Pulmonary valve replacement in tetralogy of Fallot - who and how?

BACKGROUND AND AIM: Pulmonary regurgitation is the most common complication in repaired tetralogy of Fallot patients. Severe chronic pulmonary regurgitation can be tolerated for decades, but if not treated, it can progress to symptomatic, irreversible right ventricular dilatation and dysfunction. We investigated clinical associations with pulmonary valve replacement among patients with significative pulmonary regurgitation and how interventional developments can change their management. METHODS: All adult patients with repaired tetralogy of Fallot who were followed at an adult CHD Clinic at a single centre from 1980 to 2022 were included on their first outpatient visit. Follow-up was estimated from the time of correction surgery until one of the following events occurred first: pulmonary valve replacement, death, loss to follow-up or conclusion of the study. RESULTS: We included 221 patients (116 males) with a median age of 19 (18-25). At a median age of 33 (10) years old, 114 (51%) patients presented significant pulmonary regurgitation. Among patients with significant pulmonary regurgitation, pulmonary valve replacement was associated with male gender, older age at surgical repair, and longer QRS duration in adulthood. Pulmonary valve replacement was performed in 50 patients, including four transcatheter pulmonary valve implantations, at a median age of 34 (14) years. CONCLUSION: Pulmonary regurgitation affects a large percentage of tetralogy of Fallot adult patients, requiring a long-term clinical and imaging follow-up. Sex, age at surgical repair and longer QRS are associated with the need of PVR among patients with significative pulmonary regurgitation. Clinical practice and current literature support TPVI as the future gold standard intervention.

Screening of cardiac allograft vasculopathy in heart transplant patients with coronary computed tomography angiography.

Although coronary angiography (CA) is the gold standard for coronary allograft vasculopathy (CAV) screening, non-invasive modalities have arisen as potential alternatives, such as coronary computed tomography angiography (CCTA). CCTA also quantifies plaque burden, which may influence medical treatment. From January 2021 to April 2022, we prospectively included heart transplant recipients who performed CCTA as a first-line method for CAV detection in a single center. Clinical, CCTA, and CA data were collected. 38 patients were included, 60.5% men, aged 58±14 years. The most frequent cause of transplantation was dilated cardiomyopathy (42.1%), and the median graft duration was 10 years [interquartile range (IQR) 9]. The median left ventricle ejection fraction was 61.5% (IQR 6). The median calcium score was 17 (IQR 231) and 32 patients (84.2%) proceeded to CCTA: 7, 24, and 1 patients had a graded CAV of 0, 1, and 2, respectively. Most patients (37.5%) had both calcified and non-calcified plaques, and the median number of affected segments was 2 (IQR 3). The remaining six patients had extensive coronary calcification, so CA was performed: 4 had CAV1, 1 had CAV2, and 1 had CAV3. During follow-up (12.2±4.2 months), there were neither deaths nor acute coronary syndromes. After CCTA, therapeutic changes occurred in about 10 (26.3%) of patients, mainly related to anti-lipid intensification; such changes were more frequent in patients with diabetes after heart transplant. In this cohort, CCTA led to therapeutic changes in about one-quarter of patients; more studies are needed to assess how CCT may guide therapy according to plaque burden.

Managing Allergic Nickel Dermatitis in Occupational Settings: A Case Report.

Contact dermatitis is a common cutaneous inflammatory condition, triggered by exposure to irritant substances or allergens. Nickel is the most prevalent allergen, a metal widely used in accessories, furniture, office materials, food and in industry, with multiple exposure pathways, making it difficult to assess which exposure is causing allergic dermatitis. Here, we report a case of an administrative worker with chronic hand eczema, limited to the radial metacarpophalangeal region of the left hand, caused by occupational exposure to nickel, confirmed by nickel deposition test on the hand and a positive test with a metallic stapler used at her workplace.

Underreporting of work accidents associated with blood-borne risk factors.

BACKGROUND: Work accidents (WA) due to percutaneous or mucocutaneous injury are extremely frequent among health professionals. The notification of these accidents ensures not only the compliance with legal requirements, but it also enables health institutions to develop, implement and evaluate strategies to prevent them. This study aimed to estimate the proportion of underreporting of work accidents caused by percutaneous and mucocutaneous lesions in a hospital setting, as well as its determinants. METHODS: A self-administered questionnaire was made available to all hospital employees. Age, gender, professional category and type of service adjusted odds ratios (OR) and 95% confidence intervals (95%CI) were computed by multivariate logistic regression models. RESULTS: Underreporting of WA associated with biological risk factors was high, particularly in accidents by mucocutaneous injury (80.9%). Physicians were the professional category that least reported this type of work accidents (OR=4.64; 95%CI 2.20-9.78). The main determinants of underreporting were the underestimation of the risk of transmission and the excessive bureaucracy. CONCLUSIONS: The underreporting of work accidents associated with biological risk factors was considerable and it contributes to a high degree of uncertainty on accidents' characterization.

Acute Aortic Regurgitation Due to Endocarditis Caused by Disseminated Gonococcal Infection: A Case Report.

ABSTRACT: A 23-year-old man presented with cough and progressive shortness of breath. Echocardiogram showed a biscupid aortic valve with a large vegetation causing severe regurgitation. Blood cultures were positive for Neisseria gonorrhoeae sensitive to cefotaxime and penicillin. Despite direct antibiotherapy, the patient required cardiac surgery with aortic valve replacement.

Esophageal varices: A rare non-cardiac finding in echocardiography.

A 43-years-old patient with hepatitis C and HIV co-infection was referred to debridement of a left sternoclavicular septic arthritis. Due to suspicion of endocarditis, the patient underwent transthoracic echocardiogram which revealed an mass posterior to left atrium and descending aorta. A thoracic computed tomography revealed esophageal varices. Transesophageal echocardiogram was not performed. The patient has progressed favorably.

Mobilization of an anomalous retroaortic coronary artery to prevent myocardial ischemia after aortic valve replacement.

Abnormal distribution may put coronary arteries at risk of damage during valvular surgery, especially if it is not identified during a preoperative examination. In this case report, we describe an approach to an anomalous right coronary artery during aortic valve replacement.

Perioperative Extracorporeal Membrane Oxygenation for Refractory Cardiopulmonary Failure Complicating Papillary Muscle Rupture.

The prognosis of papillary muscle rupture (PMR) leading to acute mitral regurgitation, pulmonary oedema, and cardiogenic shock remains dismal, with survival dependent on prompt recognition and surgical intervention. The use of extracorporeal membrane oxygenation (ECMO) for circulatory and/or respiratory support in critically ill patients failing conventional treatment has significantly increased in the past few years, mainly owing to technology improvements that have rendered the provision of this technique simpler and safer. In this report, four cases of refractory cardiopulmonary collapse complicating ischaemic and traumatic PMR successfully managed perioperatively with ECMO are presented. In this context, a review of the potential role of perioperative ECMO support for cardiogenic shock secondary to cardiac mechanical complications is also provided.

Cardiothoracic surgery during the Covid-19 pandemic: Perioperative care, safety, and surgical results.

BACKGROUND: Covid-19 was declared a pandemic by the World Health Organization (WHO) on 11 March 2020. Responses to this crisis integrated resource allocation for the increased amount of infected patients while maintaining an adequate response to other severe and life-threatening diseases. Though cardiothoracic patients are at high risk for Covid-19 severe illness, postponing surgeries would translate to increased mortality and morbidity. We reviewed our practice during the initial time of the pandemic, with emphasis on safety protocols. METHODS: From 11 March to 15 May 2020, 148 patients underwent surgery at the Department of Cardiothoracic Surgery of Centro Hospitalar Universitário de São João. The clinical characteristics of the patients were retrospectively registered, along with novel containment and infection prevention measures targeting the new coronavirus. RESULTS: The majority of adult cardiac patients were operated on an emergency basis. Hospital mortality was 1.9% (n = 2 patients). Most adult thoracic patients were admitted from home, with a diagnosis of neoplastic disease in 60% of patients. Hospital mortality was 3.3% (1 patient). Fifteen children underwent cardiothoracic surgery. There was no mortality. The infection prevention procedures applied, totally excluded the transmission of Covid-19 in the department. CONCLUSION: While guaranteeing a prompt response to emergent, urgent, and high priority cases, novel safety measures in individual protection, patients circuits, and preoperative diagnoses of symptomatic and asymptomatic infection were adopted. The surgical results corroborate that it was safe to undergo cardiothoracic surgery during the initial time of the Covid-19 pandemic. The new policies will be maintained while the virus stays in the community.

Influence of Respiratory Muscle Training on Patients' Recovery after Lung Resection.

This prospective experimental study aimed to compare effects of 3 different home-based postoperative respiratory muscle training protocols - inspiratory, expiratory and combined, in the patients' postoperative recovery, regarding safety and respiratory muscle function, pulmonary function, physical fitness, physical activity (PA), dyspnoea and quality of life (QoL). Patients were divided in four groups Usual Care (UCare), inspiratory (IMT), expiratory (EMT) or combined muscle training (CombT) according to group allocation. Significant treatment*time interactions were found for maximal inspiratory pressure (MIP) (p=0.014), sedentary PA (SEDPA) (p=0.003), light PA (LIGPA) (p=0.045) and total PA (p=0.035). Improvements were observed for MIP in CombT (p=0.001), IMT (p=0.001), EMT (p=0.050). SEDPA reduced in EMT (p=0.001) and IMT (p=0.006), while LIGPA increased in both groups (p=0.001), as well as Total PA (p=0.005 and p=0.001, respectively). In UCare, CombT, and EMT, QoL improved only for Usual Activities. In conclusion, the addition of respiratory muscle training to physiotherapy usual care is safe and effective to increase MIP and contribute to improve physical activity. The CombT showed greater improvement on MIP, while IMT compared to EMT, was more effective to improve physical activity.

Embolization Of Implanon Devices Lung Sparing Videoassisted Thoracic Surgery.

A 31-year-old-woman with an etonogestrel implant on her left upper arm presented with unfavorable change in her menstrual bleeding pattern and requested for its removal. The non-palpable device was perceptible in the left hemithorax by radiography. Thoracic computed-tomography showed migration to a sublobar branch of the left lower pulmonary artery. Despite the absence of thoracic symptoms and the lack of management guidelines, the device was removed by a lung sparing approach with videoassisted thoracic surgery, due to the unknown long-term effect of the embolized implant.

Early And Midterm Outcomes Following Aortic Valve Replacement With Mechanical Versus Bioprosthetic Valves In Patients Aged 50 To 70 Years.

OBJECTIVES: To compare 7-year survival and freedom from reoperation, as well as early clinical and hemodynamic outcomes, after surgical aortic valve replacement (SAVR) with mechanical or bioprosthetic valves in patients aged 50-70 years. METHODS: single-center retrospective cohort study including adults aged 50-70 years who underwent SAVR in 2012 with a mechanical or bioprosthetic valve. Median follow-up was 7 years. Univariable analyses were performed using Kaplan-Meier curves and Log-Rank tests for survival and freedom from reoperation analyses. Multivariable time-to-event analyses were conducted using Cox Regression. RESULTS: Of a total of 193 patients, 76 (39.4%) received mechanical valves and 117 (60.6%) received bioprosthetic valves. A trend for better survival was found for mechanical prostheses when adjusting for EuroSCORE II (HR: 0.35; 95%CI: 0.12-1.02, p=0.054), but using a backward stepwise Cox regression prosthesis type was not retained by the model as an independent predictor of survival. Moreover, mechanical prostheses showed trends for higher freedom from reoperation (100% vs. 95.5%, Log-Rank, p=0.076), higher median EuroSCORE II (2.52% vs. 1.95%, p=0.06) and early mortality (7.9% vs. 2.6%, p=0.086). However, after adjusting for EuroSCORE II, there was no significant difference in early mortality (OR: 2.3, 95%CI: 0.5-10.5, p=0.272). Regarding hemodynamic performance at follow-up echocardiogram, there were no differences other than left ventricular mass regression, which was not as pronounced in the mechanical group (-12% vs. -21%, p=0.002). CONCLUSION: Mechanical and bioprosthetic aortic valves prostheses showed similar mid-term survival in the 50-70 age group. Further prospective and larger studies are needed to provide evidence-based recommendations on this topic.

Impact of Weight Loss With Intragastric Balloon on Bone Density and Microstructure in Obese Adults.

The historical concept that obesity protects against bone fractures has been questioned. Weight loss appears to reduce bone mineral density (BMD); however, the results in young adults are inconsistent, and data on the effects of weight loss on bone microstructure are limited. This study aimed to evaluate the impact of weight loss using an intragastric balloon (IGB) on bone density and microstructure. Forty obese patients with metabolic syndrome (mean age 35.1 ± 7.3 yr) used an IGB continuously for 6 mo. Laboratory tests, areal BMD, and body composition measurements via dual-energy X-ray absorptiometry, and volumetric BMD and bone microstructure measurements via high-resolution peripheral quantitative computed tomography were conducted before IGB placement and after IGB removal. The mean weight loss was 11.5%. After 6 mo, there were significant increases in vitamin D and carboxyterminal telopeptide of type 1 collagen levels. After IGB use, areal BMD increased in the spine but decreased in the total femur and the 33% radius. Cortical BMD increased in the distal radius but tended to decrease in the distal tibia. The observed trabecular bone loss in the distal tibia contributed to the decline in the total volumetric BMD at this site. There was a negative correlation between the changes in leptin levels and the measures of trabecular quality in the tibia on high-resolutionperipheral quantitative computed tomography. Weight loss may negatively impact bone microstructure in young patients, especially for weight-bearing bones, in which obesity has a more prominent effect.

[Surgery in the dark - a case of Cardiac Ochronosis]. / Cirurgia no Escuro ­ Um Caso de Ocronose Cardíaca.

Alkaptonuria is a rare genetic disorder related to tyrosine metabolism. The cardiovascular manifestations are rare being the aortic stenosis the most commonly reported. We present a case of 72-year-old women who underwent aortic valve replacement with intraoperative findings in the aortic valve and the aortic wall suggestive of Cardiac Ochronosis. Once it is a rare disease there are issues related to the natural history of the disorder that still unknown, namely the type of aortic prothesis in use. For this reason, we find essential the documentation and follow-up of all these rare cases.

A Alcaptonúria é uma doença genética rara, relacionada com o metabolismo da tirosina. As manifestações cardiovasculares são a forma de apresentação menos comum da doença, sendo a estenose aórtica a patologia mais frequentemente encontrada. No presente artigo, apresentamos o caso de uma doente do sexo feminino de 72 anos proposta para cirurgia eletiva de substituição valvular aórtica com alterações intraoperatórias sugestivas de Ocronose Cardíaca. Atendendo à raridade da doença, muito há por esclarecer acerca da sua história natural, nomeadamente no que se refere ao tipo de próteses utilizadas, motivo pelo qual é essencial a documentação e seguimento destes casos.

Lung Hernia Related with a Rope Bullfight: Case Report.

Lung herniation is an uncommon entity which was fully classified in 1845 after the study of several case reports. Acquired lung hernia, especially traumatic, is the most common etiology. In the absence of clear guidelines, management of lung hernia is made in a case-by-case basis. We present an asymptomatic middle lobe hernia perceptible on physical examination, but diagnosed initially by imaging studies. Patient medical history included a blunt bull trauma fourteen years before.

Pulmonary Sequestration Supplied By The Circumflex Artery - A Rare Case Report.

Pulmonary sequestration (PS) is a rare congenital malformation, even more when its arterial supply is a coronary artery. We present a case of a 68-year-old man admitted in the emergency room with an acute coronary syndrome and no evidence of significant coronary disease. Instead, he had an abnormal branch from the circumflex coronary artery nourishing a mass in the left lower pulmonary lobe. A coronary steal phenomenon was proposed to explain the clinical presentation. An anterior left thoracotomy with ligation of the abnormal branch and atypical resection of the lung segment comprising the sequestration was performed.

[Safety and feasibility of conservative aortic valve surgery: single center experience]. / Segurança e Exequibilidade da Cirurgia Conservadora da Válvula Aórtica: Experiência de um Centro Cirúrgico Nacional.

BACKGROUND: In selected cases, aortic valve repair (RVAo) is an alternative to prostesic aortic valve replacement. AIM: To compare mid-term survival, need of reoperation and echocardiographic findings associated with RVAo. METHODS: Retrospective single-center cohort study including consecutive patients younger than 70 years-old, with non-stenotic aortic valve disease, who underwent RVAo between 2012 and 2017. A comparison was made with a group of patients who underwent mechanical aortic valve replacement (SVAo) in the same period. The groups were characterized and compared using Chi-Square and t-tests for independent samples and survival and reoperation were analyzed using Kaplan-Meier curves and Cox regressions. RESULTS: We included 72 patients submitted to RVAo. Mean follow-up time was 4 years, maximum 7. Although the mean age was relatively low (47±13 years), patients undergoing RVAo presented a lower prevalence of rheumatic etiology (3%). The cardiopulmonary bypass (148±74 minutes) and cross clamping aortic times (108±52 minutes) are the usual times for this type of surgery and similar to those of the comparing group (SVAo). In the echocardiographic follow-up (median of 3 months), we verified a left ventricular mass regression of 21% and a prevalence of aortic insufficiency of 4%. At 7 years, cumulative survival and freedom from reoperation of patients undergoing RVAo were 98.8% and 97.6%, respectively. CONCLUSION: RVAo can be a safe and effective alternative, with good mid-term results if patient selection is judicious.

Introdução: Em casos selecionados, a reparação da válvula aórtica (RVAo) constitui uma alternativa à substituição por prótese. Objetivo: Avaliar a sobrevida e necessidade de reoperação a médio prazo, bem como o resultado funcional após RVAo. Métodos: Estudo de coorte retrospetivo, unicêntrico incluindo consecutivamente doentes com idade ≤70 anos, submetidos a RVAo por doença da válvula aórtica não-estenótica, entre 2012-2017. Os resultados foram comparados com os obtidos após substituição valvular aórtica por prótese mecânica (SVAo) no mesmo período. Os grupos foram caracterizados e comparados utilizando testes Qui-Quadrado e t para amostras independentes e a sobrevida e reoperações foram analisadas através de curvas de Kaplan-Meier e regressões de Cox. Resultados: Foram incluídos 72 indivíduos submetidos a RVAo. O follow-up médio foi de 4 anos, máximo de 7. Apesar da idade média relativamente baixa à data da intervenção (47±13 anos), os doentes submetidos a RVAo apresentam uma baixa prevalência de etiologia reumática (3%). Os tempos de circulação extracorporal (148±74 minutos) e de clampagem aórtica (108±52 minutos) são os habituais para este tipo de cirurgias e semelhantes aos do grupo SVAo. Durante o seguimento ecocardiográfico (mediano de 3 meses) verificou-se uma regressão de massa do ventrículo esquerdo de 21% e uma prevalência de insuficiência aórtica de 4%. Aos 7 anos, a sobrevida cumulativa e a sobrevida livre de reoperação dos doentes submetidos a RVAo foram, respetivamente, 96,4% e 94,4%. Conclusões: Com uma seleção adequada dos doentes, a RVAo pode ser uma alternativa segura e efetiva, com bons resultados a médio prazo.

What About Having a Hydropneumothorax Every Month?

INTRODUCTION: Endometriosis is a pathological, benign, inflammatory condition characterized by the presence of endometrial glands and stroma outside the uterine cavity, typically in the pelvis. In rare conditions, this estrogen-dependent disease may be extrapelvic, presenting with a variety of symptoms, including Thoracic Endometriosis. METHODS: A 37 year-old woman presented with her third right hydropneumothorax in three months. Her medical history included infertility, an ovarian mass (in study), biliary diskinesia and protein C deficiency. The CT showed a bleb in the right inferior lobe and a pleural effusion. A detailed clinical history revealed a temporal relationship of the hydropneumothoraxes and her menses. RESULTS: She underwent a videothoracoscopy: there were macroscopic tissue alterations all over the parietal and visceral pleura. We performed a biopsy of one of those spots (of the parietal pleura) and an atypical resection of the apex of the apical segment of the right inferior lobe, where the bleb was. A talc pleurodesis was also performed. The patient was discharged at day 1 and is currently under regular follow-up in ambulatory, with no recurrent pneumothoraxes for two months. The histopathology was compatible with a pleural Endometriosis. CONCLUSION: Thoracic endometriosis is a clinical diagnosis, although the histopathologic confirmation is preferred (but not necessary): it should be suspected in reproductive age women who present with hemothorax, pneumothorax, hemoptysis, chest or scapular pain, lung nodules or diaphragmatic rupture perimenstrually, especially right-sided. Most commonly it presents as catamenial pneumothorax and/or hemothorax. Those with high clinical suspicion and/ or imaging supportive of the diagnosis, should undergo an interventional procedure (thoracoscopy), both for diagnose and management. Primary treatment is chest tube drainage. Prevention of recurrence can be medical (hormonal suppression) or surgical (lung resection, pleurectomy, pleurodesis).

Survival After Bilateral Internal Mammary Artery In Coronary Artery Bypass Grafting: Are Women at Risk?

INTRODUCTION: To compare survival and safety of BIMA versus SIMA CABG between males and females at our tertiary care center. METHODS: Single-center retrospective cohort including consecutive patients with at least 2 left coronary system (LCS) vessel disease who underwent isolated CABG with at least 1 IMA conduit and a minimum of 2 conduits targeting the LCS between 2004 and 2013. All-cause mortality was the primary outcome, secondary outcomes were in-hospital mortality and reoperation due to sternal wound complications (SWC). Kaplan-Meier analysis after inverse probability weighting using propensity score (IPW) was used to compare BIMA and SIMA CABG amongst genders. Results were confirmed by subgroup analysis. RESULTS: BIMA CABG was performed in 39% out of 2424 eligible procedures and in 27% of 460 females. No differences were found in survival after BIMA and SIMA CABG (median and maximum follow-up of 5.5 and 12 years, respectively) but a statistical interaction was observed with gender (P<0.001). Females who underwent BIMA CABG showed higher mortality (weighted HR in females subset: 3.16; 95%CI: 1.56-6.29, P=0.001). BIMA CABG showed a higher incidence of reoperations due to SWC (IPW adjusted model OR: 1.74; 95% CI: 1.16-2.60) that were mostly ascribable to males (weighted OR in males: 3.10; 95%CI: 1.74-5.51, P<0.001). CONCLUSION: Females may experience higher mortality after BIMA CABG which should be further explored.

Freedom Solo Versus Trifecta Bioprotheses: Clinical and Hemodynamic Evaluation after Propensity Score Matching.

INTRODUCTION: To compare stentless Freedom Solo and stented Trifecta aortic bioprostheses regarding hemodynamic profile, left ventricular mass regression, early and late postoperative outcomes and survival. METHODS: Longitudinal cohort study of consecutive patients undergoing aortic valve replacement (from 2009 to 2016) with either Freedom Solo or Trifecta at one centre. Local databases and national records were queried. Postoperative echocardiography (3-6 months) was obtained for hemodynamic profile (mean transprosthetic gradient and effective orifice area) and left ventricle mass determination. After propensity score matching (21 covariates), Kaplan-Meier analysis and cumulative incidence analysis were performed for survival and combined outcome of structural valve deterioration and endocarditis, respectively. Hemodynamics and left ventricle mass regression were assessed by a mixed- -effects model including propensity score as a covariate. RESULTS: From a total sample of 397 Freedom Solo and 525 Trifecta patients with a median follow-up time of 4.0 (2.2- 6.0) and 2.4 (1.4-3.7) years, respectively, a matched sample of 329 pairs was obtained. Well-balanced matched groups showed no difference in survival (hazard ratio=1.04, 95% confidence interval=0.69-1.56) or cumulative hazards of combined outcome (subhazard ratio=0.54, 95% confidence interval=0.21-1.39). Although Trifecta showed improved hemodynamic profile compared to Freedom Solo, no differences were found in left ventricle mass regression. CONCLUSION: Trifecta has a slightly improved hemodynamic profile compared to Freedom Solo but this does not translate into differences in the extent of mass regression, postoperative outcomes or survival, which were good and comparable for both bioprostheses. Long-term follow-up is needed for comparisons with older models of bioprostheses.