EBV treatment in hyperinflated patients with heterogeneous emphysema without collateral ventilation resulted in clinically meaningful benefits in lung function, dyspnea, exercise tolerance, and quality of life, with an acceptable safety profile. Clinical trial registered with www.clinicaltrials.gov (NCT02022683).

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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is ministernotomy superior to conventional approach for aortic valve replacement (AVR)? Altogether, more than 115 papers were found using the reported search, of which six 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. We conclude that ministernotomy can be performed safely for AVR, without increased risk of death or other major complication; however, few objective advantages have been shown. Ministernotomy can be offered on the basis of patient choice and cosmesis rather than evident clinical benefit.

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Esmolol at millimolar concentrations causes diastolic ventricular arrest by two mechanisms: at 1 mmol/L (and below), the pronounced negative inotropic effect is due largely to inhibition of L-type Ca(2+) channels; additionally, higher concentrations prevent action potential conduction, probably due to the inhibition of fast Na(+) channels.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with acute aortic intramural haematoma (IMH) is open surgical repair superior to conservative management. IMH is defined as a clinical condition related to but pathologically distinct from aortic dissection. In this potentially lethal entity, there is haemorrhage into the aortic media in the absence of an intimal tear. Altogether more than 204 papers were found using the reported search terms, from which six systematic reviews 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. IMH represents 17% of all dissections, whereas in postmortem studies this condition is found in 4-13%. The 30-day mortality of IMH is 24% (36% with type A and 12% with type B IMH; P<0.05). With surgical repair, 30-day mortality of type A IMH was 14% for patients treated surgically and 36% for patients treated medically with a P-value of 0.02. Survival at 1, 2, 3, 5 and 10 years was respectively: 81+/-21%, 87+/-8%, 83+/-6%, 65+/-22% and 44+/-14%. In contrast, with 8% mortality associated with medical treatment, prognosis of type B IMH is more favourable without surgical intervention, the latter associated with a 30-day mortality of 33% (P<0.05). Symptomatic patients and those with rapid progression or overt dissection during follow-up need emergent surgery. Ascending aortic diameter of >50 mm or subadventitial haematoma thickness of >12 mm should be considered as the candidates for early surgery. Although IMH seems to have an improved prognosis over aortic dissection, survivors of IMH are at significant risk for progressive aortic abnormalities, including aortic rupture, aneurysm, and ulceration. We conclude that surgical treatment of aortic IMH involving the ascending aorta with open distal replacement of ascending aorta results in lower mortality and longer survival compared to conservative management. IMH affecting the descending aorta can be managed with medical or endovascular interventional approach. In this latter group, serial imaging of the aorta is recommended, as aneurysm formation is not uncommon.

The predominant method of myocardial protection during cardiac surgery is hyperkalaemic cardioplegia, inducing depolarised arrest. Since its development in the 1970s, the only real change has been to alter the vehicle to blood. Although blood cardioplegia was shown to be 'superior' to crystalloid cardioplegia, this advantage is marginal and might explain the continuous use of crystalloid cardioplegia by some surgeons. To achieve significant improvements in cardioplegic protection, more radical and conceptual changes in the solution, such as those potentially achieved by 'polarised' arrest, should be explored.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: does intermittent cross-clamp fibrillation provide equivalent myocardial protection compared to cardioplegia in patients undergoing bypass graft revascularisation? Altogether, 58 papers were found using the reported search, of which 13 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. We identified 13 studies, of which eight were randomised prospective trials. None of these studies found increased mortality, seven analyzed serum cardiac enzymes and showed that intermittent ischemic arrest provides equal or better protection compared to cardioplegic techniques. Two studies found an increased usage of inotropes and intra aortic balloon pump (IABP) in the intermittent ischemic arrest group. We conclude that intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate postoperative outcome comparable to cardioplegic arrest in first-time coronary artery bypass graft (CABG). The ischaemic duration associated with intermittent cross-clamp fibrillation is invariably shorter than that associated with cardioplegic arrest, and this may be one explanation for the comparable outcomes. There may also be an element of preconditioning protection during the intermittent cross-clamp fibrillation method, as has been shown experimentally. During elective CABG in patients with no clinical evidence of aortic or cerebro-vascular disease, the incidence of peri-operative microemboli (ME) and postoperative neuropsychological disturbances are shown to be comparable with both techniques of myocardial preservation.