is still here! The collateral damage.

J Card Surg 2020 Sep 11;35(9):2134-2136. Epub 2020 Jul 11.

Department of Cardiovascular and Thoracic Surgery, General Hospital of Athens "Evangelismos", Athens, Greece.

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http://dx.doi.org/10.1111/jocs.14791DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405193PMC
September 2020

Epicardial cardioverter defibrillator implantation due to post-fontan ventricular tachycardia.

Ann Card Anaesth 2020 Apr-Jun;23(2):235-236

Department of Cardiothoracic Surgery, General Hospital of Athens "Evangelismos", Athens, Greece.

Long-term survival of patients submitted to a Fontan procedure is reduced because of arrhythmias. Late post-Fontan ventricular tachycardia is extremely rare, but it can be fatal. Consequently, the implantation of an implantable cardioverter defibrillator may be required. The implantation of such a device after a Fontan operation can be rather difficult due to anatomic reasons that exclude transvenous approach. Epicardial ICD implantation is a treatment option for these patients. Transatrial approach, shock ICD coils placement in azygos vein or directly in the pericardium are possible alternatives. We hereby present a successful epicardial implantable cardioverter defibrillator implantation in a post-Fontan 39-year-old man suffering from ventricular tachycardia.
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http://dx.doi.org/10.4103/aca.ACA_234_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336958PMC
March 2021

Cardioplegic storage solution: Is it the guardian of saphenous vein graft endothelium?

J Card Surg 2020 May 24;35(5):996-1003. Epub 2020 Mar 24.

Cardiothoracic Surgery Department, School of Medicine, University Hospital of Ioannina, Greece.

Introduction: Despite their suboptimal long-term patency, saphenous vein grafts are the most widely used conduits to achieve complete revascularization during coronary artery bypass grafting (CABG). Although vein storage critically impairs endothelial integrity, contradictory data concerning optimal storage solutions exist. The aim of this study is to explore any in vitro impact of cardioplegic solutions and temperature on vein grafts endothelial integrity during their storage.

Materials And Methods: A single-center, prospective trial including 40 consecutive patients was conducted. Eligibility criteria included patients submitted to CABG receiving at least one vein graft. An excess segment of the graft was harvested and divided into four different parts. Each one of them was stored under different conditions; either in a conventional heparin-enriched blood solution or in a cardioplegic solution, at room temperature (20°C-22°C) and in the refrigerator (5°C). Endothelial integrity was evaluated via immunohistochemistry using an antibody against CD31.

Results: Endothelial integrity (measured in a scale from 1-worst to 5-best) was significantly better after cardioplegic solution storage (2.83 ± 0.15 and 3.10 ± 0.13 in cold and room temperature, respectively) compared with storage in conventional solutions (2.23 ± 0.16 and 2.0 ± 0.15 in cold and room temperature, respectively). A significant effect of cardioplegic storage solution, as well as of cold temperature and cardioplegic solution interaction on endothelial preservation was reported, whereas storage temperature did not prove a significant factor by its own.

Conclusions: Cardioplegic storage solutions result in significantly better endothelial preservation compared with conventional heparin-enriched blood solutions. The association with superior clinical outcomes remains to be proved.
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http://dx.doi.org/10.1111/jocs.14519DOI Listing
May 2020

The Perceval S valve. Making the good better… or optimal?

Eur J Cardiothorac Surg 2020 04;57(4):812-813

Cardiac Surgery Department, General Hospital of Athens Hippocratio, Athens, Greece.

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http://dx.doi.org/10.1093/ejcts/ezz315DOI Listing
April 2020

Editor's Choice - Cryopreserved Allografts for Arterial Reconstruction after Aorto-Iliac Infection: A Systematic Review and Meta-Analysis.

Eur J Vasc Endovasc Surg 2019 Jul 12;58(1):120-128. Epub 2019 Jun 12.

Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA.

Objective: Native and aortic graft infections are rare, but they represent one of the most life threatening complications of vascular surgery. Several materials and surgical approaches have been developed so far. Among them, cryopreserved allografts have been proposed as a treatment option. A systematic review and meta-analysis was conducted to investigate the role of cryopreserved allografts for arterial reconstruction after aorto-iliac infection.

Methods: The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Patient baseline characteristics were investigated, along with 30 outcomes after use of cryopreserved arterial allografts for reconstruction after aorto-iliac infection. Pooled proportions with 95% CIs of outcome rates were calculated.

Results: A total of 31 studies, including 1,377 patients, finally participated in the meta-analysis. Among the early outcomes, 30 day mortality was 14.91% (95% CI 11.78-18.31). Peri-anastomotic rupture/allograft disruption rate was 5.90% (95% CI 2.77-9.88), while pooled aneurysmal degeneration/allograft dilatation was 4.99% (95% CI 1.60-9.68). A pooled rate of 3.11% (95% CI 1.60-4.98) was estimated for pseudoaneurysm formation after the use of cryopreserved arterial allografts, while the allograft thrombotic/stenotic complication rate and peri-anastomotic infection were 12.19% (95% CI 7.90-17.15) and 3.32% (95% CI 1.90-5.03), respectively. Mortality during follow up was 19.24% (95% CI 11.97-27.58), while allograft related mortality during follow up was 3.58% (95% CI 1.56-6.15). A pooled allograft related re-operation rate was estimated at 24.87% (95% CI 17.89-32.51).

Conclusions: The use of cryopreserved allograft seems to be a safe and durable option with acceptable outcomes for treatment of aorto-iliac infection.
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http://dx.doi.org/10.1016/j.ejvs.2019.03.003DOI Listing
July 2019

Lobectomy due to Pulmonary Vein Occlusion after Radiofrequency Ablation for Atrial Fibrillation.

Korean J Thorac Cardiovasc Surg 2018 Aug 5;51(4):290-292. Epub 2018 Aug 5.

Department of 1st Pulmonary Medicine, Thoracic Diseases General Hospital Sotiria, National and Kapodistrian University of Athens.

Radiofrequency ablation is an effective treatment for atrial fibrillation. Pulmonary vein stenosis/occlusion is one of its rare complications. Herein, the case of a 50-year-old man with hemoptysis and migratory pulmonary infiltrations after transcatheter radiofrequency ablation for atrial fibrillation is presented. Initially, pneumonia, interstitial pulmonary disease, or lung cancer was suspected, but wedge resection revealed hemorrhagic infiltrations. Chest computed tomography pulmonary angiography detected no left superior pulmonary vein due to its total occlusion, and left upper lobectomy was performed. Post-ablation pulmonary vein occlusion must be strongly suspected in cases of migratory pulmonary infiltrations and/or hemoptysis.
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http://dx.doi.org/10.5090/kjtcs.2018.51.4.290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089619PMC
August 2018

Alexander the Great's Life-Threatening Thoracic Trauma.

Korean J Thorac Cardiovasc Surg 2018 Aug 5;51(4):241-246. Epub 2018 Aug 5.

Department of English Literature, University of Athens.

Alexander the Great was a world-class leader with tremendous courage. He paid no heed to the dangers of the battlefield, so he was always in the front lines. However, his excessive courage put his life in danger. Herein, we present an analysis of the information contained in the chronicles about a very severe, life-threatening thoracic trauma that nearly killed the great . The detailed descriptions made by Arrianus allow us to conclude that Alexander the Great experienced a nearly fatal case of tension pneumothorax. Information on how he was managed is also presented.
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http://dx.doi.org/10.5090/kjtcs.2018.51.4.241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089630PMC
August 2018

Frozen Elephant Trunk: An Alternative Surgical Weapon Against Extensive Thoracic Aorta Disease. A Three-Year Meta-Analysis.

Heart Lung Circ 2019 Feb 11;28(2):213-222. Epub 2018 Jun 11.

Vascular Surgery Department, "Attikon" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.

Background: Conventional open total arch replacement is the treatment of choice for surgical aortic arch pathologies. However, it is a two-stage procedure related to high cumulative and interval mortality rates. Hybrid type III aortic arch reconstruction, the so-called "frozen elephant trunk" is a one-stage alternative approach.

Methods: A meta-analysis and detailed review of the literature published from January 2013 until December 2016, concerning frozen elephant trunk hybrid approach was conducted and data for morbidity and mortality rates were extracted.

Results: Among 989 patients included, the pooled 30-day or in-hospital mortality rate was 5.04% (95%CI=1.13-10.74), stroke rate was 2.38% (95%CI=0.13-6.30), and the irreversible paraplegia due to spinal cord injury rate was 0.63% (95%CI=0.00-2.73). Finally, the pooled cumulative survival at 1year was remarkably high (86.7%, 95%CI=81.08-92.90).

Conclusions: Frozen elephant trunk is a safe alternative to conventional elephant trunk repair for extensive aortic arch pathologies with acceptable short- and mid-term results, avoiding the interval mortality hazard.
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http://dx.doi.org/10.1016/j.hlc.2018.04.306DOI Listing
February 2019

Oesophageal necrosis after thoracic endovascular aortic repair: a minimally invasive endovascular approach-a dramatic complication.

Interact Cardiovasc Thorac Surg 2019 01;28(1):9-16

Department of Cardiovascular and Thoracic Surgery, General Hospital of Athens "Evangelismos", Athens, Greece.

There are few cases in the literature reporting dysphagia caused by oesophageal compression by the aorta due to acute or chronic aortic pathology. This type of dysphagia is called dysphagia aortica. Thoracic endovascular aortic repair is nowadays the treatment of choice for anatomically suitable patients experiencing complicated Type B aortic dissection. Oesophageal necrosis is a rare but fatal complication following thoracic endovascular aortic repair. Extrinsic oesophageal compression by the thrombosed aneurysmal sac, a mediastinal haematoma or extensive thrombosis in the false lumen of a dissected aorta and acute vascular occlusion of the oesophageal supply are possible mechanisms. When oesophageal necrosis is suspected, endoscopic examination and computed tomography imaging should be performed repeatedly. Oesophagoscopy will confirm the diagnosis revealing a black, diffusely necrotic and ulcerated oesophageal mucosa. It is critical to intervene before full-thickness oesophageal wall necrosis and mediastinitis occur. Guidelines are absent because of the rarity of this complication. Moreover, lack of a large series does not permit the establishment of guidelines either. However, oesophagectomy of the impaired oesophagus is the only chance for survival. Unfortunately, survival rates are disappointing. Prevention and awareness is the cornerstone of success. Early endoscopic examination when oesophageal necrosis is suspected due to even minimal symptoms will detect this fatal menace on time.
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http://dx.doi.org/10.1093/icvts/ivy193DOI Listing
January 2019

Aortic Arch Reconstruction: Are Hybrid Debranching Procedures a Good Choice?

Heart Lung Circ 2018 Nov 30;27(11):1335-1349. Epub 2018 Mar 30.

Vascular Surgery Department, "Attikon" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.

Introduction: Conventional open total arch replacement is the treatment of choice for surgical aortic arch pathologies. However, it is an invasive procedure, requiring cardiopulmonary bypass and deep hypothermic circulatory arrest leading to significant morbidity and mortality rates. Hybrid aortic arch debranching procedures without (type I) or with (type II) ascending aorta replacement seek to limit operative, bypass, and circulatory arrest times by making the arch repair procedure simpler and shorter.

Material And Methods: A meta-analysis and detailed review of the literature published from January 2013 until December 2016, concerning hybrid aortic arch debranching procedures was conducted and data for morbidity and mortality rates were extracted.

Results: As far as type I hybrid aortic arch reconstruction is concerned, among the 122 patients included, the pooled endoleak rate was 10.78% (95%CI=1.94-23.40), 30-day or in-hospital mortality was 3.89% (95%CI=0.324-9.78), stroke rate was 3.79% (95%CI=0.25-9.77) and weighted permanent paraplegia rate was 2.4%. In terms of type II hybrid approach, among 40 patients, endoleak rate was 12.5%, 30-day or in-hospital mortality rate was 5.3%, stroke rate was 2.5%, no permanent paraplegia was noticed and late mortality rate was 12.5%.

Conclusions: Hybrid aortic arch debranching procedures are a safe alternative to open repair with acceptable short- and mid-term results. They extend the envelope of intervention in aortic arch pathologies, particularly in high-risk patients who are suboptimal candidates for open surgery.
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http://dx.doi.org/10.1016/j.hlc.2018.03.016DOI Listing
November 2018

Pulmonary actinomycosis masquerading as lung cancer: keep it in mind.

ANZ J Surg 2019 07 8;89(7-8):966-968. Epub 2018 Feb 8.

Cardiothoracic Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece.

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http://dx.doi.org/10.1111/ans.14397DOI Listing
July 2019

Sutureless aortic valve implantation in patient with porcelain aorta via unclamped aorta and deep hypothermic circulatory arrest.

Ann Card Anaesth 2017 Oct-Dec;20(4):447-449

Department of Cardiac Surgery, Extracorporeal Circulation Unit, Evangelismos General Hospital of Athens, Athens, Greece.

Severe atherosclerotic calcification of the ascending aorta, the so-called porcelain aorta, precludes cardiac surgeons from placing an aortic cross-clamp and direct aortic cannulation due to the increased risk of systemic embolism and stroke. In the present report, we support the option of sutureless valve implantation in a case of a porcelain ascending aorta, with deep hypothermic circulatory arrest and also without aortic cross-clamp.
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http://dx.doi.org/10.4103/aca.ACA_70_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5661317PMC
June 2018

Endovascular stent grafting for ascending aorta diseases.

J Vasc Surg 2017 11 19;66(5):1587-1601. Epub 2017 Aug 19.

Department of Vascular Surgery, "Attikon" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.

Objective: Conventional open surgery encompassing cardiopulmonary bypass has been traditionally used for the treatment of ascending aorta diseases. However, more than one in five of these patients will be finally considered unfit for open repair. We conducted a systematic review and meta-analysis to investigate the role of thoracic endovascular aortic repair (TEVAR) for aortic diseases limited to the ascending aorta.

Methods: The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We investigated patients' baseline characteristics along with early (30 days/in-hospital stay) and late (beyond 30 days/in-hospital stay) outcomes after TEVAR limited to the ascending aorta and not involving the arch vessels. Separate analyses for case reports and case series were conducted, and pooled proportions with 95% confidence intervals (CIs) of outcome rates were calculated.

Results: Approximately 67% of the patients had a prior cardiac operation. TEVAR was performed mainly for acute or chronic Stanford type A dissection (49%) or pseudoaneurysm (28%). The device was usually delivered through the femoral artery (67%), and rapid ventricular pacing was used in nearly half of the patients. Technical success of the method was 95.5% (95% CI, 87.8-99.8). Among the early outcomes, conversion to open repair was 0.7% (95% CI, 0.1-4.8), whereas mortality was 2.9% (95% CI, 0.02-8.6). We estimated a pooled rate of 1.8% (95% CI, 0.1-7.0) for neurologic events (stroke or transient ischemic attack) and 0.8% (95% CI, 0.1-5.6) for myocardial infarction. Late endoleak was recorded in 16.4% (95% CI, 8.2-26.0), and 4.4% (95% CI, 0.1-12.4) of the population died in the postoperative period. Finally, reoperation was recorded in 8.9% (95% CI, 3.1-16.4) of the study sample.

Conclusions: TEVAR in the ascending aorta seems to be safe and feasible for selected patients with various aortic diseases, although larger studies are required.
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http://dx.doi.org/10.1016/j.jvs.2017.07.064DOI Listing
November 2017

Myocardial revascularization without extracorporeal circulation; Why hasn't it convinced yet?

Ann Card Anaesth 2017 Apr-Jun;20(2):219-225

Department of Cardiothoracic Surgery, University Hospital of Patras, School of Medicine, Rion 26500, Patras, Greece.

Extracorporeal circulation has led to a great development in cardiovascular surgery during the last five decades. Its time-proven efficacy and safety have made on-pump coronary artery bypass grafting (CABG) the gold standard method of surgical revascularization. However, coronary revascularization on cardiopulmonary bypass and the accompanying aortic manipulation are related to plenty of deleterious complications. Therefore, off-pump CABG surgery was established to avoid complications. Nevertheless, despite the initial enthusiasm on this technique, only 20% of myocardial revascularization procedures worldwide are performed off-pump. Not only are off-pump cardiac procedures more technically difficult but also they do not provide better results in terms of graft patency, completeness of revascularization, repeat revascularization requirement, cost, and quality of life. Completeness of revascularization and anastomotic quality should not be compromised to avoid cardiopulmonary bypass.
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http://dx.doi.org/10.4103/aca.ACA_39_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5408529PMC
November 2017

Transaortic video-assisted excision of a left ventricular hemangioma.

J Card Surg 2017 Mar 15;32(3):201-202. Epub 2017 Feb 15.

Cardiothoracic Surgery Department, General Hospital of Athens "Evangelismos," Athens, Greece.

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http://dx.doi.org/10.1111/jocs.13108DOI Listing
March 2017

Hippocrates Quoted "If an Empyema Does Not Rupture, Death Will Occur": Is Medical Thoracoscopy Able to Make It Rupture Safely?

J Bronchology Interv Pulmonol 2017 Jan;24(1):15-20

Departments of *Thoracic Surgery ‡General Surgery, General Oncology Hospital of Kifissia "Agioi Anargyroi", Kifissia, Athens, Greece Departments of †Respiratory Medicine §Thoracic Surgery, King's College Hospital, London ∥Department of Thoracic Surgery, Nottingham University Hospital, Nottingham, UK.

Background: The aim of this study was to evaluate the safety and efficacy of medical thoracoscopy through a single port [single-port medical thoracoscopy (S-MT)] for the treatment of empyema thoracis in its early stages.

Methods: We performed a retrospective analysis reviewing the medical records of 84 patients referred for empyema and treated by medical thoracoscopy at our Thoracic Departments from January 2001 until November 2014. S-MT was performed under local anesthesia with neuroleptoanalgesia and spontaneous breathing using a single 1-cm incision for debridement and lavage of the pleural cavity.

Results: A total of 84 patients underwent S-MT for pleural empyema stage I (9 patients, 10.7%) or II (75 patients, 89.3%). Median age was 61.8 years (range, 18 to 84 y). Male to female ratio was 3.76. Surgery was performed 5 to 26 days after the onset of symptoms. Macroscopically complete debridement of the pleural cavity was achieved in 71 patients (84.5% of cases). The rest 15.5% of cases required video-assisted thoracoscopic surgery or open decortication due to trapped-lung syndrome. Median operation time was 45 minutes (range, 30 to 94 min). No intraoperative complications occurred. In-hospital mortality was zero, whereas in-hospital morbidity rate was 16.7%. Median hospital stay was 7.8 days (range, 3 to 18 days). Recurrence rate was 4.8% as 4 patients experienced a relapse of empyema.

Conclusion: It seems that S-MT is a minimally invasive, safe and effective procedure for the treatment of pleural empyema with very good results in early stages of the disease and reduced time of hospital stay.
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http://dx.doi.org/10.1097/LBR.0000000000000310DOI Listing
January 2017

Cardiac surgery or interventional cardiology? Why not both? Let's go hybrid.

J Cardiol 2017 01 8;69(1):46-56. Epub 2016 Oct 8.

Cardiovascular and Thoracic Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece.

A hybrid strategy, firstly performed in the 1990s, is a combination of tools available only in the catheterization laboratory with those available only in the operating room in order to minimize surgical morbidity and face with any cardiovascular lesion. The continuous evolution of stent technology along with the adoption of minimally invasive surgical approaches, make hybrid approaches an attractive alternative to standard surgical or transcatheter techniques for any given set of cardiovascular lesions. Examples include hybrid coronary revascularization, when an open surgical anastomosis of the left internal mammary artery to the left anterior descending coronary artery is performed along with stent implantation in non-left anterior descending coronary vessels, open heart valve surgery combined with percutaneous coronary interventions to coronary lesions, hybrid aortic arch debranching combined with endovascular grafting for thoracic aortic aneurysms, hybrid endocardial and epicardial atrial fibrillation procedures, and carotid artery stenting along with coronary artery bypass grafting. The cornerstone of success for all of these methods is the productive collaboration between cardiac surgeons and interventional cardiologists. The indications and patient selection of these procedures are still to be defined. However, high-risk patients have already been shown to benefit from hybrid approaches.
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http://dx.doi.org/10.1016/j.jjcc.2016.09.007DOI Listing
January 2017

Total arterial revascularization: A superior method of cardiac revascularization.

Hellenic J Cardiol 2016 May - Jun;57(3):152-156. Epub 2016 Jun 24.

Cardiothoracic Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece.

For over 40 years, the left internal thoracic artery has been used as the gold standard for myocardial revascularization and anastomosis over the left anterior descending artery due to its excellent patency rates. However, the right internal thoracic artery behaves in the same manner as the left, also having excellent long-term patency. Hence, no patient should be deprived of the benefits of total arterial revascularization allowed by the bilateral use of both internal thoracic arteries.
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http://dx.doi.org/10.1016/j.hjc.2016.06.002DOI Listing
June 2017

Novel no touch technique of saphenous vein harvesting: Is great graft patency rate provided?

Ann Card Anaesth 2016 Jul-Sep;19(3):481-8

Department of Cardiothoracic Surgery, University Hospital of Ioannina, School of Medicine, 45500 Ioannina, Greece.

Coronary artery bypass grafting surgery effectively relieves signs and symptoms of myocardial ischemia. The left internal thoracic artery (LITA) graft is the gold standard having 90-95% patency rate at 10 years, whereas only 50% of saphenous vein (SV) grafts are patent at 10 years. However, there is a novel "no touch" technique in order to harvest an SV complete with its cushion of surrounding tissue, thus maintaining its endothelium-intact. Significantly superior short- and long-term graft patency rates comparable to LITA grafts can be achieved. Consequently, the SV may be revived as an important conduit in coronary artery bypass surgery.
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http://dx.doi.org/10.4103/0971-9784.185537DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971977PMC
March 2017

Mechanisms of oxidative stress and myocardial protection during open-heart surgery.

Ann Card Anaesth 2015 Oct-Dec;18(4):555-64

Department of Cardiovascular and Thoracic Surgery, "Evangelismos'' General Hospital of Athens, Athens, Greece.

Cold heart protection via cardioplegia administration, limits the amount of oxygen demand. Systemic normothermia with warm cardioplegia was introduced due to the abundance of detrimental effects of hypothermia. A temperature of 32-33°C in combination with tepid blood cardioplegia of the same temperature appears to be protective enough for both; heart and brain. Reduction of nitric oxide (NO) concentration is in part responsible for myocardial injury after the cardioplegic cardiac arrest. Restoration of NO balance with exogenous NO supplementation has been shown useful to prevent inflammation and apoptosis. In this article, we discuss the "deleterious" effects of the oxidative stress of the extracorporeal circulation and the up-to-date theories of "ideal'' myocardial protection.
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http://dx.doi.org/10.4103/0971-9784.166465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4881677PMC
July 2016

Cardiac tumors: a retrospective multicenter institutional study.

J BUON 2015 Jul-Aug;20(4):1115-23

Cardiac Surgery Department, General Hospital of Athens "Evangelismos'", Athens, Greece.

Purpose: Primary cardiac tumors are uncommon but not extremely rare. Cardiac tumors, mostly intracavitary, include benign and malignant tumors that arise from the endocardium, heart valves or myocardium. This retrospective study summarizes the experience of the Cardiac Surgery Departments of three tertiary Hospitals in this field, and particularly in cardiac myxomas, over the last 29 years. Herein, we present the results of cardiac tumors excision in relation to postoperative morbidity and mortality.

Methods: Between 1985 and 2014, 117 patients, aged from 16 to 82 years, underwent resection of a cardiac tumor.

Results: Ninety one of the tumors (77.78%) were myxomas, 15 of them (12.82%) were other primary cardiac tumors, 7 of them (5.98%) were infra-diaphragmatic tumors and the remaining 4 tumors (3.42%) were benign intracavitary masses (thrombi). Patients operated on for a cardiac tumor had a 30-day mortality rate of 3.29%. Atrial fibrillation appeared in 21 out of 91 patients (23.07%) operated on for cardiac myxoma, while neurological complications were observed in 3 patients (3.29%). Re-exploration for bleeding was performed in 5 out of 91 cases (5.49%) and recurrence occurred in 4.39% of myxomas.

Conclusions: Despite being rare, primary cardiac tumors require open heart intervention soon after their diagnosis in order to prevent complications and achieve low mortality rates.
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November 2015
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