Preoperative statin therapy for adults undergoing cardiac surgery.

BACKGROUND: Despite significant advances in surgical techniques and perioperative care, people undertaking cardiac surgery due to cardiovascular disease are more prone to the development of postoperative adverse events. Statins (5-hydroxy-3-methylglutaryl-co-enzyme A (HMG-CoA) reductase inhibitors) are well-known for their anti-inflammatory and antioxidant effects and are established for primary and secondary prevention of coronary artery disease. In addition, statins are thought to have clinical benefits in perioperative outcomes in people undergoing cardiac surgery. This review is an update of a review that was first published in 2012 and updated in 2015. OBJECTIVES: To evaluate the benefits and harms of preoperative statin therapy in adults undergoing cardiac surgery compared to standard of care or placebo. SEARCH METHODS: We performed a search of the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 9, 2023), Ovid MEDLINE (1980 to 14 September 2023), and Ovid Embase (1980 to 2023 (week 36)). We applied no language restrictions. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing any statin treatment before cardiac surgery, for any given duration and dose, versus no preoperative statin therapy (standard of care) or placebo. We excluded trials without a registered trial protocol and trials without approval by an institutional ethics committee. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology. Primary outcomes were short-term mortality and major adverse cardiovascular events. Secondary outcomes were myocardial infarction, atrial fibrillation, stroke, renal failure, length of intensive care unit (ICU) stay, length of hospital stay and adverse effects related to statin therapy. We reported effect measures as risk ratios (RRs) or mean differences (MDs) with corresponding 95% confidence intervals (CIs). We used the RoB 1 tool to assess the risk of bias in included trials, and GRADE to assess the certainty of the evidence. MAIN RESULTS: We identified eight RCTs (five new to this review) including 5592 participants. Pooled analysis showed that statin treatment before surgery may result in little to no difference in the risk of postoperative short-term mortality (RR 1.36, 95% CI 0.72 to 2.59; I2 = 0%; 6 RCTs, 5260 participants; low-certainty evidence; note 2 RCTs reported 0 events in both groups so RR calculated from 4 RCTs with 5143 participants). We are very uncertain about the effect of statins on major adverse cardiovascular events (RR 0.93, 95% CI 0.77 to 1.13; 1 RCT, 2406 participants; very low-certainty evidence). Statins probably result in little to no difference in myocardial infarction (RR 0.88, 95% CI 0.73 to 1.06; I2 = 0%; 5 RCTs, 4645 participants; moderate-certainty evidence), may result in little to no difference in atrial fibrillation (RR 0.87, 95% CI 0.72 to 1.05; I2 = 60%; 8 RCTs, 5592 participants; low-certainty evidence), and may result in little to no difference in stroke (RR 1.47, 95% CI 0.90 to 2.40; I2 = 0%; 4 RCTs, 5143 participants; low-certainty evidence). We are very uncertain about the effect of statins on renal failure (RR 1.04, 95% CI 0.80 to 1.34; I2 = 57%; 4 RCTs, 4728 participants; very low-certainty evidence). Additionally, statins probably result in little to no difference in length of ICU stay (MD 1.40 hours, 95% CI -1.62 to 4.41; I2 = 43%; 3 RCTs, 4528 participants; moderate-certainty evidence) and overall hospital stay (MD -0.31 days, 95% CI -0.64 to 0.03; I2 = 84%; 5 RCTs, 4788 participants; moderate-certainty evidence). No study had any individual risk of bias domain classified as high. However, two studies were at high risk of bias overall given the classification of unclear risk of bias in three domains. AUTHORS' CONCLUSIONS: In this updated Cochrane review, we found no evidence that statin use in the perioperative period of elective cardiac surgery was associated with any clinical benefit or worsening, when compared with placebo or standard of care. Compared with placebo or standard of care, statin use probably results in little to no difference in MIs, length of ICU stay and overall hospital stay; and may make little to no difference to mortality, atrial fibrillation and stroke. We are very uncertain about the effects of statins on major harmful cardiac events and renal failure. The certainty of the evidence validating this finding varied from moderate to very low, depending on the outcome. Future trials should focus on assessing the impact of statin therapy on mortality and major adverse cardiovascular events.

Sutureless bioprosthesis for aortic valve replacement: Surgical and clinical outcomes.

BACKGROUND: Aortic valve stenosis is the most common adult valve disease in industrialized countries. The aging population and the increase in comorbidities urge the development of safer alternatives to the current surgical treatment. Sutureless bioprosthesis has shown promising results, especially in complex procedures and in patients requiring concomitant surgeries. OBJECTIVES: Assess the clinical and hemodynamic performance, safety, and durability of the Perceval® prosthetic valve. METHODS: This single-center retrospective longitudinal cohort study collected data from all adult patients with aortic valve disease who underwent aortic valve replacement with a Perceval® prosthetic valve between February 2015 and October 2020. Of the 196 patients included (mean age 77.20 ± 5.08 years; 45.4% female; mean EuroSCORE II 2.91 ± 2.20%), the majority had aortic stenosis. RESULTS: Overall mean cross-clamp and cardiopulmonary bypass times were 33.31 ± 14.09 min and 45.55 ± 19.04 min, respectively. Mean intensive care unit and hospital stay were 3.32 ± 3.24 days and 7.70 ± 5.82 days, respectively. Procedural success was 98.99%, as two explants occurred. Four valves were reimplanted due to intraoperative misplacement. Mean transvalvular gradients were 7.82 ± 3.62 mmHg. Pacemaker implantation occurred in 12.8% of patients, new-onset atrial fibrillation in 21.9% and renal replacement support was necessary for 3.1%. Early mortality was 2.0%. We report no structural valve deterioration, strokes, or endocarditis, and one successfully treated valve thrombosis. CONCLUSIONS: Our study confirms the excellent clinical and hemodynamic performance and safety of a truly sutureless aortic valve, up to a 5-year follow-up. These results were consistent in isolated and concomitant interventions, solidifying this device as a viable option for the treatment of isolated aortic valve disease.

Definitive Treatment Of Primary Spontaneous Pneumothorax A 10 Year Experience.

OBJECTIVES: Primary spontaneous pneumothorax (PSP) is defined as a pneumothorax without obvious underlying lung disease. Definitive treatment should be offered to patients with recurrent or persistent PSP. The aim of this study was to compare the effectiveness of medical pleurodesis (MP) with video assisted thoracic surgery (VATS) on definitive treatment of PSP. METHODS: 10 years' retrospective study of PSP patients that underwent VATS or MP. Baseline characteristics, perioperative and follow-up data were compared. RESULTS: A total of 133 patients were included (MP=54; VATS=79). Baseline characteristics were similar between groups, with a male predominance (MP 83.6 vs VATS 85.5%) with a mean age of 24.78 and 25.81 years old, respectively. Post interventional length of hospital stay was similar (MP 4.94 vs VATS 4.47 days, p=0.20), but chest tube duration was longer in the VATS group (MP 2.94 vs VATS 3.56 days, p=0.03). The overall complications rate was low with no statistically significant difference between groups (MP 5/54 vs VATS 7/79, p=1.00). Regarding the follow-up, MP had a significant higher PSP recurrence rate (MP 11.1% vs VATS 1.3%, p=0.042), most occurring over the first two years. CONCLUSION: Despite both MP and VATS are safe methods with short hospital stay and few complications associated, the results of this study show that VATS had a significantly lower rate of recurrences. Overall, VATS should be offered as the first line treatment to patients with PSP.

Giant Pleural Tumor And Severe Hypoglycemia: Doege-Potter Syndrome In A Previously Healthy Female.

AIntroduction: Doege-Potter's syndrome is a rare paraneoplastic syndrome, consisting in hypoglycemia and solitary fibrous tumor of the pleura. These tumors represent < 5% of all pleural tumours and can only be cured by surgery. In this article, we report a case of a patient presenting with severe hypoglycemia, as the only symptom, and a mass occupying the entire left hemithorax. Case presentation: A54 year old female with severe hypoglycemia, a chest radiography with almost total opacification of the left hemithorax and a computed tomography scan with a mass in the left hemithorax. Surgery was performed and a mass with 30cm × 18cm × 11cm weighing 3195g was resected. The postoperative course was uneventful with immediate resolution of the hypoglycemia. The immunohistochemistry diagnosis was solitary fibrous tumor of the pleura. Conclusions: Solitary fibrous tumor of the pleura are very rare. Less than 5% are associated with hypoglycemia, taking the form of Doege-Potter Syndrome. Radiation therapy and chemotherapy have shown low response rate and complete surgical resection is the only procedure that offers cure. This case reports describes a rare giant solitary fibrous tumor of the pleura with severe hypoglycemia, successfully treated by surgery. Long-term follow-up of the patient after the surgery is necessary for detection of any possible recurrence.

Age Is Not Just A Number For A Rapid Deployment Valve In Octogenarians.

INTRODUCTION: Aortic valve stenosis (AS) is the most common valvular pathology in the elderly and surgery (AVR) remains the gold-standard. However, transcatheter aortic valve replacement (TAVI) has become an emerging alternative to surgery. In a recent survey from the European Society of Cardiology, 9,4% stated that age was the main reason to propose for TAVI. METHODS: Single-center retrospective study including 353 patients (149 ≥80 years-old;204 with 60-69 years-old) submitted to AVR between 2013-2016. Primary endpoint was survival. Secondary outcomes included the rate of post- -operative complications. Long-term survival was determined by Kaplan-Meier survival analysis. Continuous variables were analyzed with t-test and linear regression and categorical variables with chi-square or Fisher. RESULTS: clinical characteristics were similar between the two groups. Both had similar survival at 30 days, 12 (93,29% 60-69yo vs 91,47% ≥80yo) and 24 months (88,34% 60-69yo vs 86,11% ≥80yo). However, rapid deployment valves (RD) had better survival rates in elderly patients. Cross-clamp time was lower in ≥80yo group, with higher percentage of RD valves (20,1% vs 4.9% in 60-69yo). The rate of post-operative atrial fibrillation was higher in >80yo group (29,06% vs. 17,28%,p=0,0147). In all patients, cross-clamp time was directly related to ventilation time(p=0,025) and chest drainage(p=0,0015). CONCLUSION: AVR after 80yo is safe. Cross-clamp time is directly correlated with ventilation time and bleeding, with a stronger correlation in patients over 80yo. RD valves reduce cross-clamp times, so their use in elderly may improve surgery outcome. Prospective studies are needed to evaluate if age may be clinical criteria for a RD.

Platelet Count Drop After Rapid Deployment Aortic Valve Implantation.

BACKGROUND: A transient postoperative drop in platelet count is an expected finding after aortic valve replacement using extracorporeal circulation. The implantation of the Perceval valve has been associated with a more intense drop of platelet count compared to other bio-prostheses. This study analyses and compares the platelets progression associated with the Perceval and Intuity valves. METHODS: The data was collected retrospectively for patients submitted to isolated aortic valve replacement with the Perceval valve (80 patients) and the Intuity valve (141 patients) in our institution between March 2014 and December 2018. The groups were further divided into those who receive platelet transfusion and those who did not. RESULTS: The minimum values of platelet count were 54% and 67% of the preoperative platelet count in the patients treated with a Perceval and an Intuity valves, respectively (p<0.001). In the patients transfused with platelets, the minimum values were 52% and 79% of the preoperative platelet count, respectively (p<0.01). Recovery of the count was faster in the patients treated with an Intuity valve. Abnormal bleeding and transfusion of packed red blood cells were not significantly different between groups (without platelet transfusion: p=0.71 and p=0.99, respectively; with platelet transfusion: p=0.58 and p=0.99, respectively). CONCLUSION: Compared to the Intuity valve, the Perceval valve is associated with a transient, but significant, drop in platelet count. This drop was not associated to an increased risk of bleeding. Platelet transfusion, in this setting, should be judicious and not only ruled by absolute values.

Infective Endocarditis after Transcatheter Aortic Valve Implatation.

INTRODUCTION: Transcatheter aortic valve implantation has emerged as an effective alternative to the traditional method of surgical aortic valve replacement in high risk or inoperable patients. Infective endocarditis after transcatheter aortic valve implantation is a post-operative complication with a high rate of mortality, and thus far, very few cases of successful surgery have been reported. CASE PRESENTATION: The authors report the case of a patient that underwent transcatheter aortic valve implantation and developed an infective endocarditis following the procedure. Corrective surgery for transcatheter aortic valve's removal and aortic valve replacement was successfully performed. CONCLUSIONS: Given the increasing use of transcatheter aortic valve implantation, endocarditis will become increasingly relevant in the near future. As in conventional aortic prosthesis, for some cases, medical therapy alone is not enough. Under optimal conditions, surgery is a safe option and should be considered and discussed in a Heart Team, patient by patient.

Concomitant Ascending Aortic Replacement and Aortic Valve Replacement Using Rapid Deployment Bioprosthesis.

INTRODUCTION: The association between aortic valve disease and dilatation of the ascending aorta is well known and concomitant surgery is recommended when the aortic diameter is higher than 45mm. The use of the rapid deployment valves allows less cross-clamping and cardiopulmonary bypass times for both isolated and combined procedures in comparison to regular valves. We describe our initial experience of concomitant aortic valve and the ascending aortic replacement, using the rapid deployment valve Edward Intuity EliteTM. CASE PRESENTATION: All patients were male, with a mean age of 72-years-old. The mean cross-clamping time was 48 minutes, with a mean cardiopulmonary time of 61 minutes. The mean time of ICU stay was 4 days. All the patients had follow-up 1 and 3 months after discharge and were doing well. CONCLUSIONS: The rapid deployment aortic valves have recognized advantages in aortic valve replacement. Our small experience reinforces that replacement the ascending aortic and aortic valve with this prothesis is one procedure that can benefits from generalization without increased risks and with potentially better clinical outcomes. Larger cohort studies would allow clarification over this subject.

[Persistent left superior vena cava with agenesis of the right superior vena cava in a patient with complete atrioventricular block]. / Agenésia da Veia Cava Superior Direita com Persistência da Veia Cava Superior Esquerda Associada a Bloqueio Aurículo-ventricular Completo.

Persistant left superior vena cava is a rare systemic venous anomaly that can be associated with agenesis of the right superior vena cava. It is usually assymptomatic and discovered incidentally during surgery or other procedures. The authors present the case of a 72-year-old male submitted to an aortic valve replacement surgery. After sternotomy, persistant left superior vena cava and absence of the right superior vena cava were identified. The patient developed complete atrioventricular block after surgery, requiring the implantation of a definitive cardiac pacemaker through the brachiocephalic vein and coronary sinus. This case highlights and ilustrates the clinical implications of the described systemic venous anomalies, discussing the necessary management both in the perioperative and intraoperative periods.

A persistência da veia cava superior esquerda é uma alteração rara do sistema venoso, que pode ou não estar associada a agenesia da veia cava superior direita. É normalmente assintomática e diagnosticada maioritariamente durante a realização de procedimentos cirúrgicos ou não invasivos. Apresentamos um caso clínico de um homem de 72 anos, submetido a cirurgia de substituição de válvula aórtica, com diagnóstico intra-operatório de agenesia da veia cava superior direita e persistência da veia cava superior esquerda. O doente desenvolveu bloqueio aurículo-ventricular completo no período pós-operatório, com necessidade de colocação de um pacemaker definitivo pela veia braquiocefálica e através do seio coronário. Este caso pretende demonstrar as possíveis implicações clínicas com a identificação desta alteração, e as modificações necessárias da estratégia cirúrgica.

Surgical Treatment of an Advanced Stage Thymoma in a Good's Syndrome Patient - Case Report.

We report a rare case of an advanced stage thymoma with right superior pulmonary lobe, superior vena cava, innominate vein and pericardium invasion in a patient with Good's syndrome. In a multidisciplinary discussion, surgical resection was deemed the best initial approach, since invaded structures could be safely managed. The tumor was fully resected and included partial resection of the superior pulmonary lobe, superior vena cava and innominate vein. The encircled right phrenic nerve was dissected from the tumor and preserved. The superior vena cava and innominate vein were reconstructed using autologous pericardium patch. Immunoglobulin replacement and radiotherapy were initiated afterwards. No signs of relapse at 6 months follow-up. In such advanced cases, aggressive surgical intervention should be considered as first line of treatment, as long as full resection can be anticipated, since complete resection is the leading factor for long-term prognosis.

Minimal invasive cardiac mass resection, post-thoracic radiotherapy: a safe approach?

Minimal invasive cardiac surgery by right mini-thoracotomy for cardiac mass resection has emerged as an alternative to median sternotomy, for being less associated to postoperative complications and a faster recovery. Thoracic radiotherapy, widely used for cancer treatment, can result in pulmonary adhesions making it impossible to access the heart by thoracotomy. We report a case of a patient submitted to bilateral thoracic radiotherapy, with a cardiac mass in the left atrium, successfully treated by surgical resection, as well the intraoperative procedure done to make the minimally invasive approach possible.

A cirurgia cardíaca minimamente invasiva por mini-toracotomia direita para ressecção de massas cardíacas surgiu como alternativa à esternotomia mediana convencional, por se encontrar associada a menos complicações no pós-operatório e a uma recuperação mais rápida. A radioterapia torácica, muito utilizada como adjuvante no tratamento do cancro da mama, pode resultar em adesões pulmonares que tornam difícil o acesso ao coração por toracotomia. Reportamos o caso clínico de uma doente submetida a radioterapia torácica bilateral, com posterior diagnóstico de uma massa na aurícula esquerda, submetida a ressecção cirúrgica, assim como o procedimento realizado para tornar a abordagem minimamente invasiva possível.

[Minimally invasive approach vs full sternotomy for aortic valve and ascending aorta replacement: results from our center]. / Abordagem Minimamente Invasiva vs Esternotomia Total no Tratamento da Patologia Valvular Aórtica e da Aorta Ascendente: Resultados de um Centro.

BACKGROUND: Aortic valve disease is the most common valvular heart disease. Surgical aortic valve replacement remains the gold-standard of treatment. Recently, minimally invasive approaches have been developed to reduce surgical trauma and to compete with percutaneous treatment of valvular heart disease. Minimally invasive approaches are associated with reduced perioperative morbidity and mortality. METHODS: Single-center retrospective study comparing clinical data of patients submitted to surgical treatment of aortic stenosis by limited sternotomy versus conventional sternotomy between January 2014 and August 2016. RESULTS: The demographic and clinical characteristics between the two groups were similar. Median surgery time was 142.5 min by limited sternotomy vs 98.15 min by conventional sternotomy (p< 0.0001). Total surgery time was 142.5 min for limited sternotomy vs 98.15 min conventional sternotomy (p< 0.0001). Aortic cross-clamping time and cardiopulmonary bypass time were 58.58 and 72.92 min for limited sternotomy vs 37.46 and 72.92 min for conventional sternotomy (p<0.0001). There were not statistically significant differences between the two groups regarding pos-operative time of ventilation (8.05h ± 1.65 limited sternotomy vs 16.31h ± 9.67 conventional sternotomy, p=0.42) and post-operative blood loss (432cc limited sternotomy vs 539cc conventional sternotomy, p=0.14). Use of vasopressor support was higher with limited sternotomy (46% vs 27.3% conventional sternotomy, p=0.07), although it was not statistically significant. Rate of re-operation (8% limited sternotomy vs 5.5% conventional sternotomy, p=0.90), median intensive care unit length of stay (59.04h limited sternotomy vs 50.75h conventional sternotomy, p=0.47) and total hospital length of stay (6.96 days limited sternotomy vs 7.7 days sternotomy, p=0.75) had no differences between the two groups. The rate of post-operative complications was similar between the two groups. DISCUSSION: In our population there were not significant differences between the two approaches. It may be related to the early phase of the learning curve and to our good results concerning conventional sternotomy. Although surgery time, aortic cross-clamping time and cardiopulmonary bypass time were higher with limited sternotomy, it was not related to higher rates of post-operative complications. Limited sternotomy reduces surgical trauma and has cosmetic advantages. Our data encourages the minimally invasive surgery program of our Department.

gold standard. Nas últimas décadas têm sido desenvolvidas abordagens minimamente invasivas para reduzir o trauma cirúrgico e competir com as novas estratégias percutâneas. As abordagens minimamente invasivas estão associadas a menor morbilidade peri-operatória e menor mortalidade. Métodos: Estudo retrospectivo que compara os resultados do tratamento da patologia valvular aórtica e da aorta ascendente por mini-esternotomia e por esternotomia total no nosso centro entre Janeiro de 2014 e Agosto de 2016. Resultados: Os dois grupos de doentes apresentavam características demográficas e clínicas semelhantes. O tempo médio de cirurgia foi 142.5 min no grupo da mini-esternotomia e 98.15 min no grupo da esternotomia (p< 0,0001). O tempo de clampagem e de circulação extra-corporal (CEC) foi de 58.58 e 72.92 min com mini-esternotomia e 37.46 e 72.92 min com esternotomia (p<0,0001). Não houve diferenças significativas entre os dois grupos no tempo de ventilação invasiva pós- -operatória (8.05h ± 1.65 na mini-esternotomia vs 16.31h ± 9.67 esternotomia, p=0.42) e no volume drenado pelos drenos torácicos (média 432cc mini-esternotomia vs 539cc esternotomia, p=0.14). A necessidade de suporte aminérgico foi superior no grupo da mini-esternotomia (46% vs 27.3% no grupo da esternotomia, p=0.07), não sendo estatisticamente significativo. A taxa de re-operação foi semelhante nos dois grupos (8% mini-esternotomia vs 5.5% esternotomia, p=0.90). O tempo de internamento na UCI e tempo total de internamento foi semelhante estre os dois grupos, não havendo diferenças estatisticamente significativas (59.04h mini-esternotomia vs 50.75h esternotomia, p=0.47 e 6.96 dias na mini-esternotomia vs 7.7 dias na esternotomia, p=0.75). A ocorrência de complicações foi semelhante nos dois grupos. Conclusão: Na nossa amostra de doentes não houve diferenças entre os dois grupos. Tal deve-se provavelmente ao facto deste procedimento, durante o período estudado, se encontrar na fase inicial da curva de aprendizagem e aos bons resultados da abordagem por esternotomia-convencional. Apesar das diferenças nos tempos de cirurgia, CEC e clampagem da aorta, não houve diferenças na incidência de complicações. O procedimento minimamente invasivo tem vantagens estéticas e reduz o trauma cirúrgico. Estes dados servem de incentivo ao desenvolvimento da técnica cirúrgica no nosso serviço.

Minimally invasive bypass of the left anterior descending coronary artery.

INTRODUCTION: Minimally invasive revascularization of the left anterior descending coronary artery has gained popularity. Recently, the emergence of new surgical instruments and the improvement of the technique, allowed its use by routine. Its use in Heart Team allows excellent results. Our aim is to present the results of patients undergoing this technique in our center. METHODS: Retrospective study of patients submitted to minimally invasive revascularization of the left anterior descending coronary artery at our center. RESULTS: We identified 14 patients. The mean age was 67 years old. In the total of the procedures, 79% were elective and 21% urgent. The ventricular function was preserved in 86% of the patients. In the preoperative catheterization, 64% of the patients showed single disease of the anterior descending coronary artery, 29% had trunk lesions and 3 vessels and 7% had lesion of 2 vessels. The mean Euroscore II was 4.8%. The mean time of surgery was 103 minutes with a mean blood loss of 250mL. The main complications were wound dehiscence and revision of hemostasis. The mean hospitalization rate was 6.2 days. The hospital survival rate was 100%. CONCLUSION: Minimally invasive revascularization allows coronary artery bypass grafting with the best conduit. Revascularization may be total in single disease of the left anterior descending artery, or in case of multivessel disease, achieved with hibrid revascularization, with angioplasty of the remaining vessels. This technique has shown to be promising and safe, being the discussion in Heart Team of the patient candidates essential for achieving the best results.

Introdução: A revascularização minimamente invasiva da artéria descendente anterior tem ganho popularidade. Recentemente, o surgimento de novos instrumentos cirúrgicos e aperfeiçoamento da técnica, permitiu que seja utilizada por rotina. O seu uso em Heart Team permite excelentes resultados. O nosso objetivo é apresentar os resultados do nosso centro, dos doentes submetidos a esta técnica. Métodos: Estudo retrospetivo dos doentes submetidos a revascularização minimamente invasiva da artéria coronária descendente anterior, no nosso centro. Resultados: Foram identificados 14 doentes. A média de idade foi de 67 anos. Do total de procedimentos, 79% foram eletivos e 21% urgentes. A função ventricular encontrava-se conservada em 86% dos doentes. No cateterismo pré-operatório, 64% dos doentes apresentou doença única da descendente anterior, 29% lesão do tronco e 3 vasos e 7% lesão de 2 vasos. O Euroscore II médio foi de 4,8%. O tempo médio de cirurgia foi 103 minutos, com uma perda média de sangue de 250mL. As principais complicações foram deiscência da ferida operatória e revisão da hemóstase. A média de internamento foi de 6,2 dias. A taxa de sobrevida hospitalar foi 100%. Conclusão: A cirurgia minimamente invasiva permite a revascularização da artéria coronária mais importante, com o melhor conduto. A revascularização pode ser total, em doença única da descendente anterior, ou em caso de doença multivaso, conseguida com revascularização híbrida, com angioplastia dos restantes vasos. Esta técnica tem-se mostrado promissora e segura, sendo a discussão dos doentes candidatos em Heart Team, essencial para obter os melhores resultados.

Rapid Deployment Aortic Valves in Elderly Patients: Age is not just a Number.

INTRODUCTION: Aortic valve stenosis (AS) is the most common valvular pathology in the elderly. Surgical aortic valve replacement (AVR) remains the gold-standard of treatment for AS. However, emerging transcatheter aortic valve replacement (TAVR) has become an increasing alternative to surgery. In a recent survey from the European Society of Cardiology, 9,4% of the physicians stated that age was the main reason to propose for a TAVR instead of surgery. METHODS: We performed a single-center retrospective study including 353 patients (149 patients over 80 years-old, compared to 204 patients between 60-69 years-old) consecutively submitted to AVR between January 1, 2013, and December 31, 2016, to compare the results of both groups in AVR surgery and how we can improve surgery outcome in older patients. RESULTS: The demographic and clinical characteristics between the two groups were similar. There were no significant differences in survival between the two groups at 30 days (96,57% 60-69yo vs. 96,64% >80yo), 12 months (89,57% 60-69yo vs. 93,51% >80yo) and 24 months (85,92% 60-69yo vs. 87,62% >80yo). The postoperative complication rates were similar in the two groups, excluding the rate of post-operative atrial fibrillation, higher in the >80 years-old group (29,06% vs. 17,28%, p=0,0147). ICU and average hospital length of stay was similar between the two groups (p>0,05). In all patients, Euroscore II was directly correlated to intensive care unit length of stay (p=0,0044). In all patients, extracorporeal circulation and aortic cross-clamp times were directly correlated to invasive ventilation time (p=0,0254 and p=0,0101) and to post- -operative bleeding (p=0,0002 and p=0,0015). However, in the subgroup analysis, aortic cross-clamp time was directly correlated to ventilation time (p=0,0397) and to intensive care unit length of stay (p=0,0493) in the >80yo patients, but that was not verified in the 60-69yo patients (p=0,0942, p=0,3801, respectively). CONCLUSION: Survival rates are similar between the two groups, with similar post-operative complications. Post-operative atrial fibrillation and the use of blood and blood products are more common in patients over 80 years-old. In older patients, lower periods of extracorporeal circulation and aortic cross- -clamp much be achieved to reduce invasive ventilation time, post-operative bleeding and ICU and hospital length of stay, improving post-operative recovery. It has been shown that rapid deployment aortic valves reduce extracorcoporeal circulation and aortic cross-clamp times, so their use in elderly patients must improve surgery recovery and outcome.

[Video-assisted thoracic sympathectomy - the results from a center outpatient surgery program]. / Simpaticectomia torácica por vídeo-toracoscopia ­ experiência de um programa de cirurgia de ambulatório.

BACKGROUND: The outpatient surgery program from our department has started in 2014 to improve patient access to surgery and to reduce the surgical waitlist. Focused on the thoracic surgery, the most common intervention is the surgical treatment of primary hyperhidrosis by thoracic sympathectomy by video-assisted thoracoscopic surgery (VATS). It is performed according to the patient's symptoms, with section or application of surgical clips between R2-R5. MATERIALS AND METHODS: Retrospective study including all the patients submitted to thoracic sympathectomy by video- -assisted thoracoscopy surgery from our department's outpatient surgery program from January 2014 to January 2016. RESULTS: In our outpatient program we performed 198 thoracic sympathectomy by VATS. The mean age of the patients was 32,8 years old. 63,6% of the patients were females and 36.4% were males. From the 198 endoscopic thoracic sympathectomy performed, 181 (91,4%) were performed bilatellary with section between R3-R5, 12 (6,1%) were performed with the application of surgical clips in R2-R4 and 3 (1.5%) could not be performed due to the presence of pleuropulmonary adhesions. One of the patients was re-operated due to recurrent symptoms and another patients had surgery to remove the surgical clips (bilaterally in R2) due to exaggerated abdominal compensatory hyperhidrosis. Three patients had pneumothorax. CONCLUSION: The surgical treatment of primary hyperhidrosis was the most frequent procedure in our outpatient surgery program. The procedure without the use of a thoracic drainage allowed its inclusion in the outpatient surgery program. Excluding 3 patients, all the patients were discharged within 12 hours after the surgery. The good results and the reduction of the surgical waitlist encourage the cardiothoracic outpatient surgery program.

Introdução: O programa de cirurgia de ambulatório do Serviço de Cirurgia Cardiotorácica do HSM-CHLN iniciou-se em Janeiro de 2014, com o intuito de melhorar a acessibilidade dos pacientes e reduzir a lista de espera. Focada essencialmente na área da Cirurgia Torácica, a actividade de ambulatório assenta sobretudo no tratamento cirúrgico videoassistido (VATS) da hiperhidrose primária axilar e palmar. A correção da hiperhidrose axilar e palmar através da simpaticectomia torácica é realizada de acordo com os sintomas do doente, com laqueação uni ou bilateral ou aplicação de clips entre R2-R5. Neste artigo apresentamos a experiência do nosso serviço na realização de simpaticectomia torácica por VATS através do programa de Cirurgia de Ambulatório. Materiais e métodos: Estudo retrospectivo de análise de dados clínicos de doentes submetidos a simpaticectomia torácica por VATS através do programa de cirurgia de ambulatório entre Janeiro de 2014 e Janeiro de 2016. Resultados: Foram efectuadas 198 simpaticectomias torácicas por VATS no período descrito. Os pacientes tinham em média 32,8 anos, sendo 63.6% do sexo feminino e 36.4% do sexo masculino. Das 198 simpaticectomias torácicas por VATS realizadas, 181 (91,4%) foram bilaterais com laqueação ao nível de R3-R5, 12 (6,1%) foram realizadas com aplicação de clips em R2-R4, e em 3 doentes (1.5%) a cirurgia não pode ser realizadas pela presença de aderências pleuro-pulmonares. Um paciente foi submetido a novo procedimento por recorrência dos sintomas e outro paciente foi submetido a remoção dos clips aplicados bilateralmente em R2 por hiperhidrose abdominal compensatória acentuada. Três doentes desenvolveram pneumotórax. Conclusão: O tratamento cirúrgico da hiperhidrose palmar e axilar através da simpaticectomia bilateral constitui o procedimento mais frequente na cirurgia de ambulatório do Serviço de Cirurgia Cardiotorácica do Hospital de Santa Maria do Centro Hospitalar Lisboa Norte. A realização do procedimento sem colocação de drenagens torácicas permitiu realizá-lo no regime de ambulatório. Trata-se de um procedimento eficaz, com baixa taxa de recidiva de sinais e sintomas e com rápida recuperação. Com exceção de 3 doentes, todos tiveram alta nas primeiras 12h pós-operatório. Os bons resultados obtidos e a redução da lista de espera constituem um incentivo para a manutenção do programa de ambulatório da Cirurgia Cardiotorácica.

[Results of the utilization of the ECMO-VA following cardiac surgery, in the Department of Cardiothoracic Surgery of Santa Maria Hospital]. / Resultados Da Utilização Da Ecmo-va Em Doentes Pós Cirurgia Cardíaca No departamento De Cirurgia Cardiotorácica Do Hospital De Santa Maria.

OBJECTIVES: Extracorporeal membrane oxygenation through a veno-arterial circuit (ECMO-VA) is an organ support option in refractory cardiogenic shock, when the primary cause of decompensation is thought to be reversible. We report the clinical results of this technique in patients submitted to cardiac surgery at our center. METHODS: We present a retrospective study of patients that underwent ECMO-VA after cardiac surgery and subsequent admission at the intensive care unit (ICU), in our center. The data were collected from clinical records. The statistical analysis was made with an SPSS 22.0 data base. RESULTS: We report data on 7 patients with an average age of 62 years. The mean SAPS II was 56 points, the Euroscore II was 17% and the British Columbia Cardiac Surgery Intensive Care Score was 71%. 57% of patiens underwent myocardial revascularization surgery, 29% were submitted to valvular surgery and 14% of the patients underwent an aortic surgery. All of the patients underwent peripheral cannulation, 71% of which was placed during surgery and in the remaining 29%, immediately after. All of the patients were put on mechanical ventilation and 86% needed an intra-aortic baloon and renal support. The main complications were acute renal injury (100%), coagulopathy (86%), emergency re-sternothomy (43%) ischaemia of the cannulated limb (29%) and central nervous system complications (29%). The average time of ECMO-VA use was 5 days and the mean stay in the ICU was 19 days. In 57% of patients, the de-cannulation was successful. The average in-patient survival was 43%. CONCLUSION: Extracorporeal membrane oxygenation through a veno-arterial circuit (ECMO-VA) is an organ support option in refractory cardiogenic shock, when the primary cause of decompensation is thought to be reversible. The timely utilization of the procedure is crucial in cases with high probability of reversible causes of cardiogenic shock, where the rational for its use is to allow time for the myocardium to recover. The main difficulty identified for the procedure was the selection of patients that would benefit from this organ support, since there are no clear guidelines in the literature for its application. In our center, we obtained a survival rate of 43%, in line with values from international centers which report a survival rate between 20-40%. The use off this tool is indispensable for a center of cardiothoracic surgery. Without this technique, the surviving patients would present a high rate of mortality and consequently our surgical work would be frustrating.

Left Partial Anomalous Pulmonary Venous Return and Mitral Stenosis in an Adult.

Partial anomalous pulmonary venous return (PAPVR) is a relatively common congenital cardiac malformation in which one to three pulmonary veins drain to a systemic vein, the right atrium or the coronary sinus, resulting in a left-to-right shunt and the risk of developing pulmonary hypertension (PHT). It is frequently associated to other congenital cardiac defects (mainly atrial septal defect) but seldom associated with acquired cardiac disease, and normally involves the right lung. When it involves the left lung, the surgical correction in children is normally performed without prosthetic material. The authors report a case of associated mitral stenosis and left PAPVR corrected with comissurotomy and extra-anatomic derivation with a synthetic vascular graft.

The impact of cardiopulmonary bypass time on the Sequential Organ Failure Assessment score after cardiac surgery.

OBJECTIVES: Postoperative organ dysfunction is common after cardiac surgery, particularly when cardiopulmonary bypass (CPB) is used. The Sequential Organ Failure Assessment (SOFA) score is validated to predict morbidity and mortality in cardiac surgery. However, the impact of CPB duration on postoperative SOFA remains unclear. METHODS: This is a retrospective study. Categorical values are presented as percentages. The comparison of SOFA groups utilized the Kruskal-Wallis chi-squared test, complemented by ad hoc Dunn's test with Bonferroni correction. Multinomial logistics regressions were employed to evaluate the relationship between CPB time and SOFA. RESULTS: A total of 1032 patients were included. CPB time was independently associated with higher postoperative SOFA scores at 24 h. CPB time was significantly higher in patients with SOFA 4-5 (**P = 0.0022) or higher (***P < 0.001) when compared to SOFA 0-1. The percentage of patients with no/mild dysfunction decreased with longer periods of CPB, down to 0% for CPB time >180min (50% of the patients with >180m in of CPB presented SOFA ≥ 10). The same trend is observed for each of the SOFA variables, with higher impact in the cardiovascular and renal systems. Severe dysfunction occurs especially >200 min of CPB (cardiovascular system >100 min; other systems mainly >200 min). CONCLUSIONS: CPB time may predict the probability of postoperative SOFA categories. Patients with extended CPB durations exhibited higher SOFA scores (overall and for each variable) at 24 h, with higher proportion of moderate and severe dysfunction with increasing times of CPB.