[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.

Uniportal VATS Lobectomy: Subxiphoid Approach.

INTRODUCTION: Interest in uniportal video-assisted thoracic surgery (VATS) is rapidly growing worldwide because it represents the surgical approach to the lung with the least possible trauma and in recent years the subxiphoid approach has been used in the field of thoracic surgery as it is associated with lesser pain because there is no intercostal nerve damage and it provides excellent cosmetic outcomes. This technique was recently introduced for major pulmonary resections and even bilateral approaches in selected patients. METHODS: We present a case of a 66 years old male, former smoker (45 unit pack year) who had a thorax CT (computorized tomography) scan for worsening complaints of cough with sputum production. The CT scan revealed a right upper lobe nodule (16x14mm) with ground glass density and fissure retraction. The pulmonary function tests showed mild bronchial and bronchiolar obstruction. It was decided to undergo surgical treatment. The surgical approach was a subxiphoid uniportal lung resection. RESULTS: The patient was positioned in a left lateral position with 60 degrees of inclination. The surgeon and scrub nurse were located in front of the patient and the assistant in the opposite side. A 3cm midline vertical incision was made below the sterno-costal triangle. The rectus abdominis was divided and the xiphoid process was partially resected. The right pleura was opened by finger dissection. The pericardial fatty tissue was removed and a soft tissue retractor was placed. A 10- mm, 30-degrees video camera and double articulated instruments combined with several specific longer VATS instruments were used through the same subxiphoid incision.It was performed a wedge resection and after the diagnosis of adenocarcinoma in the intraoperative histological examination, the patient underwent a right upper lobectomy and complete mediastinal lymphadenectomy by the same approach.The post-operative period was uneventful, the chest tube was removed in the third postoperative day. The pain control was excellent, with a maximum of pain grade 1 in the Visual Analogue Scale.The patient was discharged in the fourth postoperative day. CONCLUSION: The subxiphoid approach is a variant of uniportal VATS approach without opening the intercostal space with its striking advantages in terms of pain control and cosmetics in selected patients. However, this technique has yet some limitations such as the control of major bleeding and the performance of a complete oncologic lymph node dissection related to its surgical complexity expected in emerging techniques. Further studies are necessary to certify the feasibility, safety and benefits of this approach.

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.

[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.

Correction: The Meaning of Lymphadenopathies During Adjuvant Durvalumab After Chemoradiotherapy for Lung Cancer: Thinking Beyond Disease Progression.

[This corrects the article DOI: 10.7759/cureus.26729.].

Case report: Using DNA short tandem repeats to confirm nongestational origin of pulmonary choriocarcinoma.

Gestational trophoblastic neoplasias (GTN) are malignant neoplasms that occur in pregnant or recently pregnant women. Choriocarcinoma (CCA) is a highly aggressive and rare GTN, and cases outside the female genital tract are commonly seen as secondary manifestations of gynecologic disease. In this paper, we describe the case of a 40 years-old female patient with a primary pulmonary CCA who was surgically treated and for whom the confirmation of the primary origin of the tumor was possible using a DNA short tandem repeat genotyping. Distinction between gestational and non-gestational trophoblastic neoplasia is crucial as they require different therapeutic approach and have different prognoses.

The Meaning of Lymphadenopathies During Adjuvant Durvalumab After Chemoradiotherapy for Lung Cancer: Thinking Beyond Disease Progression.

Immune-checkpoint inhibitors (ICIs) have become the mainstay of treatment for many malignancies. With this new strategy, relevant immune-related adverse events (irAEs) have been reported, some of which can be mistaken for disease progression. To better illustrate the current challenges in diagnosing and managing a patient under adjuvant ICI treatment, we present the case of a 67-year-old female patient with stage IIIB unresectable, epidermal growth factor receptor (EGFR)-mutated, non-small-cell lung cancer who was initially treated with chemoradiotherapy, followed by immunotherapy with durvalumab. During the course of immunotherapy, the patient presented with madarosis and erythematous and endured skin lesions, in addition to lymphadenopathies and pulmonary infiltrates. She was started on first-line palliative treatment with an EGFR tyrosine kinase inhibitor. After reviewing the case, a multidisciplinary team meeting suggested diagnostic procedures, including a transbronchial needle aspiration from mediastinal lymph nodes. The histologic examination showed chronic systemic inflammation and non-caseating granulomas of the sarcoid type. In this case, palliative treatment was suspended and systemic therapy with prednisolone was initiated. The patient became asymptomatic and the previously observed radiologic abnormalities resolved. This case highlights the importance of early recognition and appropriate treatment of irAEs, mainly because these conditions remain poorly understood and are probably underdiagnosed. Considering differential diagnosis is paramount to guide clinical management, despite curative or palliative treatment intent.

[Images in cardiology after clinical observation - aortic dissection in Marfan syndrome]. / Imagens em Cardiologia mas depois da clínica em Cardiologia - Dissecção da aorta num doente com Síndrome de Marfan.

INTRODUCTION: Stanford type A aortic dissection is a rare phenomenon with high short-term mortality and clinical manifestations that can make differential diagnosis a lengthy process requiring several diagnostic examinations. OBJECTIVES: Based on a case report, the aim is to highlight the importance of physical examination in the initial management of these patients and of rapid access to a surgical center. A brief review follows on the diagnosis and treatment of ascending aortic dissection, and its specific nature in Marfan syndrome. CASE REPORT: A 33-year-old man was admitted to the emergency department of a district hospital with chest and back pain associated with vomiting, 20 hours after symptom onset. Initial physical examination revealed an aortic systolic murmur and musculoskeletal morphological abnormalities compatible with Marfan syndrome. Given suspected aortic dissection, a transthoracic echocardiogram was immediately performed, which showed an extensive intimal flap originating at the sinotubular junction. He was transferred to the cardiothoracic surgery department of a referral hospital where he was treated by a Bentall procedure. CONCLUSION: In this case, careful physical examination during initial assessment raised the suspicion that this patient was in a high-risk group for aortic dissection, thus avoiding unnecessary and lengthy exams. This diagnosis requires emergent surgical treatment, and so direct contact in real time between those making in the diagnosis and the surgeon is essential, as well as protocols governing immediate access to a surgical center.