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Libman-Sacks endocarditis of the mitral valve was first described by Libman and Sacks in 1924. Currently, the sterile verrucous vegetative lesions seen in Libman-Sacks endocarditis are regarded as a cardiac manifestation of both systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). Although typically mild and asymptomatic, complications of Libman-Sacks endocarditis may include superimposed bacterial endocarditis, thromboembolic events, and severe valvular regurgitation and/or stenosis requiring surgery. In this study we report two cases of mitral valve repair and two cases of mitral valve replacement for mitral regurgitation (MR) caused by Libman-Sacks endocarditis. In addition, we provide a systematic review of the English literature on mitral valve surgery for MR caused by Libman-Sacks endocarditis. This report shows that mitral valve repair is feasible and effective in young patients with relatively stable SLE and/or APS and only localized mitral valve abnormalities caused by Libman-Sacks endocarditis. Both clinical and echocardiographic follow-up after repair show excellent mid- and long-term results.

AimsTo investigate whether chronic heart failure (CHF) is associated with a general dysfunction of the haematopoietic compartment. Methods and resultsBone marrow was obtained during coronary artery bypass graft surgery from 20 patients with CHF (age 67 + 6 years, 75% NYHA class ≥ III, LVEF 32 + 6%), and 20 age-and gender-matched control patients with normal cardiac function. CD34+ haematopoietic progenitor cells were isolated and cultured with increasing doses of erythropoietin (0.02-10 IU/mL, EPO), myeloid growth factors or a mix of both. After 14 days, burst forming units erythroid (BFU-E), and granulocyte or monocyte colony forming units (CFU-G, CFU-M, respectively) were counted. Apoptosis and erythropoietin-receptor (EPO-R) density were quantified by flow cytometry. Throughout the EPO dose range, the CD34 + cells from CHF patients produced a two-fold lower number of BFU-E colonies compared with controls (P ¼ 0.02). The resistance to EPO was associated with markedly increased apoptosis during erythroid differentiation in CHF patients compared with controls [5.3% (2.9-8.1%) vs. 1.5% (0.8-3.4%), P ¼ 0.01]. Erythropoietin-receptor expression was, however, comparable between CHF patients and controls and the anti-apoptotic cytokine interleukin-3 did not rescue erythropoiesis. In the myeloid cultures, the number of CFU-G and CFU-M colonies was also two-fold lower in CHF patients compared with controls (both P , 0.01). In the mixed-culture assay, myelopoiesis and erythropoiesis were reduced to a similar magnitude in CHF patients. The impaired clonogenic potential was independently associated with clinical and biochemical severity of CHF, but not with the presence of anaemia. ConclusionChronic heart failure is associated with profound and general bone marrow dysfunction, simultaneously affecting multiple haematopoietic lineages.--

Mitral valve repair for partial or incomplete post-MI PMR is reliable and provides good short- and long-term results, provided established repair techniques are used and adjacent tissue is not friable. PMR type and adjacent tissue quality ultimately determine the feasibility and durability of repair.

Local treatment for pulmonary oligometastases (one to five lesions) using metastasectomy or stereotactic ablative radiotherapy (SABR) was investigated in a cohort that received multidisciplinary tumor board-based treatment decisions. The first choice of treatment was surgery; SABR was recommended in cases of adverse clinical factors. Propensity score-adjusted and unadjusted overall survival was the primary end point; local control and time to failure of a local-only treatment strategy were also analyzed. With a minimum follow-up time of 5.8 years, the 5-year overall survival rate was 41% for surgery (n = 68) and 45% for SABR (n = 42). Again not different for the two modalities, 40% of patients were free from failure of a local-only treatment strategy, and 20% were free from any progression at 5 years. The 5-year local control rate was 83% for SABR and 81% for surgery. Despite treatment selection clearly disadvantaging SABR against surgery, even unadjusted outcome was not better when pulmonary oligometastases were surgically removed rather than irradiated.

Background: Positron emission tomography (PET) is accurate for mediastinal staging of lung cancer but has a moderate positive predictive value, necessitating pathological verification. Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) is a technique for tissue verification of mediastinal and upper retroperitoneal abnormalities. The use of EUS-FNA may decrease the number of surgical procedures and thereby staging costs. Methods: EUS-FNA was used prospectively for the cytological assessment of mediastinal and/or upper retroperitoneal PET hot spots in patients with suspected lung cancer. Only if EUS-FNA was positive for malignancy was subsequent mediastinoscopy or exploratory thoracotomy cancelled. The cost effectiveness of EUS-FNA was determined. Results: Of 488 consecutive patients with suspected lung cancer, 81 were enrolled with mediastinal and/ or upper retroperitoneal PET hot spots. EUS-FNA was positive in 50 (62%) patients, negative in six, and inconclusive in 25. Of the 31 negative or inconclusive patients, 26 underwent surgical staging (resulting in 14 patients with and 12 without mediastinal malignancy), while five patients had mediastinal metastases during follow up. No EUS-FNA related morbidity or mortality was encountered. The accuracy of the decision to proceed to surgery (or not) on the basis of EUS-FNA was 77% (95% CI 68 to 86). EUS-FNA detected more mediastinal abnormalities than PET except for the upper mediastinal region. Addition of EUS-FNA to conventional lung cancer staging reduced staging costs by 40% per patient, mainly due to a decrease in surgical staging procedures. Conclusion: EUS-FNA can replace more than half of the surgical staging procedures in lung cancer patients with mediastinal and/or upper retroperitoneal PET hot spots, thereby saving 40% of staging costs.

BackgroundPrimary palmar and/or axillary focal hyperhidrosis is a frequent disorder characterized by excessive sweating beyond physiological needs, often leading to a substantial impairment of quality of life. Over the years several minimally invasive surgical treatments have been described, however results vary, and due to a lack of uniform surgical approach, technique and nomenclature are often difficult to compare. In this prospective study we sought to evaluate the safety and effectiveness of our standardized technique of single-port, one-stage bilateral thoracoscopic sympathicotomy.MethodsOn a prospective basis a hundred consecutive patients with severe or intolerable primary hyperhidrosis underwent one-stage bilateral single-port thoracoscopic sympathicotomy. Primary outcome was measured in pre- vs. post-operative Hyperhidrosis Disease Severity Scale scores. Location and extend of compensatory hyperhidrosis, and satisfaction with the procedure were registered.ResultsA significant reduction in mean Hyperhidrosis Disease Severity Scale score (3.69 ± 0.47 preoperatively vs. 1.06 ± 0.34 postoperatively) (p < 0.001) was observed. In 97 (97%) out of the 100 enrolled patients a >80% reduction in sweat production was achieved. Compensatory hyperhidrosis was seen in 27 patients (27%). It was rated as mild by 21 patients (78%) and as moderate by 6 (22%) of these patients. No severe compensatory hyperhidrosis was reported. Major complications, such as intraoperative bleeding, infections, and Horner’s syndrome were not observed.ConclusionsHighly selective sympathicotomy at well-defined levels with a one-stage bilateral single-port transaxillary thoracoscopic approach is a save procedure, with excellent and reproducible immediate results in the treatment of primary palmar and/or axillary hyperhidrosis.