Total Aortic Arch Replacement With E-Vita OPEN PLUS Hybrid Prosthesis - Initial Experience From A Single Surgical Center.

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.

Safety And Risk Factors For The Morbidity And Mortality Of Pneumonectomy: A Retrospective 10- Year Study In A Single Institution.

OBJECTIVES: Pneumonectomy is a procedure with high post-operative morbidity and mortality. This study aims to assess and identify possible risk factors that can affect post-operative outcome, therefore determining the safety of pneumonectomy in specific groups. METHODS: A total of 63 patients submitted to pneumonectomy at our centre, from February 2008 to February 2018, were included in our retrospective study. Age, gender, side of intervention, diagnosis, pre-operative symptoms, substance abuse and comorbidities were assessed. Early and late post-operative complications, as well as death were our major outcomes. We analysed the impact of preoperative variables on major outcomes using SPSS statistics. RESULTS: We found a 9,8% surgery-related mortality and 1-year survival rate of 76,2%. The incidence of early complications in our population was of 35% while eleven patients (17,4%) developed late post-operative complications. No statistical difference was found when comparing survival time between genders or age groups. Right sided pneumonectomies seem to be associated with an higher mortality risk. No other association between risk factors and outcomes reached statistical significance in both univariate and multivariate analysis. CONCLUSIONS: Pneumonectomy is a viable option regardless of age whenever the patient has a good functional and cardiopulmonary status. Gender and diagnostic group do not seem to influence adverse event risk, although right-sided pneumonectomies show an increased risk for post-operative death. Care should be taken with patients submitted to neoadjuvant therapy. All patients should be encouraged to cease smoking as early as possible before surgery, given the increased risks for post-operative complications.

Predictors of Acute Kidney Injury Associated with Cardiopulmonary Bypass.

OBJECTIVES: To study the incidence of acute kidney injury (AKI) in the postoperative period of cardiac surgery in patients without preoperative renal insufficiency who underwent cardiac surgery with cardiopulmonary bypass (CPB), and to explore the association between the incidence of AKI and predictors related to CPB. METHODS: Observational, cross-sectional study. Participants were divided in two groups, those who developed AKI in the postoperative period and those who did not develop AKI. Kidney Disease: Improving Global Outcomes - Clinical Practice Guideline for Acute Kidney Injury (KDIGO) classification was used to characterize AKI. The analysis included preoperative variables (anthropometric data, cardiovascular risk factors and blood parameters), as well as the type of surgery, intraoperative variables related to CPB, and postoperative creatinine variation. Association between variables was studied with binary logistic regression. RESULTS: We have included 329 patients, of which 62 (19%), developed AKI. There were statistically significant differences between the groups in age (p<0.001; OR (95%)-1.075 (1.037-1.114)), duration of CPB (p=0.011; 1.008 (1.002-1.014)), urine output during CPB (p=0.038; 0.998 (0.996-0.999)), mannitol and furosemide administration during CPB, (respectively, p=0.032; 2.293 (1.075-4.890) and p=0.013; 2.535 (1.214-5.296)). CONCLUSIONS: A significant number of patients developed AKI in the postoperative period of cardiac surgery and this incidence was influenced by factors related to CPB, namely: age, duration of CPB, urine output during CPB, mannitol and furosemide administration during CPB.

Surgical treatment of concomitant severe heart disease and lung cancer.

The concomitant presentation of lung cancer and severe heart disease requiring intervention is a scenario that many clinicians have to face. Its common physiopathological substratum is unknown and it is believed that tobacco plays a role. From a surgical point of view, these patients pose various technical challenges and medical literature is scarce in providing solid answers. The aim of this report is to review our experience with cases undergoing combined surgical treatment of both heart disease and lung cancer, aiming to analyse patients' characteristics, operative technical considerations and related outcomes. A total of five patients were included, with two synchronous procedures, two cases with lung surgery being performed first and one case commenced with cardiac surgery. All cancers were non-small-cell lung carcinoma or carcinoid tumors and cardiac disease was mostly represented by severe aortic stenosis. Lobectomy was performed in two thirds of patients and minimally invasive techniques were used in 60% of the procedures. All valvular patients received a bioprosthesis. There was one immediate complication, with good recovery on follow-up, and there were no late events (median follow-up of 1,8 ±1,1 months). The analysis of these cases highlights the complex nature of these challenging patients and reinforces the importance of devoting efforts to offer the most suitable solutions for each scenario.

A apresentação concomitante de cancro do pulmão e doença cardíaca severa necessitando intervenção é um cenário frequente na prática clínica. O seu substrato fisiopatológico comum é desconhecido e acredita-se que o tabagismo possa ser um agente associado. Do ponto de vista cirúrgico, estes pacientes colocam vários desafios técnicos e a literatura médica é escassa em providenciar respostas robustas. O objetivo deste relato consiste em rever a nossa experiência com casos submetidos a tratamento cirúrgico combinado das patologias supracitadas, visando analisar as características dos pacientes, considerações das técnicas operatórias e eventos relacionados. Um total de cinco pacientes foram incluídos, com dois procedimentos síncronos, dois casos que tiveram a cirurgia pulmonar como primeiro procedimento e um caso iniciado com cirurgia cardíaca. Histologicamente, todos os cancros eram carcinomas pulmonares de não pequenas células ou tumores carcinóides e a patologia cardíaca mais representativa foi a estenose valvular aórtica. A lobectomia foi executada em 2/3 dos pacientes e em 60% dos casos foram utilizadas técnicas minimamente invasivas. Todos os pacientes valvulares receberam próteses biológicas. Houve uma complicação pós-operatória imediata, com recuperação favorável, e não ocorreram eventos tardios no seguimento (duração mediana de 1,8 ±1,1 meses). A análise destes casos enfatiza a complexa natureza destes pacientes desafiantes e reforça a importância em dedicar esforços para oferecer as soluções mais adequadas para cada cenário.

Uniportal Video-assisted Thoracic Surgery Anatomical Resections - Does Previous Tobacco Exposure Adversely Influence Post-Operative Outcomes?

A high percentage of patients presenting for lung surgery are either current or former smokers, which is typically associated with many anatomical and physiological pulmonary changes. The influence of tobacco on postoperative pulmonary complications remains controversial. The main goal of this study was to analyse the effects of smoking on the risk of post-operative complications and morbidity in patients submitted to lung resection surgery through uniportal VATS. Peri-operative data on all cases of anatomical lung resection surgery through single-port VATS performed between December 2013 and July 2018 at three Portuguese institutions were collected and retrospectively reviewed Demographic data, diagnosis, pre-operative lung function tests, in-hospital length of stay (LOS) and intra and post-operative drainage levels were registered. Patients were divided in two groups according to tobacco exposure. Post-operative complications and morbidity were compared through statistical analysis We performed 313 procedures, 303 of which were evaluated in regard to outcome. Mean age at time of surgery was of 62,85 years (SD=12,24). One hundred and sixty patients (52,81%) had a history of tobacco use, while 47,19% (n=143) had never smoked. Non-smokers had significantly better lung function than smokers (p<0,05). Smoking history showed a contribution to post-operative prolonged air leaks (p=0,025) morbidity (p=0,05), 2-day longer LOS (µ=5,36 days vs. µ =7,53 days; p<0,05), longer operative times and higher intra and post-operative drainage levels. A history of smoking during a patient's life negatively impacts morbidity in patients submitted to uniportal VATS for anatomical lung resection, increasing early post-operative complications and prolonging in-hospital stays.

Correction of adult-type VSD causing aortic valve endocarditis through aortotomy.

Ventricular septal defects are the most common congenital abnormality diagnosed in children but account for only 10 percent of congenital heart defects in adults. Although many defects close spontaneously before adulthood, many others persist, predisposing to endocarditis, and other complications. Herein, we report a case of a known, asymptomatic, perimembranous ventricular septal defects that has complicated at 53 years of age with the need for surgery due to native aortic valve endocarditis and concomitant severe aortic regurgitation. We opted to surgically repair the ventricular septal defects with a pericardial patch through the necessary aortotomy used for aortic valve replacement (Figure 1 and 2). The surgery was straightforward. Postoperative course was only marked by the need of a permanent pacemaker implantation due to a sick sinus syndrome, which was diagnosed before the surgery. Thus, we emphasize the role of surgery in repairing ventricular septal defects and the importance of choosing the appropriate approach, especially when concomitant heart lesions are present.

As comunicações interventriculares são a lesão congénita mais comummente diagnosticada em idade pediátrica mas representam apenas 10% dos defeitos cardíacos congénitos em idade adulta. Apesar da maioria das comunicações interventriculares encerrarem espontaneamente antes da idade adulta, muitas persistem predispondo a endocardite e outras complicações. Apresentamos um caso de comunicação interventricular perimembranosa assintomática até à idade adulta, que complicou aos 53 anos com endocardite da válvula aórtica nativa associada a regurgitação aórtica severa, necessitando, por isso, de correção cirúrgica. Optamos pela correção cirúrgica implantando um retalho de pericárdio heterólogo através da aortotomia necessária para a substituição valvular aórtica (Figure 1 and 2). A cirurgia decorreu sem intercorrências. De referir apenas, no pós-operatório, a necessidade de implantação de um pacemaker permanente dado existência prévia de doença do nó sinusal. É de salientar a importância do papel da cirurgia na correção de comunicações interventriculares e a necessidade de escolher a abordagem cirúrgica mais apropriada, especialmente, quando existem lesões cardíacas concomitantes.

Minimally invasive aortic coarctation correction and aortic valve replacement without syetnotomy.

Aortic coarctation and bicuspid aortic valve frequently coexist. Correction frequently require an aggressive, invasive approach. Here we present a case of a two-stage minimally invasive intervention without sternotomy to correct aortic coarctation and replace the native bicuspid aortic valve. This case illustrates the potential of minimally invasive procedures with minimal trauma and fast recovery. Besides, it facilitates future cardiac interventions, such as anticipated surgical prosthesis and/or ascending aorta replacement.

A coartação aórtica e a bicuspidia aórtica coexistem frequentemente. A sua correção obriga frequentemente a uma intervenção agressiva e invasiva. Apresentamos um caso de uma intervenção faseada minimamente invasiva sem esternotomia para corrigir a coartação da aorta e substituir a válvula aórtica bicúspide nativa. Este caso ilustra o potencial de procedimentos minimamente invasivos com trauma mínimo e recuperação rápida. Além disso, facilita futuras intervenções cardíacas, como a substituição da prótese biológica e/ou da aorta ascendente, que se antecipam neste doente.

[In dubio pro malum - a clinical case to reflect]. / In dubio pro malum ­ um caso clínico para reflectir.

Patients with cardiac pathology alone are already complex, when this is associated with oncologic pathology, or it's mere suspicion, the patient becomes even more complex. We present a clinical case of a patient with severe aortic stenosis with suspected cancer disease, whose diagnostic study could not be performed due to the patient's clinical condition. The option to intervene surgically was widely debated, never being a consensus among surgeons. There are many doubts about a clinical case of this type, and it is not easy to make a decision to operate. In case of doubt, the decision must always be in favor of the patient: in dubio pro malum.

Se os doentes com patologia cardíaca, por si só, já são doentes complexos, quando a esta se associa patologia oncológica, ou a sua mera suspeição, o doente torna-se ainda mais complexo. Apresentamos um caso clínico de um doente com estenose aórtica severa, com suspeita de doença oncológica, cujo estudo diagnóstico não se poderia realizar devido ao facto de o estado clínico do doente não permitir tolerar o mesmo. A opção de intervir cirurgicamente foi uma opção amplamente debatida, nunca se encontrando um consenso entre os cirurgiões. São imensas as dúvidas levantadas perante um quadro clínico deste tipo, não sendo fácil a tomada de decisão de operar. Em caso de dúvida, a decisão deve ser sempre a favor do doente: in dubio pro malum.

Improvement in left intraventricular pressure gradients after aortic valve replacement in aortic stenosis patients.

NEW FINDINGS: What is the central question of this study? Normal diastolic and systolic intraventricular pressure gradients are decreased when left ventricular filling and/or emptying are compromised. We hypothesized that in patients with severe aortic valve stenosis, a condition that interferes with ventricular filling and emptying, those gradients would be disturbed. What is the main finding and its importance? We showed the existence of intraventricular pressure gradients throughout the cardiac cycle in the human left ventricle. Moreover, we demonstrated, for the first time, that diastolic and systolic gradients, which are markers of normal ventricular filling and emptying, respectively, improved in patients with severe aortic valve stenosis immediately after valve replacement. The present study was conducted to characterize left intraventicular pressure gradients, which are markers of normal cardiac function, in patients with severe aortic stenosis, a condition that interferes with ventricular filling and emptying. In 10 patients (four male; mean age 71.3 ± 4.8 years old) undergoing aortic valve replacement, two high-fidelity pressure catheters were inserted inside the cavity of the left ventricle through an apical puncture and positioned in the apex and outflow tract below the aortic valve. Pressures were continuously acquired and gradients calculated as apical minus outflow tract pressure, before and immediately after aortic valve replacement. During early filling, we recorded a negative intraventricular gradient along the basal portion of the left ventricle in the apical direction (-0.82 ± 0.45 mmHg), which increased to -3.97 ± 0.42 mmHg after aortic valve replacement. In late filling, intraventricular flow was now directed towards the outflow tract, with a positive pressure gradient both before (+1.23 ± 0.37 mmHg) and after surgery (+2.12 ± 0.58 mmHg). During systole, before surgery we observed a positive pressure gradient between the apex and outflow tract during both rapid (+1.60 ± 0.21 mmHg) and slow ejection phases (+1.68 ± 0.12 mmHg), whereas after aortic valve replacement the positive gradient (+1.54 ± 0.15 mmHg) during rapid ejection was inverted (-3.92 ± 0.34 mmHg) during the slow ejection phase. We demonstrated that in patients with severe aortic stenosis both diastolic and systolic intraventricular pressure gradients are significantly attenuated but can be restored immediately after aortic valve replacement. The assessment and measurement of intraventricular pressure gradients and their modulation in pathophysiological conditions may provide novel insights into cardiac physiology.

Three-year Experience on 477 Patients Undergoing Uniportal Video-Assisted Thoracoscopic Surgery.

INTRODUCTION: Uniportal video-assisted thoracic surgery (VATS) technique has been described both for diagnostic and therapeutic indications. Outcomes after uniportal VATS have never been reported in Portuguese large series. We review the safety and efficiency of our initial experience with uniportal VATS. METHODS: In a retrospective study of prospectively collected data, 477 uniportal VATS procedures were analyzed between June 2014 and June 2017. All procedures were performed without rib spreading. Patients' demographic data, preoperative and postoperative management as well as results were analyzed. RESULTS: The mean age of patients was 47,9 years (range, 10 to 86), and 155 (32,5%) patients were female. The uniportal VATS procedures included 156 (32,7%) anatomical major lung resections, 80 (16,8%) one or multiple wedge resections, 172 (36,1%) blebectomies and/ or pleurectomies, 24 (5%) mediastinal lesions, 16 (3,3%) empyema drainage and decortications and other indications in 29 (6,1%) cases. Median operative ime and surgical drainage for uniportal VATS for anatomical major lung resections was 95 minutes (range, 40 to 245) and 100 ml (range, 0 to 650), respectively. Conversion to either 2 or 3 port VATS or mini-thoracotomy was necessary in 7.1% of the surgeries, often due to adhesions, incomplete lung collapse or bleeding. The chest drain was removed after a median of 3 days (range, 0 to 34). Median hospital stay was 3 days (range, 1 to 41). Postoperative complication rate was 12,4% mainly due to prolonged air leak 8,4% (n=40). There was no perioperative mortality. CONCLUSION: Uniportal VATS is a feasible and safe technique for various indications in thoracic surgery. The perioperative results are promising. Excellent results with minimal morbidity and short hospital stay are amongst its strong points. It can be performed by thoracic surgeons experienced in the postero-lateral thoracotomy approach.

Uniportal Video-Assisted Thorascoscopic Surgery - The New Paradigm in the Surgical Treatment of Lung Cancer.

INTRODUCTION: The progressive development and improvement of minimally invasive approaches in the field of thoracic surgery allowed to establish video-assisted thoracoscopic (VATS) anatomic lung resections as the present technique of choice in the treatment of early stage lung cancer. METHODS: The purpose of this study was to evaluate the surgical outcomes of patients who performed uniportal VATS anatomic lung resections for the treatment of primary lung cancer. The patients' demographics, approach and type of surgery, postoperative morbidity and mortality and overall survival were analyzed. RESULTS: From December 2013 through September 2017, 173 patients underwent uniportal VATS anatomic lung resections for the treatment of lung cancer. Surgery was performed in 92 male and 81 female with a mean age of 63.5 years (range 19- 83 years). All surgeries began by a single- -port VATS approach, being necessary to add an extra port in 9 surgeries and conversion to mini-thoracotomy in 10 procedures (conversion rate of 5.8%) due to bleeding and/ or technical difficulties. All kinds of anatomic lung resection were performed: 154 lobectomies, which represents 89.0% of the procedures (93 upper lobectomies, 12 middle lobectomies and 49 lower lobectomies), 10 bilobectomies (5.8%) and 9 anatomic segmentectomies (5.2%). Mean lymph node stations dissected was 2.48 stations (range 1-8 stations). The mean surgical time was 112.2 minutes (range 40-245 minutes) and mean intra-operative drainage was 155.6ml (range 0-1400ml). Median hospitalization time was 5 days (range 2-28 days). There was no operative or 30-days mortality and the main complication observed was persistent air leakage in 38 patients (22.0%). Non-small-cell lung cancer (NSCLC) was the main histologic type of cancer (n=149; 86.1%), followed by carcinoid tumours (n=20; 11.6%) and other histologic type (n=4; 2.3%). The mean follow-up time was 15 months (range 0-45 months) and the overall survival was 94.5%. CONCLUSION: We believe that uniportal VATS anatomic lung resection with systematic lymphadenectomy is technically safe and feasible and it is an alternative approach to thoracotomy or conventional thoracoscopic in the treatment of lung cancer. This approach has demonstrated to be reproducible, comprising all the advantages of a minimal invasive surgery, without jeopardizing the efficiency of the oncologic treatment. Therefore, we suggest that this technique could have a broader implementation and development in all national surgical centers. The issues of patient acceptability, cosmetic and oncologic results, and cost-effectiveness remain to be determined in the future throughout multi-institution randomized controlled trials and long-term follow-up.

Predictors of Acute Kidney Injury in the Postoperative Period of Cardiac Surgery Associated with Cardiopulmonary Bypass.

INTRODUCTION: Acute kidney injury (AKI) in the postoperative period of cardiac surgery occurs in 1 to 30% of the patients, mainly caused by ischemia secondary to renal hypoperfusion. Cardiopulmonary bypass (CPB) has a deleterious effect on renal function, constituting an aggression to the patient's homeostasis. AIM: To evaluate the incidence of AKI in the postoperative period of cardiac surgery in patients without preoperative renal insufficiency who underwent cardiac surgery with CPB, and explore the association between incidence of AKI and predictors related to CPB. METHODS: Observational, retrospective, cross-sectional study. Participants were divided in two groups, those who developed AKI in the postoperative period and those who did not develop AKI. KDIGO Clinical Practice Guideline for Acute Kidney Injury classification was used to characterize AKI. The preoperative variables analysed were anthropometric data, cardiovascular risk factors and blood parameters. The type of surgery, intraoperative variables related to CPB and postoperative creatinine variation were also analysed. The association between variables was studied using binary logistic regression. RESULTS: Of the 329 patients included, 62 (18.8%), developed AKI. There were statistically significant differences between the groups in age (p<0.001), CPB time (p=0.011), diuresis during CPB (p=0.038) and mannitol and furosemide administration during CPB (respectively, p=0.032 and p=0.013). Odds ratio showed a significant positive association between AKI and age (OR (95%)- 1.08 (1.04-1.11)), CPB time (OR (95%)-1.01 (1.00-1.01)), mannitol and furosemide administration during CPB (respectively, OR (95%)-2.29 (1.08-4.89) and OR (95%)-2.54 (1.21-5.30)). CONCLUSIONS: This study shows that a significant number of patients developed AKI in the postoperative period of cardiac surgery and this incidence was influenced by factors related to CPB.

[Papillary muscle rupture as a manifestation of SLE in the puerperium]. / Rotura de Músculo Papilar como Manifestação de Lupus Eritematoso Sistémico no Puerpério.

Systemic Lupus Erythematosus (SLE) and Antiphospholipid Syndrome (APS) are two autoimmune diseases that may have serious cardiovascular manifestations, especially when associated. We report the clinical case of a young female, in the puerperium, with SLE in acute phase, who developed a sudden heart failure due to rupture of the papillary muscle. She underwent emergent cardiac surgery, with replacement of the mitral valve by a biological prosthesis. The postoperative course had no major intercurrences. Catastrophic SAF was concluded as a final diagnosis, due to the presence of anti-phospholipid antibody, to the attainment of multiple organs by thromboembolic phenomena, with histological documentation of micro-thrombi in cardiac tissue. This condition has a mortality rate of about 50%, despite treatment.

O Lúpus Eritematoso Sistémico (LES) e a Síndrome Antifosfolípido (SAF) são duas doenças auto-imunes que podem ter manifestações cardiovasculares graves, principalmente quando associadas. Apresentamos o caso clínico de uma doente jovem, puérpera, com LES em fase de agudização, que desenvolveu um quadro súbito de insuficiência cardíaca grave, por ruptura de músculo papilar. Foi submetida a cirurgia cardíaca emergente, com substituição da válvula mitral por prótese biológica. O período pós-operatório decorreu sem intercorrências de relevo. Como diagnóstico final concluiu-se SAF catastrófica, devido à presença de anticorpo anti-fosfolípido, ao atingimento de múltiplos órgãos por fenómenos trombo-embólicos, com documentação histológica da presença de micro-trombos no tecido cardíaco. Esta condição tem uma taxa de mortalidade de cerca de 50%, apesar do tratamento.

Aortic Valve Replacement With Perceval® Bioprosthesis: Initial Single-Center Experience.

INTRODUCTION: Aortic valve replacement (AVR) is the gold standard for the treatment of severe or symptomatic aortic valve stenosis. Less invasive procedures have been developed as an alternative to the conventional technique of full sternotomy approach with stented prosthesis. The Perceval® aortic valve (LivaNova, Milan, Italy) is a sutureless bioprosthesis, of which several reports have shown promising results in terms of mortality, morbidity and hemodynamic performance, especially with a less invasive approach. METHODS: Between March 2016 and September 2017, 43 patients underwent AVR with Perceval® bioprosthesis. The mean age was 74.3±6.8 years, 24 (55.8%) patients were female, and the mean EuroSCORE II was 4.1±0.6. Concomitant procedures were CABG (n=11; 25.6%), mitral valve surgery (n=2; 4.7%) and tricuspid valve surgery (n=1; 2.4%). RESULTS: Isolated AVR were performed in 31 patients (72%), with a less invasive approach in 29 cases (67%), of which 20 patients with upper ministernotomy and 9 patients with right anterior mini-thoracotomy. Cardiopulmonary bypass and cross- clamp times were 69.8±26.6 and 49.2±18.1 minutes for isolated AVR and 106.1±32.6 and 82.9±24.9 minutes for combined procedures, respectively. Preoperative peak and mean gradients were 81.6±24.8 and 49.7±16.1 mmHg, decreasing to 22.4±10.2 and 11.9±5.8 mmHg, respectively, during follow up (mean 9.1±6.0 months). The mean effective orifice area improved from 0.77±0.18 to 1.83±0.45 cm2, and mean left ventricular ejection fraction from 55.0±10.0 to 55.2±8.4%; mean left ventricular mass decreased from 221.6±55.7 to 180.2±42.4 g/m2. Trivial paravalvular leakage occurred in 2 patients, without clinical relevance. Five patients (11.6%) needed pacemaker implantation because complete heart-block before discharge (in 4 patients postdilation modelling wasn't performed). In-hospital mortality was 9.3% (n=4), all non-valve related (mean EuroSCORE II of 9.15±4.0). CONCLUSION: AVR with the Perceval bioprosthesis is associated with low mortality rates and excellent hemodynamic performance. Sutureless technology may reduce operative times, especially in combined procedures, making minimally invasive AVR more easily reproducible.

Long-term Outcomes in Octogenarians Following Isolated Aortic Valve Replacement.

INTRODUCTION: Isolated aortic valve replacement (AVR) in elderly patients is associated with increased operative risk, due to higher prevalence of associated risk factors and other comorbidities, making outcome prediction essential. In patients with symptomatic severe aortic disease, advanced age is often a reason for a transcatheter rather than surgical aortic valve replacement. In the era of TAVI, there has been renewed interest in the outcomes of conventional AVR for high and intermediate risk patients. This study evaluates the short and long-term outcomes of elective AVR in elderly patients. METHODS: Between July 2011 and May 2015, 100 patients, aged 80 years or older, underwent elective AVR in our unit. The notes of these patients were retrospectively reviewed and follow-up information was obtained from their cardiologists and general practitioners. The average age was 82.8±2.3 years, 53.0% were female, 96.0% had severe aortic valve stenosis and their mean EuroSCORE II was 4.1±3.2 (intermediate risk). Preoperatively, 35.0% of patients were in NYHA class III or IV. Statistical analyses were done using IBM SPSS version 24. RESULTS: Median UCI and hospital stay was 2.0±3.7 and 7.0±9.5 days, respectively. Post-operatively, 2 patients required insertion of a permanent pacemaker, 3 patients suffered an ischemic stroke without sequelae, 3 required temporary renal replacement therapy, 7 required resternotomy for bleeding, 3 had sternal wound infections. No myocardial infarction was observed. In-hospital mortality was 4.0%, which was in accordance with the mean EuroSCORE II (4.1±3.2, p>0.05). One- year survival was 85.0%, three-year survival was 81.4% and five-year survival was 59.4%. At follow-up, 96.0% of patients were New York Heart Association (NYHA) Class I or II and 2 late endocarditis occurred and were medically treated. Structural valve deterioration was observed in 2 patients at 3 years follow-up. CONCLUSION: The outcome after AVR in octogenarians is satisfactory; the operative risk is acceptable and might even be reduced with an individual approach to perioperative management in high-risk patients. Patient age should not be the primary exclusion for conventional cardiac surgery for aortic valve disease.

Carotid Stenosis in Cardiac Surgery Patients.

INTRODUCTION: Ischemic stroke is a potential perioperative complication after an open heart surgery (OHS). Whether a carotid stenosis or occlusion is associated with an increased risk of perioperative stroke in patients or just a risk factor has been a concern of intense debate in the literature. METHODS: We retrospectively analyzed patients submitted to OHS between January and December2016 with known asymptomatic carotid disease. The data from 85 consecutive patients undergoing coronary artery bypass grafting, valve replacement, or both was collected. The final events registered were stroke, acute myocardial infarct or death. Our aim was to assess whether the presence of carotid stenosis precluded a higher rate of stroke after cardiac surgery. RESULTS: 70 male and 15 female patients, with a medium age of 74(min 45,max84) years were analyzed. 45(53%) patients were submitted to bypass grafting, 21(25%) to valve replacement and 19(22%) to both. Of these patients,42(49%) had unilateral significant carotid stenosis equal or greater than 50%, 12(14%) had bilateral significant stenosis and 20(24%) had a stenosis equal or greater than70%. 2(2%) patients had a previous history of neurologic event. In the peri-operative period, 3 patients (3,5%) developed transient ischemic attack (TIA) or stroke, 3(3,5%) a cardiac event and 6(7%) patients died (3 due to a cardiac event and 2 due to a neurologic event). Two (67%) of the neurologic events occurred in the corresponding side of an hemodynamic carotid stenosis although both this patients had also significant aortic arch calcification and atrial fibrillation. None of the patients that developed post-operative TIA or stroke had previously a neurologic event. CONCLUSION: Some studies reported an average stroke incidence around 1.9%following OHS. Despite carotid stenosis, other risk factors should be taken into consideration before considering OHS such as advanced age, prior stroke/TIA, unstable angina, predicted prolonged time for cardiopulmonary bypass, severe aortic arch disease and atrial fibrillation. In our studied population two of the post-operative neurologic events occurred in patients with significant bilateral stenosis, one side between50-69% and the other side 70-99%. According to the new guidelines "Management of Atherosclerotic Carotid and Vertebral Artery Disease:2017 Clinical Practice Guidelines of the European Society for Vascular Surgery" staged or synchronous carotid intervention may be considered for OHS patients with bilateral asymptomatic 70-99% carotid stenosis, or a 70-99% stenosis with contralateral occlusion. Our results may suggest that a sub-group of patients with bilateral significant (>50%) carotid stenosis may benefit from staged or synchronous carotid intervention.

Surgical Resection of Lung Metastases.

INTRODUCTION: The aim of this study was to report our experience and outcomes in patients previously diagnosed with primary malignant solid tumors who subsequently underwent surgical resection of lung nodules whose final result on the pathological exam was a metastasis. METHODS: Between January of 2008 and September of 2016, seventy-one patients underwent pulmonary resection by video-assisted thoracic surgery (VATS) or by thoracotomy, for lung metastasis. Data were collected regarding demographics, tumor features, treatment and outcome. RESULTS: The patients included in this retrospective study (n=71) underwent a total of 79 surgeries. The study sample included 44 (62%) male and 27 (38%) female with a mean age of 60.8 years (range, 20-82 years). The primary tumor site was colorectal in 46 patients, lung in 6, soft tissue in 4, kidney in 3 and others tumors in 12. Sixty-four surgeries (81%) were performed due to a solitary metastasis. Ten (13%) surgeries were performed by VATS and 69 (87%) were performed by thoracotomy. We performed 50 (63%) wedge excisions, 20 (26%) lobectomies, 8 (10%) anatomical segmentectomies and 1 (1%) right pneumonectomy. Median hospital stay was 5 days (range, 2-21 days). Postoperative complication rate was 7.6%. Postoperative mortality was 1.3%. Median follow-up was 32 months (range 0 to 86 months). Overall 3 and 5 year survival regardless of the primary tumor site was 70% and 45%, respectively. Overall 3 and 5 year survival for the colorectal carcinoma was 73% and 42%, respectively. CONCLUSION: These results support that lung metastasectomy is a safe and effective procedure for patients with treated primary tumors. A select group of patients can achieve long-term survival after resection.

Introdução: O objectivo do estudo foi descrever a nossa experiência e resultados em doentes submetidos à ressecção cirúrgica de nódulos pulmonares cujo resultado anatomo-patológico revelou tratar-se de metástases pulmonares. Métodos: Entre Janeiro de 2008 e Setembro de 2016, setenta e um doentes foram submetidos a ressecção de metástases pulmonares por cirurgia torácica vídeo-assistida (VATS) ou por toracotomia. Os dados foram colhidos atendendo à demografia, às características tumorais, ao tratamento e outcome dos doentes. Resultados: Os doentes incluídos neste estudo retrospectivo (n = 71) foram submetidos a um total de 79 cirurgias. A amostra do estudo incluiu 44 (62%) homens e 27 (38%) mulheres com uma idade média de 60,8 anos (intervalo, 20-82 anos). O local do tumor primário foi o sistema colorretal em 46 doentes, o pulmão em 6, os tecidos moles em 4, o rim em 3 e outros tumores em 12. Sessenta e quatro cirurgias (81%) foram realizadas devido a uma metástase solitária. Dez (13%) cirurgias foram realizadas por VATS e 69 (87%) foram realizadas por toracotomia. No total foram realizadas 50 (63%) ressecções em cunha, 20 (26%) lobectomias, 8 (10%) segmentectomias anatómicas e 1 (1%) pneumonectomia direita. A mediana de internamento hospitalar foi de 5 dias (intervalo, 2-21 dias) com uma taxa de complicações pós-operatórias de 7,6%. A mortalidade pós-operatória foi de 1,3%. O seguimento mediano foi de 32 meses (intervalo de 0 a 86 meses). A sobrevivência global independente do tipo de tumor primário aos 3 e 5 anos foi de 70% e 45%, respectivamente. A sobrevivência global aos 3 e 5 anos para o carcinoma colorretal foi de 73% e 42%, respectivamente. Conclusão: Estes resultados apoiam que a metastasectomia pulmonar é um procedimento seguro e eficaz para doen- tes com tumores primários tratados. E que uma selecção adequada de doentes pode alcançar uma sobrevivência a longo prazo após a ressecção.

A rare cause of hoarseness in a young patient.

Syphilis is nowadays a rare cause of aortic aneurysms in developed countries. Commonly saccular, syphilitic aneurysms are frequently single, involving the ascending aorta and arch and are frequently asymptomatic unless large enough to cause symptoms due to compression of surrounding structures or death from rupture. In this paper, the authors present the case of a 32-years old patient presenting with progressive weakness, anorexia, weight loss and hoarseness, who was diagnosed with a multiple saccular aortic aneurysms, which were syphilitic in nature. The patient underwent surgery for a hemiarch replacement after receiving a cycle of antibiotics and had an uneventful recovery. This case illustrates that, although rare, syphilis must be recognized as a potential source of aneurismal disease as it warrants antibiotic therapy and screening of involvement of other organs.

A sífilis é atualmente uma causa rara de aneurisma da aorta em países desenvolvidos. Normalmente saculares, os aneurismas sifilíticos são frequentemente simples, envolvendo a aorta ascendente e arco. São frequentemente assintomáticos a menos que grandes o suficiente para causar sintomas devido à compressão das estruturas vizinhas, ou morte por ruptura. Neste artigo, os autores apresentam o caso de um paciente de 32 anos de idade com queixas de fraqueza progressiva, anorexia, perda de peso e rouquidão, a quem lhe foi diagnosticado múltiplos aneurismas saculares da aorta, de natureza sifilítica. O paciente foi submetido a uma cirurgia de substituição do hemiarco aórtico depois de receber um ciclo de antibióticos e teve uma recuperação sem intercorrências. Este caso ilustra que, embora rara, a sífilis deve ser reconhecida como uma fonte potencial de doença aneurismática, tanto aórtica como também de outros órgãos.

Surgical management of primary spontaneous pneumothorax: 11-years experience.

INTRODUCTION: Primary spontaneous pneumothorax (PSP) is a pathology with a high recurrence rate. Surgical treatment allows the resolution of the acute episode and prevention of its recurrence. The main objective of the present study was to evaluate the outcomes of patients submitted to surgery due to PSP. METHODS: A retrospective case series review was undertaken on all patients submitted to thoracotomy or video-assisted thoracoscopic surgery (VATS) for PSP at our thoracic surgery center between January 2005 and December 2016. RESULTS: A total of 319 surgeries were performed in 298 patients with a mean age of 29.0±12.7 years. Surgical approach was thoracotomy in 30 surgeries and VATS in 289 procedures. Surgical technique included bullectomy or apical resection in 98.1% of the surgeries in combination with some kind of pleurodesis, mainly partial parietal pleurectomy plus pleural abrasion in 38.9% and only pleural abrasion in 38.9%. Median postoperative stay was 4 days. Postoperative complications occurred in 14.7% of cases, primarily due to persistent air leak (30 of the 47 complications). Recurrence rate was 4.7% (15 cases). There was no association between surgical approach or surgical technique and recurrence. CONCLUSION: Surgical treatment remains one important cornerstone for definitive treatment of PSP. Our study demonstrated that a VATS approach, particularly uniportal VATS, to perform bullectomy or apical wedge resection along with pleural abrasion can be a safe and efficient choice in the treatment and prevention of recurrence of the PSP.

Introdução: O pneumotórax espontâneo primário (PEP) é uma patologia com uma elevada taxa de recorrência. O trata- mento cirúrgico possibilita a resolução do episódio agudo e previne a sua recorrência. O principal objectivo do presente estudo foi avaliar os resultados cirúrgicos dos doentes submetidos a cirurgia devido a PEP. Métodos: Foram revistos retrospectivamente todos os doentes submetidos a toracotomia ou cirurgia vídeo-assistida (VATS) para o tratamento de PEP no nosso centro cirúrgico no período compreendido entre Janeiro de 2005 e Dezembro de 2016. Resultados: Um total de 319 cirurgias foram realizadas em 298 doentes com idade média de 29,0±12,7 anos. A abordagem cirúrgica utilizada foi toracotomia em 30 cirurgias e VATS em 289 cirurgias. A técnica cirúrgica incluiu a ressecção de bolhas enfisematosas ou ressecção atípica do ápex pulmonar em 98,1% das cirurgias, em combinação com uma técnica de pleurodese, principalmente pleurectomia parietal parcial associado a abrasão pleural em 38,9% dos casos e apenas abrasão pleural em 38,9% dos casos. O tempo mediano de internamento foi 4 dias. Ocorreram complicações pós operatórias em 14,7% dos procedimentos, sobretudo fuga aérea prolongada (30 dos 47 casos de complicações). A taxa de recorrência foi de 4,7% (15 casos). Não foi encontrada nenhuma associação estatisticamente significativa entre a abordagem ou técnica cirúrgica e a ocorrência de recorrência de PEP. Conclusão: O tratamento cirúrgico é uma das opções fundamentais no tratamento definitivo de PEP. O nosso estudo demonstrou que a VATS, sobretudo a VATS uniportal, para a realização de ressecção de bolhas enfisematosas ou ressecção atípica do ápex pulmonar associada a abrasão pleural pode ser considerada uma escolha segura e eficaz para o tratamento e prevenção de recidiva de PEP.

[Thymic lesions: A 4 years-review]. / Patologia do Timo: Revisão de 4 Anos.

INTRODUCTION: The difficulty in differentiating invasive from non-invasive thymic tumours solely by histological features, leads to the decision of resecting suspected lesions except in the presence of: (a) diffuse metastasis; or (b) typical imaging findings of thymic hyperplasia or after recovering from some recent stress. Therefore, the role of radiology is of the utmost importance in the initial evaluation and staging of thymic mediastinal masses. METHODS: The objective of this study was to elaborate a retrospective analysis of the cases of thymic lesions that underwent surgery at the Cardiothoracic Department of Centro Hospitalar Vila Nova de Gaia/Espinho (CHVNG/E), from January 2013 to December 2016, illustrating their main radiologic findings with computed tomography (CT) images. RESULTS: During the studied time period, 35 patients were diagnosed with thymic lesions including: 14 thymomas (40%), 9 thymic cysts (26%), 4 thymic hyperplasias (11%), 3 thymic carcinomas (9%), 2 thymolipomas (6%), 2 lymphomas (6%) and 1 neuroendocrine tumour (3%). The mean age of the sample was 60 years, ranging from 23 to 88 years, with a predomi- nance of the female sex (69%). In this article, 11 CT images and 1 thoracic x-ray are presented to illustrate the common imaging features of each thymic disease. Thymoma was the most frequent thymic lesion found in our 4-year case sample, similarly to what is described in literature for the adult age. CONCLUSION: Knowledge of the main radiologic findings of each pathological entity of the thymus is vital for the correct therapeutic management and disease staging, frequently allowing the differentiation of non-surgical from surgical lesions.

Introdução: A dificuldade na diferenciação de neoplasias tímicas invasivas de não invasivas apenas pelas suas caracte- rísticas histológicas, leva a que se preconize a resseção cirúrgica destas lesões, exceto na presença de: (a) metastização difusa; e (b) manifestações imagiológicas típicas de hiperplasia tímica ou após um stress corporal conhecido. Dessa forma, o papel da radiologia torna-se de suma importância na avaliação da suspeita inicial e no seu estadiamento. Métodos: O objetivo do presente trabalho foi estudar retrospetivamente os casos de patologia tímica submetidos a cirurgia pelo Serviço de Cirurgia Cardiotorácica do Centro Hospitalar Vila Nova de Gaia/Espinho (CHVNG/E) entre janeiro 2013 e dezembro 2016, ilustrando, com as respetivas imagens de tomografia computorizada (TC), as principais manifestações ima- giológicas deste espectro de lesões. Resultados: Neste período foram operados 35 doentes com patologia tímica com os seguintes diagnósticos: 14 timomas (40%), 9 quistos (26%), 4 hiperplasias tímicas (11%), 3 carcinomas tímicos (9%), 2 timolipomas (6%), 2 linfomas (6%), e 1 tumor neuroendócrino (3%). A média de idades foi de 60 anos, com idade mínima de 23 anos e máxima de 88 anos, e predomínio do sexo feminino (69%). São apresentadas 11 imagens de cortes de TC e 1 radiograma torácico, representativas das manifestações imagiológicas de cada patologia obtida. Na amostra estudada, a patologia tímica mais frequente foi o timoma, de forma semelhante ao descrito na literatura para a idade adulta. Conclusão: O conhecimento das principais características imagiológicas das diferentes entidades patológicas do timo é fulcral na orientação terapêutica, permitindo por vezes diferenciar a hiperplasia de "verdadeiras" neoplasias, e possibilitar o estadiamento das lesões.