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.

Giant Pleural Tumor And Severe Hypoglycemia: Doege-Potter Syndrome In A Previously Healthy Female.

AIntroduction: Doege-Potter's syndrome is a rare paraneoplastic syndrome, consisting in hypoglycemia and solitary fibrous tumor of the pleura. These tumors represent < 5% of all pleural tumours and can only be cured by surgery. In this article, we report a case of a patient presenting with severe hypoglycemia, as the only symptom, and a mass occupying the entire left hemithorax. Case presentation: A54 year old female with severe hypoglycemia, a chest radiography with almost total opacification of the left hemithorax and a computed tomography scan with a mass in the left hemithorax. Surgery was performed and a mass with 30cm × 18cm × 11cm weighing 3195g was resected. The postoperative course was uneventful with immediate resolution of the hypoglycemia. The immunohistochemistry diagnosis was solitary fibrous tumor of the pleura. Conclusions: Solitary fibrous tumor of the pleura are very rare. Less than 5% are associated with hypoglycemia, taking the form of Doege-Potter Syndrome. Radiation therapy and chemotherapy have shown low response rate and complete surgical resection is the only procedure that offers cure. This case reports describes a rare giant solitary fibrous tumor of the pleura with severe hypoglycemia, successfully treated by surgery. Long-term follow-up of the patient after the surgery is necessary for detection of any possible recurrence.

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.

Concomitant Ascending Aortic Replacement and Aortic Valve Replacement Using Rapid Deployment Bioprosthesis.

INTRODUCTION: The association between aortic valve disease and dilatation of the ascending aorta is well known and concomitant surgery is recommended when the aortic diameter is higher than 45mm. The use of the rapid deployment valves allows less cross-clamping and cardiopulmonary bypass times for both isolated and combined procedures in comparison to regular valves. We describe our initial experience of concomitant aortic valve and the ascending aortic replacement, using the rapid deployment valve Edward Intuity EliteTM. CASE PRESENTATION: All patients were male, with a mean age of 72-years-old. The mean cross-clamping time was 48 minutes, with a mean cardiopulmonary time of 61 minutes. The mean time of ICU stay was 4 days. All the patients had follow-up 1 and 3 months after discharge and were doing well. CONCLUSIONS: The rapid deployment aortic valves have recognized advantages in aortic valve replacement. Our small experience reinforces that replacement the ascending aortic and aortic valve with this prothesis is one procedure that can benefits from generalization without increased risks and with potentially better clinical outcomes. Larger cohort studies would allow clarification over this subject.

Infective Endocarditis after Transcatheter Aortic Valve Implatation.

INTRODUCTION: Transcatheter aortic valve implantation has emerged as an effective alternative to the traditional method of surgical aortic valve replacement in high risk or inoperable patients. Infective endocarditis after transcatheter aortic valve implantation is a post-operative complication with a high rate of mortality, and thus far, very few cases of successful surgery have been reported. CASE PRESENTATION: The authors report the case of a patient that underwent transcatheter aortic valve implantation and developed an infective endocarditis following the procedure. Corrective surgery for transcatheter aortic valve's removal and aortic valve replacement was successfully performed. CONCLUSIONS: Given the increasing use of transcatheter aortic valve implantation, endocarditis will become increasingly relevant in the near future. As in conventional aortic prosthesis, for some cases, medical therapy alone is not enough. Under optimal conditions, surgery is a safe option and should be considered and discussed in a Heart Team, patient by patient.

Minimal invasive cardiac mass resection, post-thoracic radiotherapy: a safe approach?

Minimal invasive cardiac surgery by right mini-thoracotomy for cardiac mass resection has emerged as an alternative to median sternotomy, for being less associated to postoperative complications and a faster recovery. Thoracic radiotherapy, widely used for cancer treatment, can result in pulmonary adhesions making it impossible to access the heart by thoracotomy. We report a case of a patient submitted to bilateral thoracic radiotherapy, with a cardiac mass in the left atrium, successfully treated by surgical resection, as well the intraoperative procedure done to make the minimally invasive approach possible.

A cirurgia cardíaca minimamente invasiva por mini-toracotomia direita para ressecção de massas cardíacas surgiu como alternativa à esternotomia mediana convencional, por se encontrar associada a menos complicações no pós-operatório e a uma recuperação mais rápida. A radioterapia torácica, muito utilizada como adjuvante no tratamento do cancro da mama, pode resultar em adesões pulmonares que tornam difícil o acesso ao coração por toracotomia. Reportamos o caso clínico de uma doente submetida a radioterapia torácica bilateral, com posterior diagnóstico de uma massa na aurícula esquerda, submetida a ressecção cirúrgica, assim como o procedimento realizado para tornar a abordagem minimamente invasiva possível.

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.

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.

Role of Omega-6 Fatty Acid Metabolism in Cardiac Surgery Postoperative Bleeding Risk.

Cardiac surgery is frequently associated with significant postoperative bleeding. Platelet-dysfunction is the main cardiopulmonary bypass (CPB)-induced hemostatic defect. Not only the number of platelets decreases, but also the remaining are functionally impaired. Although lipid metabolism is crucial for platelet function, little is known regarding platelet metabolic changes associated with CPB-dysfunction. Our aim is to explore possible contribution of metabolic perturbations for platelet dysfunction after cardiac surgery. DESIGN: Prospective cohort study. SETTING: Tertiary academic cardiothoracic-surgery ICU. PATIENTS: Thirty-three patients submitted to elective surgical aortic valve replacement. INTERVENTIONS: Samples from patients were collected at three time points (preoperative, 6- and 24-hr postoperative). Untargeted metabolic analysis using high-performance liquid chromatography-tandem mass spectrometry was performed to compare patients with significant postoperative bleeding with patients without hemorrhage. Principal component analyses, Wilcoxon matched-pairs signed-rank tests, adjusted to FDR, and pairwise comparison were used to identify pathways of interest. Enrichment and pathway metabolomic complemented the analyses. MEASUREMENTS AND MAIN RESULTS: We identified a platelet-related signature based on an overrepresentation of changes in known fatty acid metabolism pathways involved in platelet function. We observed that arachidonic acid (AA) levels and other metabolites from the pathway were reduced at 6 and 24 hours, independently from antiagreggation therapy and platelet count. Concentrations of preoperative AA were inversely correlated with postoperative chest tube blood loss but were not correlated with platelet count in the preoperative, at 6 or at 24 hours. Patients with significant postoperative blood-loss had considerably lower values of AA and higher transfusion rates. Values of postoperative interleukin-6 were strongly correlated with AA variability. CONCLUSIONS AND RELEVANCE: Our observations suggest that an inflammatory-related perturbation of AA metabolism is a signature of cardiac surgery with CPB and that preoperative levels of AA may be more relevant than platelet count to anticipate and prevent postoperative blood loss in patients submitted to cardiac surgery with CPB.

Inframammary approach for addressing anterior mediastinal tumours: initial experience.

BACKGROUND: Anterior mediastinal tumours account for 50% of all mediastinal masses. Surgical intervention is the standard approach for their diagnosis or treatment. Minimally invasive techniques have gained significant popularity in the last few decades due to the obvious advantages that they offer. We will describe a series composed of the first 20 patients who were submitted to a new minimally invasive video-assisted technique, which uses an inframammary incision approach involving a Thoratrak rib spreader and a Rultract Skyhook retractor. METHODS: A retrospective study was undertaken, involving all the patients in our department who were submitted to a resection of their anterior mediastinal masses by inframammary incision, using a Thoratrak rib spreader, a Rultract Skyhook retractor and video assistance. RESULTS: A total of 20 patients were included, with a mean age of 52.6. The mean surgery duration was 47 minutes, with an intraoperative blood loss of 70 mL. The mean period of hospitalisation was 2.9 days. No patients underwent conversion to open surgery, and there were no major complications. The mean size of the masses that were excised was 13.9 cm, with a mean weight of 77.3 g. The surgical margins were all free of tumour tissue, and no early recurrence was observed during the postoperative follow-up period. CONCLUSIONS: Video-assisted thoracoscopic surgery (VATS) and robot assisted thoracic surgery (RATS) account for most of the minimally invasive procedures. However, VATS has certain limitations in terms of deep perception and manoeuvrability, and RATS has the disadvantage of lacking tactile and force feedback for the surgeon. The inframammary technique allows for safe direct dissection around the vascular and nervous structures, ensuring a complete observation of the anterior mediastinum and its structures. The findings in the present study suggest that this technique is useful. We had good surgical results, short surgery times and very low blood loss, and all tumours were totally resected, with tumour-free surgical margins. The size and the right lateralisation of the mass did not present any contraindications, and the learning curve and investment were minimal. In conclusion, the inframammary approach could be a safe and useful approach for treating anterior mediastinal pathology.

Aortic Dissection Repair Using the STABILISE Technique Associated with Arch Procedures: Report of Two Cases.

INTRODUCTION: The stent assisted balloon induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique is being increasingly used for the treatment of complicated aortic dissections. However, as it is a fairly recent technique, the scientific information is limited. REPORT: In this paper we report two cases of the STABILISE technique associated with procedures in the ascending aorta and supra-aortic trunks, consisting of a "frozen elephant trunk" procedure in one case and in the other, a carotid endarterectomy associated with reimplantation of the vertebral artery and partial arch debranching. DISCUSSION: In conclusion, while acknowledging the need for longer follow up and greater experience to support the safety and efficacy of this procedure, the two cases reported confirm that the STABILISE technique is a valid endovascular alternative in the treatment of complicated aortic dissections.

Lymphangioma of the heart as a rare tumor: A case report.

INTRODUCTION: Tumors of the heart are uncommon, and lymphangiomas are among the rarest of this group, with very few cases reported. These tumors consist of a benign slow-flow vascular malformation. PRESENTATION OF CASE: We report a case of a man diagnosed incidentally with a pericardial mass and our surgical approach for its treatment. DISCUSSION: The pericardial mass of our case had no cleavage plane between the myocardium and the tumor. Because of this, rather than a total resection, with very high operative risk, a biopsy was preferred. The pathology specimen showed a benign tumor and the patient was referred to the cardiologist for regular follow-up. CONCLUSION: There is no specific investigation for diagnosing cardiac lymphangiomas, and though benign, they should be considered in the differential diagnosis of other malignant diseases of the mediastinum and definitive pathologic diagnosis is mandatory. Given the increased risk of uncontrolled bleeding related to percutaneous biopsy, the definite diagnosis is usually obtained with open surgical biopsy.

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.

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.

Cardiac surgery using a single thoracic port-current status and future directions.

Cardiac surgery is almost universally performed through a median sternotomy, an approach which is painful, unestethical, and prone to life-threatening infections. Minimally invasive cardiac surgery has tried to avoid problems associated with full sternotomy for many years. Recently, uniportal thoracic surgery was shown to be very advantageous when compared to standard thoracotomy and classical video assisted thoracic surgery (VATS). Despite very good results in lung surgery, cardiac surgery through a single thoracic port has rarely been attempted and successfully conducted. The authors present the rational, the technique, and their experience in cardiac single thoracic port surgery (CSTPS).