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.

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.

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.

Twelve Years of Complete Atrioventricular Septal Defect Repair.

BACKGROUND: Surgical repair is the standard treatment for complete atrioventricular septal defect. At our institution, this repair is performed by single patch, modified single patch or two patch techniques, according to the surgeon preferences and the surgical anatomy of the defect. The goal of this study was to evaluate our results from the last twelve years. METHODS: From June 2006 to June 2018, 81 children with complete atrioventricular septal defect (without tetralogy of Fallot or unbalanced ventricles) were submitted to surgical repair at our institution. Data from all patients was retrospectively collected and evaluated. RESULTS: The average age was 6.9 ± 13.7 months and 84% had Down syndrome. Eighty percent were symptomatic and 6 patients were previously submitted to pulmonary artery banding. No more that mild left atrioventricular valve insufficiency was found in 84% and 89% of the patients, at discharge and follow-up, respectively. Small residual septal defects were present in 27% at discharge; during follow-up, 41% of these closed spontaneously. Pulmonary hypertension at discharge and follow-up appeared in 3.7% and 1.3%, respectively. Permanente pacemaker was implanted in 3 patients. Left ventricle outflow tract obstruction was found in 3 patients and 2 needed surgical correction. At follow-up (40 ± 38 months), 90% of the patients presented NYHA functional class I. No significant differences in the main repair outcomes were found between techniques, with the exception of small residual septal defects, although the groups were unmatched. CONCLUSIONS: Overall and regardless of the technique used for the repair of complete AVSD, good early and midterm outcomes were achieved.

[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.

Surgical aortic valve replacement in octogenarians: Single-center perioperative outcomes and five-year survival.

INTRODUCTION AND OBJECTIVES: Aortic stenosis is the most common valvular heart disease. The number of octogenarians proposed for intervention is growing due to increased lifespan. In this manuscript we aim to evaluate perioperative outcome and long-term survival after surgical aortic valve replacement (SAVR) in octogenarians, comparing patients with low surgical risk (EuroscoreII <4%) with intermediate-high risk (EuroscoreII ≥4%). METHODS: A retrospective observational single-center cohort study with 195 patients aged ≥80 years old, who underwent SAVR between 2017 and 2021, was conducted. Patients were divided into two groups according to EuroscoreII: (1) Low risk (EuroscoreII <4%) with intermediate-high risk (EuroscoreII ≥4%). Continuous variables are presented in median (IQR), analyzed using Wilcoxon rank sum test; categorical variables in percentages, analyzed using chi-squared test; and survival was analyzed by Kaplan-Meier, open cohort, and the log-rank test was performed. RESULTS: The overall median age was 82 (IQR 81-83), with 4.6% of the patients ≥85 years old. 23.6% of the patients presented EuroscoreII ≥4%. No complications were observed in 26.2%, with a significantly higher rate in intermediate-high risk patients. Postoperative need for hemodynamic support was the most frequent complication, followed by postoperative acute kidney injury and the use of blood products. Overall median ICU stay was three days (2-4) and hospital length of stay (LOS) six days (5-8). Patients with intermediate-high risk and those with complications had longer ICU LOS. At 12 months, overall survival was 96.4%, at three years 94.1% and 5 years 75.4%. Patients with low surgical risk had higher survival proportions up to 5 years. CONCLUSION: SAVR in patients ≥80 years is associated with low in-hospital mortality, although a significant proportion of patients develop complications. Long-term follow-up up to five years after surgery is acceptable in octogenarians with low surgical risk.

Internal Mammary Artery Skeletonization - Review Of Current Evidence.

Internal mammary artery (IMA) harvesting is a central part in coronary artery bypass grafting (CABG). The technique of harvesting the IMA - pedicled, skeletonized, or semi-skeletonized, may influence intra-operatory and postoperatory outcomes. We aim to review current evidence regarding the advantages and disadvantages of these techniques, and their performance in certain subsets of patients.

Ascending Aorta Sacular Aneurysm.

. A 83 year old woman with history of arterial hypertension, hypothyroidism, obesity, chronic renal insufficiency and incipient dementia was transferred to our hospital after complaints of chest pain. Investigation revealed a sacular ascending aortic aneurysm with the aneurysmal sac adjacent to the sternum. Due to her age, cognitive state and risk of sternal entry, she was refused for surgery. She was discharged after coronariography showed normal coronaries and other causes of chest pain were excluded. She is still alive and stable after 40 months, with no growth of aneurysm dimensions.

Conduction Disorders And Their Clinical Impact After Sutureless/Rapid Deployment Aortic Bioprosthesis.

INTRODUCTION: Aortic stenosis remains the number one heart valve pathology. The drive to improve the surgical outcomes brought to focus rapid deployment valves (RDV), which reduce aortic cross-clamping and cardio-pulmonary bypass (CPB) times. However, some centers have reported a higher rate of conduction abnormalities and permanent pacemaker (PPM) implantation. The aim of this study was to investigate the incidence of conduction abnormalities after aortic valve replacement with RDV, as well as its impact on immediate postoperative outcomes. METHODS: Retrospective analysis of associated conductions disorders and PPM implantation rates, as well as post-operative outcomes of all patients undergoing isolated aortic valve replacement between April 2014 and December 2019 with an RDV. Comparative analysis between the group with PPM implantation and the one with no PPM implantation. Patients with previous PPM implantation, reoperations and patients with missing pre or postoperative ECG data were excluded. RESULTS: We studied 201 patients. The majority of conduction abnormalities were left bundle branch block (54,0%). Twenty-six PPM were implanted (12,6%). Pre-operative characteristic between the groups were similar and little differences were found in regard to most complications. However, the PPM group showed significantly higher rates of stroke (7.7% vs 0.0%, p=0.016) and hemodynamic support for longer than 24 hours (60.0% vs 36.1%, p=0.028). From the multivariable analysis, preoperative right bundle branch block was the only independent risk factor associated with PPM. CONCLUSIONS: PPM implantation rates with RDV are relatively high and are associated with prolonged hospital and ICU stays, postoperative stroke rates and requirement of aminergic support. Their use should be made on a case-by-case basis taking into consideration the existence of preoperative conduction disorders, especially right bundle branch block.

Low Mean Arterial Pressure During Cardiopulmonary Bypass and the Risk of Acute Kidney Injury: A Propensity Score Matched Observational Study.

INTRODUCTION: Low mean arterial pressure (MAP) periods occur frequently during cardiopulmonary bypass (CPB), and their management remains controversial. Our aim was to correlate MAP during CPB with the occurrence of post-operative acute kidney injury (AKI), considering two different parameters: consecutive and cumulative low MAP periods. METHODS: Single-centre observational retrospective study including 250 patients submitted to non-emergent aortic valve replacement, with tepid to mild hypothermia (not below 32°C). The primary outcome was the occurrence of AKI. A propensity scored matching of 43 patients was used to adjust both populations (AKI and No AKI). MAP measures were automatically and continuously recorded during CPB. Low MAP periods were analysed employing two parameters: consecutive and the cumulative sum of time. RESULTS: Patients who experienced at least 5 min with MAP <50 mmHg had an increased risk of post-operative AKI (OR infinity; 95% CI, 1.47 to infinity; P = .026). The risk is also significant with MAP <40 mmHg (OR 2.78; 95% CI 1.1-6.9; = .044) and <30 mmHg (OR 3.36; 95% CI 1.2-9.2; P = .029). Post-operative AKI was associated with cumulative and consecutive periods of low MAP. Patients with periods of low MAP had higher levels of post-operative creatinine and reduced glomerular filtration rate (GFR). Patients with AKI had prolonged endotracheal ventilation time, and ICU and ward lengths of stay. CONCLUSION: Low MAP periods during CPB are associated with an increased occurrence of post-operative AKI, leading to 1) higher creatinine levels; 2) decreased GFR and 3) longer ICU and ward lengths of stay. Both consecutive and cumulative periods of low MAP are associated with an increased risk of AKI. MAP appears to be an important contributor to post-operative AKI and should be carefully managed during CPB. Further studies must address if MAP variations lead to definitive and long-term consequences.

An alternative approach for addressing mediastinal tumours through mini-invasive surgery.

INTRODUCTION: The treatment of choice for mediastinal tumours is surgical, with the standard approach being sternotomy. Because of the invasive nature of this procedure, the management of these masses through mini-invasive surgery has become an alternative method. PRESENTATION OF CASE: We report the case of a woman with a mediastinum tumour and a new technique used for resection, through an inframammary left incision, using a Thoratrak rib spreader and Rultract Skyhook retractor assisted by a video. DISCUSSION/CONCLUSION: This approach allows a complete visualization of the mediastinum and total dissection of the tumour safely around vascular and nervous structures. The pain is minimal because there is no real rib spread but instead an anterior displacement of the upper rib. This is the first reported case of resection of a mediastinum tumour by inframammary approach using a Thoratrak rib spreader and Rultract Skyhook.

Extended thymectomy, left pneumonectomy, pericardiectomy and partial pleurectomy for a large thymoma, using only a median sternotomy.

We present a case of a large thymoma with invasion to the hilum of the lung and pleural dissemination. A 58-year-old woman was diagnosed with a type B2 thymoma, with suspected pericardium, pulmonary artery and left lung invasion and pleural metastasis (Masaoka-Koga stage IVb). A radical resection was planned after systemic chemotherapy. Through a median sternotomy, we resected the tumour, and after confirmation of pericardium and left lung invasion, we also performed resection of the pericardium, of the lung and of the pleural metastasis. The median sternotomy allowed a safe dissection of pulmonary vessels and main bronchus.

Occult Metastatic Melanoma Presenting as an Acute Coronary Syndrome.

Melanoma is a tumor that virtually involves any tissue and commonly metastasizes to the heart. It is usually not diagnosed because of the absent/nonspecific cardiac signs and symptoms. Herein, we present a case of a 41-year-old man without any cardiovascular risk factor, admitted to the emergency room with chest pain, diagnosed with a myocardial infarction. Due to the presence of a mass adjacent to the mitral valve on the cardiac ultrasound examination, causing mitral regurgitation, the patient was referred to surgery. Pathological analysis of the excised specimens diagnosed the melanoma. The chemotherapy was started and achieved a partial response. Cardiac metastases usually affect the myocardium, leaving the valves unaffected. In this case, the acute coronary syndrome was the first manifestation of the malignant melanoma. We highlight the high level of suspicion needed in these cases.