Multiple causes for an ischemic stroke: myxoma, papillary fibroelastomas and patent foramen ovale.

We report a case in which multiple uncommon causes of an ischemic vascular accident coexisted in the same patient. The patient was admitted with signs of acute stroke. Investigation workup revealed a left atrial tumor (myxoma) and a patent foramen ovale. Intraoperatively, transesophageal echocardiography added new information: papillary fibroelastomas were found in the aortic valve. This finding dictated a change in the surgical plan, adding resection of aortic valve masses to the planned excision of the left atrial tumor and patent foramen ovale closure. The uniqueness of this case derives from the coexistence of rare primary cardiac tumors. There are only five cases in literature of myxoma concomitant with fibroelastoma and the occurrence of multiple fibroelastoma is also extremely rare. Moreover this case emphasizes the benefit of the intraoperative use of transesophageal echocardiography to improve the diagnosis and management of cardiac surgical patients.

[Minimally invasive thoracic surgery: a fifteen-years experience]. / Cirurgia torácica minimamente invasiva. Experiêcia de 15 anos.

The evolution of surgical techniques has rendering possible for thoracic surgery to be performed efficiently and safely, with less aggressive approaches. Being less traumatic, minimally invasive surgery allows a faster post-operative recovery, less complications and reduces in patient days and morbidity. The authors consider as minimally invasive approaches the video-assisted thoracic surgery, as well as the minithoractomy and the ministernotomy. The present paper reviews thoracic surgeries performed for the last 15 years in a cardiothoracic surgical unit using a minimally invasive surgical approach.

[Intra-thoracic goiter: analysis of the Department's experience]. / Bócio mergulhante: Análise da casuística do Serviço.

A review of all clinical files with pre-operative diagnosis of intra-thoracic goiter operated in our Department from 2001-2009 was made. We identified 30 patients, of which 66% were females. 63% of the patients were asymptomatic, 46% had clinical or radiological findings of mediastinal structures compression and 2 patients were ventilated prior to surgery. 50% of the patients were operated on through an inferior transverse cervicotomy, the remaining were operated on through partial or complete sternotomy, with cervical approach. 6,6% of patients (n=2) had an intra-operative diagnosis of invasive thymoma, 3,3% (n=1) had a very invasive mediastinal tumor and 3,3% (n=1) had an ectopic thyroid. Average surgical length of time was of 83 minutes. In 10% of patients (n=3) post-operative invasive ventilation was required, one of which for unilateral permanent lesion of the recurrent laryngeal nerve. In the long term follow-up we assessed 18 patients. The median follow up was 53 months. One patient died at the 15th post-operatory day of pneumonia, one expired at the 30th day for anaplasic thyroid carcinoma progression and one died at the 18 month from invasive thymoma progression. One patient currently reveals evidence of local recurrence 3 patients are currently taking levothyroxine and one is taking propiltiouracil. Pathological studies revealed that 66% of cases were multinodular goiter and neoplasia was present in 13% of the patients. Other results were thymic pathology in 13% of cases (n=4), parathyroid cyst in 3,3% (n=1), and ectopic thyroid in 3,3% (n=1(.

[Pulmonary arteriovenous malformations in Rendu-Osler-Weber disease. Case report]. / Malformações arteriovenosas pulmonares: caso clínico no context de doenca de Rendu-Osler-Weber.

The authors report the clinical case of a 59 year-old woman who was incidentally diagnosed as having arteriovenous pulmonary malformation (AVPM). Through clinical history a diagnosis of Rendu-Osler-Weber disease (ROWD) was made, a disease manifesting itself through the existence of vascular malformations in the skin, mucosae and viscera (like the lungs, liver and brain). The surgical therapy offered to the patient had no complications. The essential aspects of pathofisiology, clinical manifestations and treatment of AVPM and ROWD are discussed.

[Cardiological medical treatment after coronary bypass surgery]. / Terapêutica cardiológica no pós-operatório de cirurgia coronária.

When a decision has been reached to proceed with coronary bypass surgery, this represents a therapeutical option for a partnership between surgical revascularization and an optimized multifaceted medical treatment. We report the guidelines implemented in our department concerning the secondary prevention therapy after coronary bypass surgery. The antiplatelet therapy (and its association with coumadin), the bradycardizing treatments (with a special reference to the approach of unappropriate sinus tachycardia), the specific anti-ischemic therapy, the treatment of dyslipidemia, and the antihypertensive therapy are reviewed as well as the use of additional anti-atheromatous measures, the approach of hyperuricemia and hyperhomocysteinemia, and the oral antidiabetic treatment.

[The impact of the "patient - prosthesis mismatch" in patients with aortic valve replacement.]. / Impacto do "patient-prosthesis mismatch" em doentes submetidos a substituição valvular aórtica.

UNLABELLED: Patient-Prosthesis Mismatch (PPM) is still a controversial matter in our days. We have PPM when the orifice area of an implanted aortic prosthesis valve is too small for the body surface area of an individual; this is, when the orifice area indexed to the body surface area is <0.8-0.9 cm2/m2. OBJECTIVE: Assess the impact of Patient-Prosthesis Mismatch in the short term and 2 years follow up in a group of patients submitted to aortic valve replacement. MATERIAL AND METHODS: The authors present a retrospective study involving 343 patients with a mean age of 64,68+/-12,4 years that were submitted to aortic valve replacement between January 2005 and December 2008. Data were collected from patients' files and direct contact with the patients, comparing the groups with and without PPM and correlating them in terms of Euroscore, demographics, type of implanted prosthesis, surgical times, ICU and hospital stay. The data related to short term and long term mortality as well as the NYHA class evolution were also obtained. RESULTS: Using the cut-off related to effective orifice area index 0,9 cm2/m2 we found PPM in 109 patients (31.7%). When comparing the two groups, we found that PPM seems to be related to advanced age (p=0.001), biological prosthesis (p=0.01) and, as expected, with use of valves less than 21 (p<0,05). A statistical significant difference was found for: 1) short-term mortality in patients with PPM (p<0,001), however, there were no differences in 2 years mortality and NYHA class between the groups; 2) aorta's cross clamping and extra corporeal circulation time (p=0.047 and p=0.036, respectively).

[Surgery of pulmonary metastasis]. / Cirurgia das metáses pulmonares.

UNLABELLED: Between April 1993 and December 2007, 92 patients underwent the complete resection of pulmonary metastases, 47 mens (51.1%) and 45 womens (49.9%). 26 patients (27.2%) had solitary pulmonary metastasis, 25 (26.1%) multiple pulmonary metastasis and 41 (44.5%) patients presented bilateral pulmonary metastasis. 42 patients (45.6%) presented pulmonary metastasis recurrence, 14 patients (15.2%) a second recurrence and 6 patients (6.5%) a third pulmonary metastasis recurrence. 49 patients (53.2%) were reoperated. The mean cumulative survival after complete resection was 78.4 months (+/- 52.5 months). There were no operative mortality. CONCLUSION: Thys work demonstrated that every attempt should be made to completely ressect all clinically detected metastases. Complete resection of pulmonary metastasis, even in recurrent disease is compatible with long-term survival.

[Results of an experience with the Bentall procedure]. / Cirurgia de bentall. Experiência e resultados do serviço.

OBJECTIVES: The authors report a retrospective study of patients who underwent a Bentall procedure in the Cardio-Thoracic Surgery Department of Hospital Santa Maria, Lisbon. MATERIAL AND METHODS: Data were obtained from 42 patients who underwent the Bentall procedure between 1991 and 2008. Different parameters were compared as well as the short and long term results. RESULTS: The median age was 58,5 years being 88% of patients of male gender. 32 (76,27%) presented with ascending aorta degenerative aneurism, 6 p (14,3%) with type A aortic dissection and 4p (9,5%) with Marfan syndrome. 10p(23.8%) had associated coronary artery disease and there were 6p (14.3%) who underwent emergency surgery. Among the risk factors associated, 24 p (57,1%) had hypertension, 12 p (28,6%) dyslipidemia, 4p (9,5%) had history of smoking, 7 p (16,7%) diabetes, 6 p (14,3%) CPOD, 2 p (4,8%) renal dysfunction and 2 had a recent myocardial infarction. There were 7p (16,7%) with left ventricular dysfunction (EF<40%); 25 p were in NYHA class II-III. The hospitalar mortality was of 2,77% in non-emergent cases, and 33,3% in emergent operations. After 30 days, 92,8% of patients were alive. The 1-year survival was 90,4% and after 5 years of 85,7%. CONCLUSIONS: The Bentall procedure obtained good results in short and long term and, despite the emerging of new and more complex techniques like remodelling and reimplantation, our results support the maintenance of this procedure as the preferential treatment for aortic root and valvular disease.

[Kommerell diverticula associated with dysphagia: a clinical case and review of the literature]. / Disfagia associada a divertículo de Kommerell. Caso clínico e revisão bibliográfica.

We report the case of a young female with disphagia and weigth loss caused by a vascular ring associated with right aortic arch, Kommerell diverticula, and left retroesophageal ligamentum arteriosum (ductus arteriosus). The patient underwent surgical treatment. A left thoracotomy was performed. Surgical technique included diverticulum ressection and an aortopexia. There were no major complications. We also discuss the incidence, pathology, diagnosis, clinical features and treatment of this rare disease.

[Quadricuspid symmetric aortic valve]. / Válvula aórtica quadricúspide simétrica.

The quadricuspid aortic valve is a rare aortic valve congenital malformation. The 2D transthoracic ultrasound (TTU) is not always effective in diagnosing quadricuspid aortic valves. The aim of this article is to present a case treated in our department, initially diagnosed as a mainly stenotic aortic valvular disease, while reviewing the clinical cases described so far. The authors report the case of a 74 year-old female patient with a mainly stenotic aortic valvular disease diagnosed by TTU. The only known risk factor was arterial hypertension. She underwent elective surgery in June 2005. The surgery consisted in replacing the quadricuspid aortic valve by a Carpentier Perimount no 21 Ao prosthesis. There were no post-operative complications. The patient revealed no symptoms in the post-operative 6 months and 1 year follow-up visits. The quadricupid aortic valve is a rare congenital malformation, with a considerable risk of serious complications. Patients with this diagnosis should be exhaustively studied. Medical literature describes some cases of quadricuspid aortic valve operated in other clinical centres. We present here the only case operated in our department in a 20-years period.

[Titanium transverse plate fixation system after sternum dehiscence in cardiac surgery]. / Sistema de fixação com placas transversais de titânio após deiscência do esterno em cirurgia cardíaca.

Steel wire sternum fixation in patients who underwent median sternotomy for cardiac surgery, is a routine procedure in our clinical practice. Sternal dehiscence either associated or not to surgical wound infection, though with low incidence, carries high morbidity, mortality and economic costs that make the research for alternative techniques a fundamental task. A new titanium transverse plate fixation system seems to be an excellent and safe alternative, that can be performed by cardiac surgeons to reconstruct the sternum in case of dehiscence. We report the surgical technique and our experience with this new treatment.

[Cervical lymphadenopathy as first manifestation of a bronchogenic cyst]. / Linfadenopatias cervicais como primeira manifestação de um quisto broncogênico. Caso clinico.

A 26-year old woman was admitted with clinical and laboratory signs and symptoms of chronic infection and multiple cervical lymphadenopathy, whose pathological studies disclosed a non-specific inflammatory reaction. Anti-tuberculosis treatment was then started, with no significant improvement. Chest CT scans was compatible with a mediastinial tumor and RMN studies revealed the presence of an infected bronchogenic cyst, which was surgically and successfully removed with complete disappearance of the infection. The authors conclude by enhancing the fact that bronchogenic cysts may course with diverse clinical manifestations and should be included in differential diagnosis of mediastinal tumors.

[Surgery of mediastinal tumors: 11-years experience]. / Cirurgia dos tumores do mediastino: experiência de 11 anos.

Between 1993 and 2004, 70 operations on patients with the diagnosis of mediastinal tumors were performed in the Cardiothoracic Surgery Department of Santa Maria Hospital. In this study we did not include diagnostic surgery of mediastinal tumors. In 70 patients treated, 63 p (90%) had the tumor located in the anterior mediastinum, 21 p with thymoma, 6 p with lymphoma, 4 p with carcinoid tumors, 1 p with sarcoma and 1 p with adenocarcinoma. 3 patients had tumors located in the medium and 4 patients in the posterior mediastinum. We analysed the results of the mediastinal tumors surgery during the 11-years period. Also, we evaluated the clinical effects of the thymectomy in myasthenia gravis.

[Pulmonary carcinoid tumors--ten years experience]. / Tumores carcinóides do pulmão: experiência de 10 anos.

Pulmonary carcinoid tumors are rare, accounting for as many as 2% of all pulmonary neoplasms and for 10% of carcinoid tumors overall. Previously classified as bronchial adenomas, actually are classified as neuroendocrine tumors. They have a subclassification into typical classed as low-grade malignant neoplasm and atypical more aggressive, with more potential to cause local invasion. In this paper, the authors report a retrospective study of 25 patients, who had the diagnosis of pulmonary carcinoid tumors and had been operated between January of 1994 and August of 2004. We conclude that this tumors must be considered malignant in the surgical approach.

[Surgical diagnosis of mediastinal pathology: eleven-years experience]. / Diagnóstico cirúrgico da patologia do mediastino: experiência de 11 anos.

Between January 1993 and December 2004, 68 patients with mediastinal pathology were submitted to diagnosis surgery. All the pathological process were located in the anterior mediastinum, and most of them were malignant (64.1%). The most common pathology was limphoma (26.5%), sarcoidosis (23.5%) and thymomas (23.5%). Seven cases consisted in ganglionar tuberculosis (10.3%), six cases were ganglionar metastases of lung adenocarcinoma (8.8%), and three cases were thymic carcinoma (4.4%). One patient had no definite diagnosis (1.5%). In this experience high diagnosis accuracy (98.5%), and low morbidity were demonstrated. Although the present video assisted thoracic surgery progress and development, mediastinoscopy still remains as a reliable, safe and efficient surgical approach for the diagnosis of mediastinal pathology.

[Video-assisted thoracic surgery in the diagnosis of interstitial diffuse pulmonary diseases]. / A cirurgia torácica vídeo-assistida no diagnóstico das doenças difusas do interstício pulmonar.

Interstitial lung diseases are best diagnosed by surgical lung biopsy. Videoassisted thoracoscopy (VATS) is less aggressive than open lung thoracotomy and its development is associated with an increased number of lung biopsies. Between July 1994 and July 2004 we performed 70 VATS biopsies for interstitial lung disease patients. Only one biopsy was considered inconclusive (1.4%). The remainder 69 (98.6%) established a final diagnosis. The results in our series show that VATS lung biopsy is a safe method with low mortality and morbidity and an excellent rentability.

["Off pump" coronary surgery and simultaneous carotid endarterectomy]. / Cirurgia coronária sem cec e endarterectomia carotídea simultânea.

The occurrence of significant carotid artery disease in patients requiring coronary artery bypass grafting (CABG), results in a dilemma regarding the best surgical management. Our philosophy has been to perform simultaneous carotid endarterectomy and CABG off-pump. We reviewed the efficacy of this therapy in six patients treated in our hospital between January 2001 and December 2002. The result was satisfactory and there was no hospital mortality.

[Pulmonary arterio-venous fistula: a clinical report]. / Fístulaartério-venosa pulmonar: a propósito de um caso clínico.

A 44 years old female was admitted with previous history of several cerebral vascular accident (CVA). A transthoracic echocardiogram showed a patent foramen ovale (PFO) that was closed, under extracorporeal circulation. The patient remained free of symptoms for ten years. In the year 2003 she was admitted to our hospital with paresthesias of the left arm. The clinical evaluation led to the diagnosis of arteriovenous fistula (AVF) of the lung. In November 2003, the patient underwent right inferior lobectomy. This is a rare association of PFO with AVF fistula of the lung with a delayed diagnosis. The differential diagnosis, the surgical treatment and the most frequent complications of this pathology are reported and discussed.

[Reoperation in mitral valve reconstructive surgery]. / Reoperações e, cirurgia reconstrutiva da válvula mitral.

UNLABELLED: In the past few years reconstructive surgery of the mitral valve has experienced a growing popularity. It is now clearly established that restoration of a normal function valve is preferable to valve replacement. The authors report the results of the mitral valve reconstructive surgery in a population of 701 patients with high incidence of restrictive lesions of rheumatic fever. This represents an experience of 14 years. 5.1% of patients who underwent mitral valvuloplasty required late reoperation for recurrent mitral valve dysfunction. Repeat mitral valve repair resulted in successful treatment for 40% of these patients. CONCLUSION: The mitral valve repair failure are: 1--Procedure related: (58.1%); a--surgical technical related--35.8%; b--no ring implantation (in restrictive lesions)--15%; c-rupture of previously chordae shortened--7.4%. 2--Valve related: (41.9%); a--progressive primary valve disease--(25.4%); b--wrong surgical indication--(15%); c--endocarditis--(1.5%).