Native mitral valve endocarditis due to Rhizobium Radiobacter - first case report.

Rhizobium Radiobacter (RR) has rarely been associated with human infection, mainly sepsis or bacteremia, and an unique case of prosthetic aortic endocarditis has been reported. We present a case of native mitral valve endocarditis to RR, to our knowledge the first clinical report of such infection.

[Elevated HDL is the main negative risk factor for coronary artery disease in the elderly patient with calcific aortic valve disease]. / Um valor elevado de HDL é o principal fator protetor contra a doença coronária no idoso com doença fibrocalcificante valvular aórtica.

UNLABELLED: In spite of high prevalences of hypertension and hypercholesterolemia, the majority of elderly patients admitted for aortic valve surgery due to calcific aortic valve disease (CAVD) do not have significant coronary artery disease (CAD). OBJECTIVE: To evaluate the lipid profile (LP) of patients undergoing surgery for CAVD and to correlate this with coronary angiographic data and prior cardiovascular risk factor profile. METHODS: This was a prospective observational cohort study of 264 consecutive patients aged >59 years (mean 72), 126 men (48%) and 138 women (52%). According to the angiographic presence (irregularities, moderate or significant lesions) or absence (normal angiogram) of significant CAD respectively, patients were divided into two groups: A (n=127, 48%) and B (n=137, 52%). A mean of 3.5 classical risk factors were identified in men and 2.6 in women. LP (obtained on admission, in the fasting state) included total cholesterol (TC), HDL, triglycerides (TG), LDL, and lipoprotein(a). RESULTS: With the exception of male gender, diabetes and HDL, the other factors studied - smoking, hypertension, TC, TG, LDL (in both statin-treated and non-statin-treated patients) and lipoprotein(a) - did not show significant differences between groups A and B; LDL was 116 +/- 40mg/dl in group A vs. 123 +/- 38mg/dl in group B, in non-statin-treated patients; significant CAD was identified in 64% of men vs. 26% of women (p < 0.001); 43% of group A had diabetes vs. 27% of group B (p<0.01); HDL was 49 +/- 14mg/dl in group A vs. 59 +/- 16mg/dl in group B (p < 0.001); HDL in group A was 49 +/- 14 mg/dl in men vs. 49 +/- 13 mg/dl in women (NS) and 45 +/- 13 mg/dl in diabetic patients vs. 52 +/- 14 mg/dl in non-diabetics (p <0.02); HDL in group B diabetic patients was 54 +/- 17 mg/dl in men vs. 56 +/- 18 mg/dl in women (NS), and HDL in group B non-diabetic patients was 55 +/- 13mg/dl in men vs. 63 +/- 17 mg/dl in women (p < 0.02). Multivariate analysis showed that only low HDL and diabetes (in women) were independent risk factors for significant CAD. The effect of male gender as a risk factor appears to be exerted mainly through lower HDL levels. CONCLUSIONS: Elevated HDL is the main negative risk factor for significant CAD in elderly high-risk but mildly dyslipidemic CAVD patients. HDL does not appear to have any protective effect in the pathophysiology of CAVD. In terms of long-term intervention, primary prevention of significant CAD should in the future be hybrid, focusing mainly on improving HDL function, but also on lowering LDL.

[New clinical aspects of cardiac myxomas: a clinical and pathological reappraisal]. / Terão os mixomas cardíacos uma nova face clínica? Estudo de reavaliação clínico-patológica.

UNLABELLED: Easy access to echocardiography and its extensive and repeated use (as is the case in Portugal) now facilitates the early diagnosis of cardiac myxoma (CM). OBJECTIVE: To re-evaluate the clinical and pathological profile of CM under current diagnostic conditions. METHODS: We performed a retrospective study of 40 patients consecutively referred for surgery (between January 2003 and January 2010) with a histologically-confirmed diagnosis of CM - 26 female (F) and 14 male (M), with a mean age of 64±12 years (range 12-81; 53% over 65, 43% over 70); 39 patients were operated (one was not operable due to major neurological deficit). Clinical characteristics, surgical protocols, follow-up records of survivors (range 1-76 months, with serial echocardiograms), and histological data were reviewed. RESULTS: The apparent incidence was 2.6 cases/million/year; the overall F/M ratio was 1.9:1 (1.3:1 in those aged over 65, similar to the general population). The CM was located in the left atrium (LA) in 92.5%, with insertion in the fossa ovalis of the interatrial septum (IAS) in 53% (only 57% of LA myxomas), and outside the IAS in 30%. The mean size was 4.6 x 3.7cm. Asymptomatic tumors occurred in 48% of the total population (sessile and/or atypically inserted in 74%; 63% of large size, over 3 x 3cm), 61% were in patients referred in the last 25 months of the study; 23% of patients showed constitutional symptoms (all with very large CMs - mean 6.7 x 5.1cm), 35% had hemodynamic/obstructive symptoms, and 15% presented with embolic events. There was evidence of CM-related mitral valve (MV) disease in 20% of patients, resulting in moderate to severe mitral regurgitation requiring associated MV surgery in 13%. Significant comorbidities were present in 69%. Surgical procedures included simple excision in 74%; septoplasty/atrioplasty associated with extensive resection of the insertion site in 26%; and combined surgery (CM excision plus other procedures) in 28%. There were significant postoperative complications in 38%. In-hospital mortality was 10%; postoperative mortality was 7.7%. Mean follow-up was 30 months (100% of survivors, 44% for >2 years); late mortality was 5.6% and no CM recurrences were observed. CONCLUSIONS: (1) CM has a higher incidence than described in the literature and mainly affects patients aged over 65; the reported predominance of female patients disappears after the age of 65. (2) Most CM cases are now asymptomatic at presentation as a result of earlier diagnosis. (3) CM is the cause of MV disease requiring surgical correction in more than 10% of cases, and is associated with significant postoperative mortality, mainly due to the presence of comorbidities.

[Left ventricular aneurysm and differential diagnosis with pseudoaneurysm]. / Aneurisma do ventrículo esquerdo e diagnóstico diferencial com pseudo-aneurisma.

Left ventricular aneurysm and pseudoaneurysm are two complications of myocardial infarction in which the role of imaging is paramount. The authors describe a case of a true aneurysm of the posterior wall, for which cardiac magnetic resonance was useful, although only intra-operative assessment confirmed the diagnosis.

[Hemangioma of the right ventricular outflow tract, clinical report]. / Hemangioma da câmara de saída do ventrículo direito, a propósito de um caso clínico.

Cardiac hemangiomas are a rare benign primary tumor with an estimated incidence of no more than 10% of cases of primary cardiac tumors. They can arise in any location but most of them occur predominantly in the right ventricle. Heart hemangiomas are usually asymptomatic and accidentally diagnosed by imaging methods such as echocardiography or nuclear magnetic resonance; however they can cause symptoms resulting from obstruction of blood flow, interference with the heart valves, arrhythmias or embolization. Surgical resection is the treatment of choice and long-term prognosis is favorable after total resection of the tumor. The authors present a case of cardiac hemangioma whose clinical diagnosis was triggered by exertional dyspnea and culminating with complete resection of the tumor. In this context, a review of this entity is made with special emphasis on imaging modalities used for diagnosis.

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

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

[Rupture of a bronchial artery aneurysm - a rare case of non-traumatic hemothorax]. / Rotura de aneurisma de artéria brônquica - um caso raro de hemotórax não traumático.

Bronchial circulation is a vascular territory rarely involved by pathology, with a few cases reported in the literature. The authors describe the clinical case of a bronchial artery aneurysm rupture, complicated by hemothorax, that required immediate surgery for effective control. The main features of the available knowledge about this rare entidy are analysed and discussed.

[Control of postoperative hemorrhage in isolated coronary bypass surgery: comparison of tranexamic acid effects in off-pump surgery with aprotinin effects in conventional surgery]. / Controlo da hemorragia pós-operatória em cirurgia coronária isolada: comparação dos efeitos do ácido tranexâmico em cirurgia sem CEC com os da aprotinina em cirurgia convencional.

UNLABELLED: In spite of the strong criticism elicited thereafter, the results of a multicentric study on the consequences of several perioperative anti-hemorrhagic strategies in cardiac surgery, published five years ago, led to the aprotinin (Aprot) withdrawal from the market and its progressive replacement by tranexamic acid (TrAc) in many surgical departments. OBJECTIVE: To evaluate the hemostatic effects and clinical consequences of TrAc use or non-use in off-pump coronary bypass surgery (CABG) and compare them with those of Aprot use or non-use in conventional (conv) CABG. MATERIAL AND METHODS: Retrospective analysis of 2 groups (Gr) of patients (pts): GrA - 252 pts undergoing isolated conv CABG (GrA1 - 185 pts submitted to an intra-operative full-dose Aprot protocol; GrA2 - 67 pts operated without Aprot); GrB - 383 pts undergoing isolated off-pump CABG (GrB1 - 136 pts submitted to an intra-operative low-dose TrAc protocol; GrB2 - 247 pts operated in absence of TrAc). Pre-operative clinical characteristics (GrA1 vs GrA2, GrB1 vs GrB2): mean age (years) - 65 vs 64 (NS), 64 vs 64; female gender - 20% vs 21% (NS), 23% vs 20% (NS); logistic Euroscore - 5.1% vs 6.2% (NS), 6.3% vs 5.5% (NS); chronic renal failure - 21% vs 27% (NS), 27% vs 25% (NS); diffuse coronary artery disease - 34% vs 42% (NS), 36% vs 30% (NS); pre-operative betablocker treatment - 64% vs 55% (NS), 74% vs 71% (NS); statin therapy for > 3 months - 78% vs 82% (NS), 81% vs 85% (NS). Pts have been operated by 4 surgeons largely experienced in both CABG modalities. Antiplatelet therapy was stopped => 4 days prior to surgery (but aspirin was maintained in high-risk pts). Results (GrA1 vs GrA2, GrB1 vs GrB2): 1) Bleeding (mL/pt - mean): 783 vs 1375 (p < 0.001), 1061 vs 1368 (p < 0.001); blood loss > 1500 mL (%pts) - 5.4% vs 34% (p < 0.0001), 12% vs 28% (p < 0.001); surgical re-exploration for bleeding - 1.1% vs 3.0% (NS), 2.2% vs 2.0% (NS). 2) Transfusion of blood products (U/pt - mean): plasma - 0.56 vs 2.19 (p < 0.001), 1.45 vs 1.03 (p < 0.05); platelets - 0.09 vs 0.22 (p < 0.02), 0.24 vs 0.15 (NS). 3) Renal function (%pts): increased serum cre- atinine - 56% vs 56%, 55% vs 38% (p < 0.001); hemofiltration use - 1.1% vs 1.5% (NS), 1.5% vs 0.4% (NS). 4) Perioperative myocardial infarction - 21.6% vs 17.9% (NS), 17.6% vs 14.6% (NS); other ischemic events - 3.2% vs 3.0% (NS), 1.5% vs 1.2% (NS). 5) Hospital mortality: 4.8% vs 4.5% (NS), 4.4% vs 1.6% (NS). CONCLUSIONS: 1) TrAc does not reduce the risk of surgical re-exploration for bleeding. 2) Taking into account the differences between conv CABG and off-pump CABG, TrAc hemostatic effect seems to be inferior to that of Aprot, without offering a better safety profile in terms of lesser renal or ischemic risk as a counterpart.

[Perioperative myocardial infarction in coronary bypass surgery: characterization of risk factors, clinical pictures and prognosis]. / Enfarte do miocárdio perioperatorio em cirurgia coronária: caracterização dos factores de risco, dos quadros clínicos e do prognóstico.

UNLABELLED: Perioperative myocardial infarction ( POMI ) in cardiac surgery is an issue that deserves to be revisited. OBJECTIVE: To evaluate the risk factors, clinical characteristics and prognosis of POMI in high-risk patients ( pts ) undergoing coronary bypass surgery ( CABG ). MATERIAL AND METHODS: Retrospective study of 694 pts undergoing isolated CABG - 252 pts with conventional CABG and 442 pts with off-pump CABG - and operated on by 4 surgeons largely experienced in both CABG modalities. POMI diagnosis: biochemical criteria - 1 ) late ( at or after 24 hrs of postoperative period ) troponin ( > 7 ng/mL ) and/or CKMBm ( > 40 ng/mL ) peak values, with inverted V-shaped curves; 2 ) prolonged troponin release ( ⋝ 48 hrs ), with a plateau-like curve ( without a well defined peak ) and a normal/abnormal CKMBm curve. POMI was diagnosed in 116 pts ( 20.6 % of conventional CABG pts and 14.5 % of off-pump CABG pts, p < 0.05 ), that constituted Group ( Gr ) A. GrA pts were compared with GrB pts ( without POMI ). RESULTS: 1 ) Risk factors ( GrA vs GrB ): female gender 30 % vs 21 % (NS ) ; logistic Euroscore 5.6 % vs 5.9 % ( NS ); pre-operative clinical instability 17 % vs 23 % ( NS ); incomplete revascularization 39 % vs 38 % ( NS ); multi-territorial vascular disease 42 % vs 32 % ( p < 0.05 ); diffuse coronary artery disease 46 % vs 33 % ( p < 0.025 ); betablocker treatment 58 % vs 70 % ( p < 0.025 ); statin therapy for > 3 months 56 % vs 81 % ( p < 0.0001 ). 2 ) POMI clinical characteristics: asymptomatic/oligosymptomatic 70 %; severe 18 %; extensive 15 %. 3 ) Dysrhythmic profile ( GrA vs GrB ): sinus tachycardia > 115 bpm 9.6 % vs 2.9 % ( p < 0.01 ); atrial pacing for > 4 hrs 5.2 % vs 17.6 % ( p < 0.01 ); very early ( up to 2 hrs of postoperative period ) atrial tachyarrhythmia 4.3 % vs 0.9 % ( p < 0.025 ). 4 ) Hospital mortality ( GrA vs GrB ); global 9.6 % vs 2.1 % ( p < 0.001 ); cardiovascular 6.1 % vs 0.7 % ( p < 0.001 ). CONCLUSIONS: 1 ) POMI is more frequent in conventional CABG. 2 ) Although frequently asymptomatic or oligosymptomatic, POMI shows adrenergic hyperactivity that significantly influences the postoperative dysrhythmic profile. 3 ) POMI is a marker of potentially ominous prognosis. 4 ) Instability of multiple coronary lesions seems to be the main non-technical POMI risk factor, and an intensive pre-operative treatment with statins may eventually exert an important role in POMI prevention.

[Left ventricle free wall rupture - a 10-year experience]. / Rotura de parede livre do ventrículo esquerdo- 10 anos de experiência.

The left ventricle free wall rupture is one of the most serious and lethal complications associated to myocardial infarction.The most common treatment in our days consists in direct closure of the rupture with pericardium or synthetic material, applied with the help of histoacryl glue, without extracorporeal circulation.Between January 2000 and September 2010, 35 consecutive patients underwent operation for left ventricle free wall rupture at our hospital.The mean age was 69,5 years and most of the patients were male ( 65,7 % ). 2,9 days was the mean time for rupture after infarction and the anterior and lateral wall were most frequently involved. 94,7 % of the patients were in shock. Surgery was performed without extracorporeal circulation using a patch of pericardium and/or Dacron Sauvage, with histoacryl glue in 85,7 % of cases.Mean time of ICU stay was 7,9 days, in-hospital global mortality 28,6 %. At 2,5 years follow-up, 86 % of the patients were alive.Despite the high morbidity and mortality associated to surgery, the procedure is now safer, simpler and quick allowing the treatment of a situation that conducted to a most certain death without management.

Impact of intraoperative transesophageal echocardiography in cardiac surgery: retrospective analysis of a series of 850 examinations.

OBJECTIVE: To evaluate the impact of intraoperative transesophageal echocardiography (TEE) on surgical decisions patients undergoing cardiac surger in a Portuguese hospital. METHODS: The authors retrospectively analyzed a series of 850 examinations performed between 2003 and 2009 in patients who underwent different cardiac surgical procedures. Medical records and TEE reports were reviewed to determine whether new information was found and whether this changed the surgical plan. RESULTS: Intraoperative TEE revealed new information in 32% of the study population and had surgical impact in 29% of all patients. TEE had the greatest impact in class I indications, but its use in class II indications also had a significant impact. No cases of morbidity or mortality were found. CONCLUSIONS: Our findings suggest that intraoperative TEE should be used routinely in all patients undergoing cardiac surgery.

[Influence of coronary revascularization on chronic ischemic stunning of the conduction system of the heart]. / Influência da revascularização coronária sobre o atordoamento isquémico crónico do sistema de condução cardíaco.

UNLABELLED: About one fourth of patients (pts) with coronary artery disease (CAD) referred for coronary bypass surgery (CABG) exhibits some kind of intraventricular conduction defect (IVCD). OBJECTIVE: To assess CABG influence on the behavior of intraventricular conduction in pts submitted to CABG. MATERIAL AND METHODS: Prospective study of 504 pts with severe CAD (3-vessel and/or left main trunk disease), divided in 2 groups (Gr) - GrA, composed of 252 pts with on-pump CABG, and GrB, with 252 pts submitted to off-pump CABG - whose pts were matched for age, gender, angiographic data, additive Euroscore, prior myocardial infarction, diabetes and hypertension. Other data (GrA vs GrB): nr of bypasses/pt 2.9 vs 2.4 (p<0.01); bypass to LAD 100% vs 100%; complete revascularization 60% vs 60%; left ventricular dysfunction 39% vs 34% (NS). Electrocardiographic study: pre-operative 12-lead ECG (within 72 hrs prior to CABG); post-operative (post-op) continuous ECG monitoring by telemetry (1 lead), including recording of data, until the discharge; post-op 12-lead ECG (up to 24 hrs after CABG), eventually repeated accordingly to the telemetric ECG evolution; ECG recordings were always performed by the same technician, with the same ECG recorder (25 mm/sec; 1 mV=10 mm). Results (GrA vs GrB): 1) Pre-operative IVCD 27% vs 24% (NS). 2) Post-op regression/abolition of IVCD (due to reversion of chronic stunning of the conduction system) 24%vs 28% (NS), occurring shortly (up to 24 hrs) after CABG termination in 95% of cases. IVCD aggravation/new IVCD 9.9% vs 0.8% (p<0.001). 3) Post-op IVCD: global figure 28% (+4.5%) vs 21% (-13%), p>0,05; stable IVCD + aggravated IV conduction 30% vs 18% (p<0.01). Post-op permanent pacing: 2 pts vs 0 pts. CONCLUSIONS: 1) A significant number (at least 24%) of pts with severe CAD and stable IVCD shows chronic ischemic stunning of the IV conduction system, which reverts after CABG. 2) Off-pump CABG (in opposition to on-pump CABG), by assuring a better intra-operative protection of the ventricular septum, promotes an improvement of intraventricular conduction in pts submitted to CABG.

[Myocardial abscess of the right ventricle anterior wall]. / Abcesso miocárdico da parede anterior do ventrículo direito.

The authors report the clinical case of a 63 old male, with a previous history of aortic mechanical replacement valve, who was admitted with fever, neutrophilic leukocytosis and c-reactive protein elevation. During admission Escherichia coli was cultured from blood, and the patient underwent repeated transthoracic and transesophageal echocardiograms, that did not reveal any abnormalities. Three weeks after admission, a new transesophageal echocardiogram showed an image suggestive of an aortic annular abscess. The patient was transferred to the Cardiothoracic Department of Santa Maria Hospital, in order to be submitted to surgical treatment. During the procedure an abscess in the anterior wall of right ventricle was diagnosed. The microbiological cultures of pus were negative. It was assumed the diagnosis of E. coli myocardial abscess. The diagnostic approach to patients with febrile syndrome and mechanical replacement valve should consider the hypothesis of infectious endocarditis and myocardial abscess, despite the rarity of its occurrence.

[Advantages of off-pump coronary bypass surgery over conventional coronary bypass surgery]. / Vantagens da cirurgia coronária sem CEC sobre a cirurgia coronária convencional.

UNLABELLED: Comparison between off-pump coronary bypass surgery ( OP-CABG )and conventional CABG ( C-CABG ) remains a controversial issue. OBJECTIVE: To compare short and long term OP-CABG and C-CABG results in high-risk patients ( pts ), in absence of usual bias. MATERIAL AND METHODS: A prospective observational study of 752 pts ( 252 pts with C-CABG and 500 with OP-CABG ) consecutively operated throughout 23 months by 4 surgeons largely experienced in both CABG modalities. For comparison of results, two groups ( Gr ) of pts were constituted - GrA, with 252 C-CABG pts, and GrB, with 252 OP-CABG pts - being the pts blindly matched for gender ( female sex - 51 pts ), age ( mean of 65 vs 64 yrs ), angiographic data ( 3 - VD ÷ left main - 92 % vs 90 % ), additive Euroscore ( mean of 4.6 vs 4.6 ), prior myocardial infarction ( 58 % vs 59 % ), history of diabetes ( 48 % vs 49 % ) or hypertension ( 83 % vs 83 % ). Other clinical data ( GrA vs GrB ): left ventricular dysfunction - 39 % vs 34 % ( NS ); logistic Euroscore - mean of 5.4 % vs 5.9 % ( NS ). Surgical results, in-hospital clinical evolution, in-hospital costs ( intra-operative and major post-operative costs ), and short-term ( mean of 50 days ) and long-term ( mean of 5 years ) follow-up were object of evaluation. Results ( GrA vs GrB ): 1 ) Nr of bypasses ÷ pt 2.9 vs 2.4 ( p < 0.01 ); nr of arterial conduits ÷ pt 1.2 vs 1.2; complete revascularization 60 % vs 60 %; surgical total time 155 ± 49 vs 136 ± 42 min ( p < 0.001 ); surgical total time in pts with 3 bypasses 157 ± 41 vs 156 ± 37 min ( NS ). 2 ) In-hospital post-operative evolution: inotropic support ( IS ) 46 % vs 29 % ( p < 0.001 ); heavy IS 14 % vs 6 % ( p < 0.025 ) ; uncomplicated post-operative course 18 % vs 26 % ( p < 0.025 ); significant CV events ( excluding atrial tachyarrhythmias ) 33 % vs 20 % ( p < 0.01 ); infection 22 % vs 14 % ( p < 0.05 ); severe complications 22 % vs 9.5 % ( p < 0.001 ); mean intensive care length of stay 4 vs 3 days ( p < 0.01 ); surgery-to-discharge length of stay 11.3 vs 9.8 days ( p ⋝ 0.05 ); in-hospital mortality ( HM ) 4.4 % vs 2.0 % ( NS ); HM + disabling chronic morbidity 7.5 % vs 3.2 % ( p < 0.05 ) . 3 ) In-hospital costs: intra-operative - superposable; post-operative - excess of about 900 euro ÷ pt in GrA. 4 ) Short-term follow-up: asymptomatic pts - 75 % vs 85 % ( p < 0.025 ); post-discharge complications - 8.3 % vs 7.7 % ( NS ); probability of being alive and asymptomatic + 17 % in GrB ( p < 0.01 ); mortality 0 % vs 0 %. 5 ) Long-term-follow-up ( 87 % vs 90 % pts ), at 5 years: pts alive with no clinical evidence of active coronary artery disease 72 % vs 75 % ( NS ); significant ÷ severe cardiac events of coronary origin 18.8 % vs 9.3 % ( p < 0.025 ); elective PTCA 4.8 % vs 2.3 % ( NS ); all-cause mortality 11.8 % vs 11.9 %; coronary mortality 6.9 % vs 4.4 % ( NS ). CONCLUSIONS: In experienced hands and before high-risk pts, OP-CABG offers lesser post-operative risks than C-CABG, with clear and positive consequences on in-hospital costs and short-term follow-up. During long-term follow-up, the revascularization benefits obtained by OP-CABG are not inferior to those conferred by C-CABG, and a significant reduction of the incidence of severe cardiac events can even be seen in a particular subset of pts.

[Ehlers-Danlos syndrome - a rare cause of spontaneous pneumothorax]. / Síndroma de Ehlers-Danlos - Uma causa rara de pneumotórax espontâneo.

Ehlers-Danlos syndrome (cutis hyperelastica), is a group of connective tissue disorders characterized by abnormalities of the skin, ligaments and internal organs. It is a hereditary syndrome, usually with autossomal dominant inheritance; that primarily affects the collagen synthesis. The skin and blood vessels are extremely fragile and elastic. The skin is soft with rubber consistency and easily bruising. There are hypermobile joints with increased extensibility. We summarize the case of a sixteen year old boy with a history of joint hypermobility since childhood and splenic fracture that was diagnosed with Ehlers-Danlos syndrome after the occurrence of recidivant spontaneous pneumothorax. We present the most common pulmonary complications of Ehlers-Danlos syndrome and discuss the importance of not forgetting the least commons etiologies of pneumothorax, in cases of spontaneous pneumothorax.

[Cardiac papillary fibroelastoma]. / Fibroelastoma papilar cardíaco.

Cardiac papillary fibroelastoma is a rare and histologically benign tumor. It is the most common valvular tumor and preferentially is found in the aortic valve (44% of the cases). They are typically smaller than 1 cm in diameter, and are characterized by having a fibrous core with elastic fibers, connective tissue and an endothelial lining. Papillary fibroelastoma are typically diagnosed incidentally during TEE. Tumor or thrombus embolizations may lead to severe complications such as stroke, myocardial infarction or even sudden death. In patients with the preoperative diagnosis of papillary fibroelastoma in addition to histories of cardiovascular and cerebrovascular injury require surgical resection to reduce the risk of future embolizations. The authors present two clinical cases of cardiac papillary fibroelastoma who were operated on in the Cardiothoracic Department from 2005 to 2006.

[Results of Dor's endoventricular repair in the management of left ventricular aneurysms]. / Resultados da reparação endoventricular de Dor no tratamento cirurgico dos aneurismas do ventrículo esquerdo.

INTRODUCTION: Left ventricular aneurysms are serious long-term complications from acute myocardial infarction that produce hemodynamic alterations in the cardiac function. OBJECTIVE: The aim of this study is to evaluate the chirurgical and clinic results of the endoventricular patch repair of the akinetic or dyskinetic portions of the left ventricle. METHODS: From August 2002 to October 2005, 20 consecutive patients underwent surgical repair of left ventricular aneurysm using the endoventricular patch repair technique. The mean age was 63,6 years, and 80% where male. Every patient have had only one episode of acute myocardial infarction, which resulted in a akinetic or dyskinetic alteration in the motility of the left ventricle. The preoperative functional class of most of the patients was class III or IV and 45% where on angina class II. In 90% of the patients the ventricular aneurysm where antero-septal. Left ventricular dysfunction was present in 65%. RESULTS: All patients underwent the Dor procedure associated with coronary artery bypass grafting. There was no perioperative mortality. One patient died in the immediate postoperative period. Four patients needed inotropic support for more than 24h and intra-aortic balloon pumping was used postoperatively in two cases. Mean hospital stay was 8,6 days. At late follow-up the functional class was I in 20%, class II in 55% and class III in 10%. The angina class was I in 65% of the cases. CONCLUSIONS: The surgical repair of left ventricular aneurysm using the endoventricular patch repair technique proved to be safe, causing significant clinical improvement and an increase in the ejection fraction.

[Surgery for volume reduction in chronic pulmonary obstructive disease]. / Cirurgia de redução de volume na doença pulmonar obstructiva crónica.

Pulmonary emphysema is an insidious disease and severe symptoms may not develop for many years. Most patients die within two years after medical treatment has became ineffective. In 1993, J. Cooper successfully revitalized lung volume reduction surgery (LVRS), the most effective emphysema treatment after lung transplantation. Distinct from Brantigan's approach, Cooper performed a simultaneous bilateral procedure through a median sternotomy. In our experience, we perform a unilateral lung volume reduction through an anterior thoracotomy. The sustained beneficial effects for up to 24 months with unilateral LVRS and the preservation of the contralateral side for future interventions if required, renders unilateral LVRS an attractive concept in this difficult palliative situation. Although several large series reported significant improvement in the short and intermediate term, controversy remains regarding the long term clinical benefit, morbidity and mortality of this procedure. A long term randomized trial comparing LVRS with ongoing medical management, the National Emphysema Treatment Trial (NETT), was conceived. The NETT results, suggest that surgery increases the chance of improved exercise capacity, reduce the risk of death among patients with upper-lobe emphysema and low exercise capacity, increase the risk among patients with non-upperlobe emphysema and high exercise capacity, and have little effect on the risk of death in the other patients.

[Grawitz tumor with invasion of the inferior vena cava and right atrium: surgical management with a multidisciplinary team]. / Tumor de grawitz com invasão da veia cava inferioraté à auricula direita: tratamento cirúrgico com equipa multidisciplinar.

In this paper, the clinical condition of a 56 year old male patient is reported, with the diagnosis of renal cell carcinoma, complicated by a tumoral thrombus, extended from the renal vein into the vena cava and right atrium, who underwent surgical treatment. The operation consisted in the radical nephrectomy associated to the vena caval thrombectomy, under extracorporeal circulation, utilizing a multidisciplinary team composed by urologists, vascular and cardio-thoracic surgeons. The main features related to the diagnosis and surgical management of this case are described and discussed, according to data taken from the most recent publications of the literature on the subject.