[Indications and results of lung resection in bronchiectasis]. / O papel da ressecção pulmonary no tratamento das bronquiectasias.

The prevalence of bronchiectasis has decreased significantly over recent decades in developed countries. However, resection for bronchiectasis still plays an important role in thoracic surgery practice in some countries such as Portugal. Between 1994 and 2004, 51 patients (29 female and 22 male) with a mean age of 38.6 years (range, 4-65 years) underwent pulmonary resection for bronchiectasis. Mean duration of symptoms was 4.8 years. Surgery was indicated because of unsuccessful medical therapy in 25 patients (49.1%), hemoptysis in 12 (23.5%), lung mass in 9 (17.6%) and lung abscess in 5 (9.8%). The surgical treatment was as follows: pneumectomy in 7 patients, bilobectomy in 3, lobectomy in 36 segmentectomy in 5. There was no operative mortality. Complications occurred in 8 patients and the morbidity rate was 15.7%. Follow-up was complete in 45 (88.2%) patients with a mean of 3.4 years. Overall, 35 (77.7%) patients were asymptomatic after surgery symptoms were improved in 7 (15.6%). Unsuccessful medical therapy was still our main indication for surgery of bronchiectasis, despite aggressive antibiotic therapy. Surgical resection was performed with acceptable morbidity and morbility rates and markedly improved symptoms in the majority of patients.

[Surgical treatment of bronchiectasis]. / Tratamento cirúrgico das bronquiectasias.

While the prevalence of bronchiectasis has decreased significantly over recent decades in developed countries, resection for bronchiectasis still plays an important part in thoracic surgery practice in some countries, such as Portugal. Between 1994 and 2004, 51 patients (29 female and 22 male) with a mean age of 38.6 years (range 4-65 years) underwent pulmonary resection for bronchiectasis. Mean duration of symptoms was 4.8 years. Surgery was indicated because of unsuccessful medical therapy in 25 patients (49.1%), haemoptysis in 12 (23.5%), lung mass in 9 (17.6%) and lung abscess in 5 (9.8%). The surgical treatment was pulmonectomy in 7 patients, bilobectomy in 3, lobectomy in 36 and segmentectomy in 5. There was no operative mortality. Complications occurred in 8 patients and the morbidity rate was 15.7%. Follow-up was complete in 45 (88.2%) patients with a mean of 3.4 years. Overall, 35 (77.7%) patients were asymptomatic after surgery, symptoms were improved in 7 (15.6%), and unchanged or worse in 3 (6.7%). Unsuccessful medical therapy was still our main indication for surgery of bronchiectasis, despite aggressive anti- biotic therapy. Surgical resection was performed with acceptable morbidity and morbidity and markedly improved symptoms in the majority of patients.

Angiotensin II acutely decreases myocardial stiffness: a novel AT1, PKC and Na+/H+ exchanger-mediated effect.

Acute effects of angiotensin II (AngII) on diastolic properties of the myocardium were investigated. Increasing concentrations of AngII (10(-9) to 10(-5) M) were added to rabbit papillary muscles in the absence (n=11) or presence of: (i) AT1 receptor antagonists, losartan (10(-6) M; n=7) or ZD-7155 (10(-7) M; n=8); (ii) ZD-7155 (10(-7) M) plus AT2 receptor antagonist PD-123,319 (2 x 10(-6) M; n=6); (iii) PKC inhibitor, chelerythrine (10(-5) M; n=8); or (iv) Na(+)/H(+) exchanger (NHE) inhibitor, 5-(N-methyl-N-isobutyl)-amiloride (10(-6) M; n=10). Passive length-tension relations were constructed before and after a single concentration of AngII (10(-5) M, n=6). Effects of AngII infusion (10 microg kg(-1) min(-1)) were evaluated in in situ rabbit hearts. AngII concentration dependently increased inotropy and resting muscle length (RL). At 10(-5) M, active tension increased 43.3+/-6.25% and RL 1.96+/-0.4%. Correcting RL to its initial value resulted in a 46+/-4% decrease of resting tension, indicating decreased muscle stiffness, as confirmed by the right and downward shift of the passive length-tension relation promoted by AngII. In the intact heart, at matched systolic pressures of 112 mmHg, AngII decreased end-diastolic pressures from 10.3+/-0.3 to 5.9+/-0.5 mmHg, and minimal diastolic pressures from 8.4+/-0.5 to 4.6+/-0.6 mmHg. AT1 blockade inhibited AngII effects on myocardial inotropy and stiffness, while PKC or NHE inhibition only significantly attenuated its effects on resting length and tension. In conclusion, AngII decreases myocardial stiffness, an effect that requires AT1 receptor activation and is mediated by PKC and NHE. This represents a novel mechanism of acute neurohumoral modulation of diastolic function, suggesting that AngII is a powerful regulator of cardiac filling.

[Iatrogenic tracheal rupture: a case report and indications for conservative management]. / Ruptura iatrogénica da traqueia: caso clínico e indicações para tratamento conservador.

Tracheal rupture after endotracheal intubation requires immediate intervention. There have been an increasing number of reports that describe nonsurgical management of this issue. We report the case of a 47-year-old woman who experienced an iatrogenic tracheal rupture during endotracheal intubation for a surgical procedure with general anaesthesia. She was successfully managed conservatively with a broad-spectrum antibiotic. We managed it non-operatively, because the patient had a small tear, was hemodynamically stable, show no evidence of infection or respiratory failure, and the diagnosis was not immediate. Bronchoscopy was a good diagnostic tool and it was used to make decisions regarding conservative management, and to detect granulation tissue and rule out any tracheal stenosis after treatment. We review available literature on conservative management of tracheal rupture. Immediate recognition and adequate treatment are very important in managing this potentially fatal situation. The final decision should be based on clinical, radiologic and bronchoscopic findings.

[Transaortic resection of left ventricular fibroelastoma]. / Exerese transaórtica de fibroelastoma do ventrícular esquerda.

Left ventricular tumors are extremely rare. Complete surgical resection is usually curative and recurrence is rare. The left atrial approach is safe and advisable when possible. We report a rare case of left ventricular tumor in a 71-year-old man presented with a cerebellar stroke. A two-dimensional echocardiogram revealed a mobile mass with the stalk attached deeply in left ventricular wall. To improve surgical access, a transversal aortotomy was performed and the mass was gently pulled and excised. Intracavitary left ventricular tumors, which are deeply situated, difficult to see, and inaccessible via left atriotomy, may be made surgically accessible by a transaortic approach. A vetriculotomy should be avoided.

[Carney's Complex: familial cardiac myxoma]. / Complexo de Carney: mixoma cardíaco familiar.

The Carney Complex is a very rare autosomal dominant disease including multiple neoplasia syndrome. This syndrome was initially described in 1985 under the rubric "...the complex of myxomas, spotty pigmentation, and endocrine overactivity". We present a case report of an old woman with Carney Complex who had the characteristic features of facial hirsutism and acromegalic facies, a large pigmented swelling over the face and a cardiac myxoma arising from the left atrium. We emphasize the need for periodic echocardiographic screening of patients and family members.

Modulation of the positive inotropic effect of pyruvate by energetic substrate availability.

Dependence of pyruvate's positive inotropic effect on energetic substrate availability and potential role of its mitochondrial uptake were investigated. Pyruvate (3, 10 and 15 mM) was added to rabbit right ventricular papillary muscles (protocol I; n = 10) and human right auricular trabeculae (protocol II; n = 6), using glucose as energetic substrate. In protocols III & IV (rabbit papillary muscles; n = 8 and n = 10, respectively) pyruvate's mitochondrial uptake was inhibited by alpha-cyano-4-hydroxycinnamate (0.5 mM) with octanoate as energetic substrate at 5 and 0.2 mM, respectively. In 8 additional rabbit papillary muscles, effects of L-alanine (10, 20 and 50 mM) were tested. In protocols I&II, pyruvate had a dose-dependent positive inotropic effect that was maximal at 10 mM, increasing in rabbit myocardium: 45.0+/-9.4% active tension, 20.5+/-7.4% peak rate of tension rise, 32.5+/-8.6% peak isotonic shortening, 31.2+/-11.7% peak rate of lengthening, 27.8+/-3.2% twitch duration. In protocol III (5 mM octanoate), pyruvate's positive inotropic effect was still present and even enhanced, while in protocol IV (0.2 mM octanoate) it was decreased and not observed with 3 mM of pyruvate. We conclude that, in rabbit papillary muscles, the positive inotropic effect of pyruvate is modulated by the availability of metabolic substrates and presumably does not depend on its mitochondrial uptake.

Remote myocardium gene expression after 30 and 120 min of ischaemia in the rat.

The aim of the present study was to investigate how early the onset of ischaemia-induced changes in gene expression is in remote myocardium, and whether these changes would be different for left and right ventricles. Wistar rats (n=27) were randomly assigned to left coronary artery (LCA) ligation for 30 or 120 min and sham groups. Evans Blue infusion revealed antero-apical left ventricle (LV) and left intraventricular (IV) septal ischaemia (35.5+/-0.6% of LV mass). LCA ligation induced transient LV systolic dysfunction and sustained biventricular slowing of relaxation. Regarding mRNA levels, type B natriuretic peptide (BNP) was upregulated in the LV at 30 (+370+/-191%) and 120 min (+221+/-112%), whilst in the right ventricle (RV) this was only significant at 120 min (+128+/-39%). Hipoxia-inducible factor 1alpha and interleukin 6 overexpression positively correlated with BNP. Inducible NO synthase upregulation was present in both ventricles at 120 min (LV, +327+/-195%; RV, +311+/-122%), but only in the RV at 30 min (+256+/-88%). Insulin-like growth factor 1 increased in both ventricles at 30 (RV, +59+/-18%; LV, +567+/-192%) and 120 min (RV, +69+/-33%; LV, +120+/-24%). Prepro-endothelin-1 was upregulated in the RV at 120 min (+77+/-25%). Ca2+-handling proteins were selectively changed in the LV at 120 min (sarcoplasmic reticulum Ca2+ ATPase, 53+/-7%; phospholamban, +31+/-4%; Na+-Ca2+ exchanger, 31+/-6%), while Na+-H+ exchanger was altered only in the RV (-79+/-5%, 30 min; +155+/-70%, 120 min). Tumour necrosis factor-alpha and angiotensin converting enzyme were not significantly altered. A very rapid modulation of remote myocardium gene expression takes place during myocardial ischaemia, involving not only the LV but also the RV. These changes are different in the two ventricles and in the same direction as those observed in heart failure.