Malignant Primary and Metastatic Cardiac Tumors: A Single-Center 27-Year Case Review.

BACKGROUND: Malignant primary cardiac tumors are exceedingly rare, and despite surgical exeresis or chemotherapy, their prognosis remains poor. Cardiac invasion by metastatic tumors, while more common, also entails an unsatisfactory outcome. This study aimed to review patients diagnosed with malignant primary and secondary cardiac tumors in a tertiary center between 1995 and 2022. METHODS: Clinical data, echocardiographic, computed tomography, and magnetic resonance assessments of tumor location and morphology, histology, treatment, and survival were retrospectively analyzed. RESULTS: Sixty malignant cardiac tumors were diagnosed: 17 primary (A) and 43 metastatic (B) tumors. A: the most common types were angiosarcoma (41%), undifferentiated sarcoma (23%), and fibrosarcoma (18%). Patients with primary tumors were younger than patients with metastatic tumors (41 ± 13 years vs. 57 ± 18 years, p = 0.001), with no significant gender difference. The most frequent presentations were heart failure (59%) and arrhythmia (23%). The most prevalent tumor location was the right heart chambers (71%), mostly in the right atrium (35%). 47% were submitted to tumor resection, and 29% received chemotherapy. The mortality rate was 82% with a median survival of 6.0 (interquartile range: 1.0-11.8) months after diagnosis (minimum of 12 days and maximum of 19 years). One patient with fibrosarcoma underwent heart transplantation and was still alive and well after 19 years. B: regarding metastatic cardiac invasion, the most common primary tumor sites were lung carcinomas (38%), thymomas (17%), and lymphomas (14%). Presentation with pericardial effusion was common (33%). The mortality rate was 72%, with a median survival of 3.6 (1.0-13.4) months (minimum of 7 days, maximum of 5 years). CONCLUSION: Diagnosis of metastatic cardiac tumors was more common than that of malignant primary tumors, both with a dismal prognosis. When radical exeresis is not possible, heart transplantation can be an option with a favorable outcome in carefully selected patients with sarcomas.

Infective endocarditis in a cohort of adult CHD patients.

BACKGROUND: CHD increases the risk of infective endocarditis due to the substrate of prosthetic materials and residual lesions. However, lesion-specific and mortality risks data are lacking. We sought to analyse clinical course and mortality of infective endocarditis in a cohort of adult CHD. METHODS: Retrospective analysis of all cases of proven and probable infective endocarditis (Duke's criteria) followed in our adult CHD clinic between 1970 and August, 2021. Epidemiological, clinical and imaging data were analysed. Predictors of surgical treatment and mortality were assessed using regression analysis. RESULTS: During a mean follow-up of 15.8 ± 10.9 years, 96 patients had 105 infective endocarditis episodes, half with previous cardiac surgery (corrective or palliative). The most frequent diagnoses were: ventricular septal defect, bicuspid aortic valve, Tetralogy of Fallot and pulmonary atresia. The site of infection was identified by echocardiography in 82 episodes (91%), most frequently in aortic (n = 27), tricuspid (n = 15), and mitral (n = 13) valves. Blood cultures were positive in 79% of cases, being streptococci (n = 29) and staphylococci (n = 23) the predominant pathogens. Surgery was necessary in 40% and the in-hospital mortality was 10.5%, associated with heart failure (p < 0.001; OR 13.5) and a non-surgical approach (p = 0.003; OR 5.06). CONCLUSIONS: In an adult CHD cohort, infective endocarditis was more frequent in patients with ventricular septal defect and bicuspid aortic valves, which contradicts the current guidelines that excludes them from prophylaxis. Surgical treatment is often required and mortality remains substantial. Prevention of this serious complication should be one of the major tasks in the care of adults with CHD.

Combining Congenital Heart Surgical and Interventional Cardiology Outcome Data in a Single Database: The Development of a Patient-Centered Collaboration of the European Congenital Heart Surgeons Association (ECHSA) and the Association for European Paediatric and Congenital Cardiology (AEPC).

The European Congenital Heart Surgeons Association (ECHSA) Congenital Database (CD) is the second largest clinical pediatric and congenital cardiac surgical database in the world and the largest in Europe, where various smaller national or regional databases exist. Despite the dramatic increase in interventional cardiology procedures over recent years, only scattered national or regional databases of such procedures exist in Europe. Most importantly, no congenital cardiac database exists in the world that seamlessly combines both surgical and interventional cardiology data on an international level; therefore, the outcomes of surgical and interventional procedures performed on the same or similar patients cannot easily be tracked, assessed, and analyzed. In order to fill this important gap in our capability to gather and analyze information on our common patients, ECHSA and The Association for European Paediatric and Congenital Cardiology (AEPC) have embarked on a collaborative effort to expand the ECHSA-CD with a new module designed to capture data about interventional cardiology procedures. The purpose of this manuscript is to describe the concept, the structure, and the function of the new AEPC Interventional Cardiology Part of the ECHSA-CD, as well as the potentially valuable synergies provided by the shared interventional and surgical analyses of outcomes of patients. The new AEPC Interventional Cardiology Part of the ECHSA-CD will allow centers to have access to robust surgical and transcatheter outcome data from their own center, as well as robust national and international aggregate outcome data for benchmarking. Each contributing center or department will have access to their own data, as well as aggregate data from the AEPC Interventional Cardiology Part of the ECHSA-CD. The new AEPC Interventional Cardiology Part of the ECHSA-CD will allow cardiology centers to have access to aggregate cardiology data, just as surgical centers already have access to aggregate surgical data. Comparison of surgical and catheter interventional outcomes could potentially strengthen decision processes. A study of the wealth of information collected in the database could potentially also contribute toward improved early and late survival, as well as enhanced quality of life of patients with pediatric and/or congenital heart disease treated with surgery and interventional cardiac catheterization across Europe and the world.

Metastatic endometrial stromal sarcoma: A rare cause of right-sided intracardiac mass.

The endometrial stromal sarcoma (EES) is a rare uterine malignancy and its intracardiac metastasis are exceedingly rare. We report a case of a 53-year-old female patient diagnosed with a metastatic tumor of a ESS in the right side of the heart, who underwent successful surgical resection and initiated chemotherapy with docetaxel and gemcitabine. At a 9-month follow-up, the patient was in New York Heart Association-Class I, without any further complications.

Right Ventricular Outflow Tract Pseudo Aneurysm After Reconstruction With Small Intestinal Submucosal Cormatrix Patch A Word Of Caution.

Tetralogy of Fallot is very prevalent with correction techniques well standardized. Whenever infundibular incisions are needed, patch reconstruction seems mandatory. Recently, the small intestinal submucosal (CorMatrix, MAC's Medical Group,) patch was introduced, with optimal results in pre-clinical studies. However, clinical results do not match its pre-clinical promises, particularly when used in right ventricular outflow tract and pulmonary artery reconstructions. We describe a case of Tetralogy of Fallot for which small intestinal submucosal (CorMatrix) patch was used as a trans-annular patch, with development of a massive pseudo-aneurysm.

Arterial Switch Operation Variables Predicting Reoperation.

OBJECTIVES: Jatene surgery or arterial switch is performed at our institution since the late nineties. We reviewed our results to identify the main causes of reoperation and, more importantly, to determine what variables predict the need for reoperation. METHODS: In this retrospective analysis were included all the 91 patients with d-TGA who underwent an arterial switch operation at our institution between 1995 and 2016. RESULTS: Mean follow-up was 10 years (range 5-25 years). Seventy-one percent of patients had simple TGA and 29% had complex TGA. The need of reoperation was 21% (n=19 patients). Right ventricle outflow tract obstruction was the main indication for reoperation (58%). The overall mortality was 9.9%. The gender (P= 0.8), diagnosis (simple or complex TGA) (P= 0,5) or the existence of palliative surgeries (P=0.9) were unable to predict the need for reoperation. The presence of anomalous coronary pattern was the only variable reaching statistical significance (P < 0.05), both in univariate and multivariate analysis. CONCLUSIONS: In our series, the main indication for reoperation after arterial switch operation was right ventricle outflow tract obstruction and the only predictive variable was the presence of anomalous coronary pattern.

Epidermoid Thymic Cyst - A Very Rare Mediastinal Mass.

OBJECTIVES: Thymic cysts represent 1-3% of all tumors in the anterior mediastinum, but their knowledge is important during the differential diagnosis of a mediastinal mass. METHODS: We describe the case of a 52 years old woman, totally asymptomatic, with an incidental diagnosis of a mediastinal mass at thoracic computed tomography evaluation. RESULTS: Thoracic magnetic resonance showed an heterogeneous mass with approximately 3,6 cm, at the anterior mediastinum. For diagnostic clarification, surgical excision was performed. The histopathological exam revealed an epidermoid thymic cyst. CONCLUSION: Surgical excision and histopathological evaluation allow definite diagnosis of this tumor, associated with a good prognosis.

Infective Endocarditis Due to Bartonella Quintana in a Patient with Biological Aortic Prosthesis.

BACKGROUND: Bartonella quintana is a facultative intracellular bacterium and the causative agent of trench fever. The disease was reported during the World Wars in pre-antibiotic era and is associated with louse infestation and poor hygiene conditions. Bartonella bacteraemia may result in endocarditis mostly in people with existing heart valve abnormalities. CASE REPORT: We report a case of endocarditis caused by B. quintana in a 77-year-old woman with previous valvulopathy. This active endocarditis case was characterized by aortic root involvement 5 years after surgical aortic valve replacement. Although the initial serological tests had induced to a presumptive diagnosis of Q fever, B. quintana infection was confirmed by PCR and sequencing. Detection of Bartonella DNA in valvular and abscess specimens was determinant to confirm Bartonella infection in the absence of other associated risk factors. CONCLUSIONS: Bartonella infection should be considered in patients with pre-existing valvular disease and with a blood culture-negative endocarditis.

Type B Aortic Dissection with Retrograde Intramural Hematoma and Pulmonary Embolism.

We report the case of 67-year old male patient who was admitted with a 2-week history of progressively worsening chest pain and dyspnea. Diagnostic investigation showed a type B aortic dissection with a retrograde intramural hematoma and bilateral pulmonary embolism. These simultaneous findings highly complicated patient management. Patient was started on anticoagulation therapy with partial resolution of pulmonary embolism after which surgical correction was performed. The patient was successfully submitted to a modified Frozen Elephant Trunk technique with a 3-branched customized Dacron tube and aortic arch replacement with E-Vita Open Plus. Patient post-operative period was uneventful, and he was discharged at the tenth postoperative day. The authors consider this case to be highly unusual regarding the clinical aspects, the challenging decision-making process and the complex surgical approach performed with a favorable outcome.

Os autores descrevem o caso de um homem de 67 anos, admitido por dor torácica e dispneia, de agravamento progressivo, com 2 semanas de evolução. A investigação diagnóstica revelou disseção aórtica tipo B com hematoma intramural retrógrado complicado com embolia pulmonar bilateral, o que constituiu um desafio na abordagem terapêutica deste doente. O doente iniciou terapêutica anticoagulante com resolução parcial da embolia pulmonar e foi submetido, posteriormente, a correção cirúrgica com a técnica Frozen Elephant Trunk modificada com implantação de um tubo Dacron com 3 ramos e substituição do arco aórtico com E-Vita Open Plus. O pós-operatório decorreu sem intercorrências e teve alta ao décimo dia de internamento. Os autores consideram este caso invulgar no que diz respeito à combinação dos aspetos clínicos com difícil manejo terapêutico e à complexa abordagem cirúrgica realizada, com desfecho favorável.

Virtual angioscopy and 3D navigation of the aorta.

The objective of this study is to demonstrate the applicability of virtual angioscopy (VA) in different forms of aortic disease where the diagnosis is unclear or uncertain. Five cases are presented where VA helped to establish a correct diagnosis and to choose the best surgical strategy by providing an intuitive image of the aorta.

Quadricuspid Aortic Valve with Mild Stenosis and Servere Insufficiency.

The quadricuspid aortic valve is a very rare congenital malformation and usually presents with aortic insufficiency. Other associated congenital malformations have been described and particularly coronary anomalies have to be considered and investigated. We report the case of an intraoperatively diagnosed quadricuspid aortic valve in a 70 years old patient and discuss the clinical relevance of this rare congenital malformation.

A válvula aórtica quadricúspide é uma malformação congénita muito rara e, geralmente, apresenta-se como uma insuficiência aórtica. Outras malformações congénitas podem estar associadas e devem ser excluídas, em particular anomalias das artérias coronárias. Apresentamos o caso clínico de um homem de 70 anos de idade submetido a cirurgia da válvula aórtica quadricúspide diagnosticada intra-operatoriamente e discutimos a sua relevância clínica.

Isolated Tricuspid Valve Surgery: Repair Versus Replacement.

INTRODUCTION: Isolated tricuspid valve surgery (ITVS) is an uncommon procedure with few studies published. We report our series of ITVS and compare surgical outcomes and mortality in patients undergoing valve repair (TVR) versus replacement (TVRep). METHODS: Retrospective study including all patients who underwent ITVS (n = 34) between July 2008 and June 2017, divided in two groups according to type of procedure: TVR 20 patients and TVRep 14 patients. We reviewed preoperative characteristics and analysed operative data, outcomes and mortality in both groups. RESULTS: Thirty-four patients underwent ITVS, mean age 58,1±15,9 years, 50% female and mean BMI 26,1kg/ m2. TVR was performed in 58,8% and TVRep in 41,2% of patients. Patients had similar demographic and baseline characteristics, except for previous cardiac surgery (TVRep 78,6% vs.TVR 35,%, p<0,05). Mean logistic EuroSCORE was 10,1% for TVRep and 6,6% for TVR (p<0,05). Etiologies were functional insufficiency (68%), endocarditis (18%), degenerative (9%), rheumatic (3%) and congenital (3%). TVR was the preferred surgical approach. Ring annuloplasty was performed for all TVR and bioprosthesis was used for all TVRep. Postoperative complications were: need for transfusional support (76,5%), inotropic support longer than 48 hours (38,2%), prolonged invasive ventilation over 24 hours (35,3%), new onset of atrial fibrillation (11,8%), duplication or postoperative creatinine over 2 mg/dl (8,8%), dialysis (8,8%), stroke (5,9%), intra-aortic balloon pump (5,9%), permanent pacemaker implantation (2,9%) and sepsis (2,9%). TVRep was associated with superior length of surgery (TVRep 291 vs. TVR 186 minutes), longer ICU stay (TVRep 17,1 vs.TVR 2,8 days), longer hospital stay (TVRep 37,1 vs.TVR 11,7 days), prolonged invasive ventilation (TVRep 71,4% vs.TVR 10%) and longer inotropic support (TVRep 78,6% vs.TVR 10%) (p<0,05). Overall 30-day and 1-year mortality were 8,8% and 17,6%, respectively. Type of procedure was not associated to 30-day mortality (TVRep 14,3% vs. TVR 5%, p<0,05), but TVRep was associated with higher 1-year mortality (TVRep 35,7% vs. TVR 5%, p<0,05). CONCLUSIONS: TVR showed better outcomes, with less postoperative complications and mortality than TVRep. This difference cannot be linked to type of pathology, although patients in the latter group may be associated to greater complexity, with higher risk and were often reoperations.

Frozen Elephant Trunk with E-Vita Open Hybrid Prosthesis for Surgical Correction of Multisegmental Thoracic Aortic Pathology: Review of Results.

INTRODUCTION: The Frozen Elephant Trunk (FET) surgery allows correction of ascending, arch and proximal descending aortic pathology, using a hybrid prosthesis at the same time. It is a complex intervention and requires a multidisciplinary team that, besides scheduling and performing the surgery, accompanies the patient (pt) throughout the postoperative period. OBJECTIVES: To review short and medium term clinical results with this technique. METHODS: Between January 2010 and September 2017, we operated 34 patients (pts) using FET. The surgery was performed under cardiopulmonary bypass (CPB) with cardio-circulatory arrest in deep hypothermia, always with bilateral antegrade selective cerebral protection and under noninvasive neuromonitorization. Antegrade and retrograde, hematic, cold, intermittent cardioplegia was used. All patients were followed in our outpatient clinic with imaging techniques. RESULTS: The mean age of the pts was 62.8 ± 11.5 years, 16 males. The mean follow-up period was 18.7 ± 16.1 months. Diagnoses were: chronic type A dissection 9 pts, ascending aortic aneurysm and distal arch 9 pts, pseudoaneurysm 1 pt, mega-aorta syndrome 11 pts. No pt was operated in acute situation. Seven pts (20.6%) were reoperations and in 4 pts (11.8%) associated cardiac procedures were required. The left subclavian was conserved in 24 pts (70.6%). CPB, aortic clamping and distal ischemia mean times were, respectively; 260, 149 and 54 minutes. Hospital mortality occurred in five pts (14.7%), 3 of which at the beginning of the series, due to mesenteric ischemia. The hospital morbidity consisted of: ventilator-associated pneumonia 3 pts (8.8%), stroke 2 pts (5.9%), perioperative infarction 1 pt (2.9%) and paraplegia 1 pt (2.9%). Seven pts (20.6%) required 9 endovascular re-interventions (TEVAR) in the distal descending aorta and in two of these an abdominal fenestrated endoprosthesis was implanted by the vascular team. Three pts presented early type IIB endoleaks, which resolved spontaneously in follow-up CT. Among the others there were no endoleaks and the expected involution of the aneurysmal sac and positive remodeling of the aorta was observed. All survivors are clinically stable, asymptomatic, in class NYHA I. CONCLUSION: The overall results are in line with the literature. Mesenteric ischaemia is the leading cause of in-hospital death. FET is a safe and effective intervention. The expandable segment of the hybrid prosthesis is an excellent landing zone to complete the procedure, when necessary, with the second stage TEVAR. Survivors acquire an excellent quality of life in the medium term. Clinical follow-up and lifelong imaging techniques are mandatory.

TEVAR - A Primary or Adjunct Procedure Helpful in the Surgical Correction of Complex Pathology of the Thoracic Aorta?

INTRODUCTION: Thoracic Endovascular Aortic Repair (TEVAR) made possible the treatment of aortic disease that previously could only be approached openly, associated with a considerable morbidity and mortality. However, it also brings new challenges influencing patient selection - favourable landing zone, good peripheral access, propensity for endoleak (EL) - that requires rigorous clinical and imaging follow- -up. OBJECTIVE: Review all patients that underwent TEVAR in our Department and assess morbidity and mortality. METHODS: From November 2007 to September 2017, 57 TEVAR were performed in our Department to 52 patients. All patients performed postoperative CT angiography within 30 days after surgery. Follow-up was carried in our Outpatient Clinic with annual imaging. Statistical analysis was performed with SPSSTM 22 (© IBM). RESULTS: Patients' mean age was 65.6 ± 10.3 years and 69.2% were male (n = 36). Mean follow-up was 48.1 ± 34.1 months. The most frequent surgical indication was thoracic aortic aneurysm (42.1%), followed by chronic type B aortic dissection (35.1%), pseudoaneurysm (10.5%), reintervention by EL (7.0%), penetrating aortic ulcer (3.5%) and traumatic dissection of the aorta (1.8%). Surgery was elective in 87.7% of cases and part of a dual stage strategy in 17.3%. In-hospital mortality was 3.9%. Survival at 1, 2 and 5 years was 87.9%, 85.6% and 71.5%, respectively. Reported complications were: need for endovascular reintervention 7.7%; complication of femoral access 7.7%; and cerebellar infarction 1.9%. Throughout follow-up, no EL was detected in 56.1% of patients. There was an incidence of early EL in 38.4%, of which 45.0% had spontaneous resolution, documented in subsequent CT scans. The most frequent was type IA (42.9%) that was also the one with the highest spontaneous resolution rate (62.5%). Mean time to diagnosis of late EL was 36.9 ± 21.4 months and occurred in 11.5% of patients, the most frequent being type IA (50.0%); there was no spontaneous resolution observed. In all cases of reintervention due to EL a good surgical result was obtained. CONCLUSION: TEVAR is a procedure with low morbidity and mortality, good long-term outcome and a relatively low incidence of EL. Most patients do not have EL during their follow-up and have an excellent survival. The most frequent early EL is type IA and about half resolve in the following months. Although rare, late EL did not present spontaneous resolution. The treatment of EL can easily be achieved with new intervention and excellent result.

Simplified Technique for Aortic Arch Replacement in Patients at High Risk for Frozen Elephant Trunk.

INTRODUCTION: Surgical approach of multisegmental pathology of the thoracic aorta, namely aortic arch / descending aorta is challenging. The Frozen Elephant Trunk (FET) has good results, with acceptable risk. However, in the subgroup of patients (pts) older than 75 years and with important comorbidities, the surgical risk is very high. OBJECTIVES: Review short-term results of this original, simplified and potentially hybrid technique developed in our Department for this subgroup of patients. METHODS: From January 2016 to September 2017, 10 pts were operated with this technique - mean age 70.2 ± 15.3 years, 7 males. The diagnoses were: 6 pts with aneurysmal disease and 4 pts with aortic dissection. Four pts had previous cardiac surgery. The surgical concept consists of 3 key points: 1) Use of a patient-tailored graft, built in a back-table, to replace the ascending aorta and arch, with side-branches proximally anastomosed to reroute the supra-aortic vessels, allowing a proximal, long Landing Zone for eventual TEVAR. 2) Debranching of the supra-aortic vessels. 3) Maintain bilateral anterograde selective cerebral perfusion. All pts were operated on cardiopulmonary bypass (CPB) with a period of hypothermic (24oC) cardiocirculatory arrest for the open distal anastomosis. Preservation of the left subclavian artery depended on paraplegia risk and was individually assessed preoperatively. In a second stage, a TEVAR was electively deployed in 2 patients. All patients were followed in our clinic and imaging clinic at 6 months and annually after surgery. RESULTS: Mean CPB, aortic cross clamping and visceral ischemia were, respectively, 196, 120 and 44 minutes. One pt died in- hospital due to bowel ischemia. Four pts had respiratory complications requiring prolonged ventilation. The mean ICU and hospital stay was, respectively, 7,8 and 23,6 days. The mean follow-up was 15.2 months and three pts died during this follow-up. One pt was re-hospitalized with deep sternal wound infection. Of the survivors, one had a stroke at 6 months postoperatively and the remainder are asymptomatic. The postoperative period of the 2 pts submitted to TEVAR was uneventful; to date, they remain surgically stable, without needing re-intervention. CONCLUSION: The technique is effective and avoids the burden of FET. The short-term results are encouraging but, in the long-term, they should be evaluated to determine their role among arch interventions, specially their value in relation to recent pure endovascular techniques with fenestrated or branched endoprosthesis. Long ICU and hospital stay points towards the implementation of measures and protocols to improve them.

Ascending Aorta Aneurysms in Octogenarians.

INTRODUCTION: Older age is often regarded as a relative contraindication for open surgery for aortic aneurysms. These individuals often have a greater comorbidity burden that predispose them for development of postoperative complications. The aim of our study is to evaluate the surgical outcomes of selected octogenarians after open aortic surgery. METHODS: We performed a retrospective observational study. We collected data from patients operated on by our team between January of 2012 to September of 2017. We performed univariate logistic regression and survival analysis to construct Kaplan Meier survival curves. RESULTS: We analysed data from 430 patients, and 31 patients fulfilled the inclusion criteria. 67.7% of the patients were male. The mean age was 81.5 ± 1.8 years. The preoperative comorbidities were hypertension (83.9%), aortic valve disease (54.8%), dyslipidaemia (48.4%), renal impairment (9.7%), type 2 diabetes mellitus (9.7%) and COPD (3.2%). As for the procedures performed the majority was aortic valve replacement and graft interposition (48.4%) followed by graft interposition (35.5%), ascending aorta and arch replacement (9.7%) and graft interposition and combined CABG (6.5%). 16.1% of the procedures were reoperations and 6.5% were performed as urgent. In-hospital mortality was 9.4% and 1-year survival was 77.4%. The mean survival time after surgery was 736.4 ± 530.3 days. As for complications, 22.6% developed respiratory complications, 6.5% had infectious complications and 3.2 developed renal and central nervous system complications. Older age was not related to early (p = 0.266) or late mortality (p = 0.779). There was no association between older age and longer ICU stay (p = 0.781) or total hospital stay (p = 0.985). CONCLUSIONS: Highly selected octogenarians benefit from surgery, having a similar rate of postoperative complications and survival, as described in the literature.

Cardiac Fibroelastoma: 10-Year Experience.

INTRODUCTION: Papillary fibroelastoma is one of the most common types of primary cardiac tumour. Though a rare pathology, its importance relates to its form of presentation, with stroke and sudden death, and the questions regarding its management. OBJECTIVES: To review the casuistic of cardiac tumours in our service, in special the papillary fibroelastomas. METHODS: clinical case series overviewing the period from 1st January 2008 to 30th September 2017. We analysed all patients submitted to cardiac surgery due to cardiac masses or tumours and verified all the pathology results to confirm the diagnosis. RESULTS: In the period selected, around 6500 surgeries were performed. Of those, 59 patients were operated on due to cardiac tumours. 81.4% were myxomas, 13.6% were papillary fibroelastomas, 3.4% were cardiac sarcomas and 1.7% were metastasis. Of the patients that had papillary fibroelastomas (n=8), 5 were male, and the mean age was 51.5 ± 16.2 years. 62.5% (n=5) had origin in the aortic valve and 37.5% (n=3) in the mitral valve. Regarding presentation, 3 patients presented with stroke, 2 patients had episodes of syncope and 3 patients were asymptomatic. After surgery, all patients remained asymptomatic and there was no evidence of recurrence. At the end of follow-up all patients were alive. CONCLUSION: Although a rare pathology, papillary fibroelastomas remain important due to their potential for embolization and cardiac chamber obstruction, therefore should be primarily treated with surgery.

Elective 2nd Stage TEVAR to Complete Frozen Elephant Trunk in the Surgical Correction of Complex Multisegmental Pathology of the Thoracic Aorta.

INTRODUCTION: Classical conventional surgery to treat multi-segmental thoracic aortic disease in two operative stages, sternotomy and left thoracotomy, is associated with significant mortality and complications. The Frozen Elephant Trunk (FET) associated with an endovascular procedure (TEVAR) allows an extensible and simplified surgical approach of the descending and thoracoabdominal aorta without increasing the risk. METHODS: Retrospective study of 8 patients (pts), 5 males, mean age 67.5 ± 4.2 years, with ascending and arch disease associated with descending aortic disease (chronic dissection 2 pts, aneurysmal disease 6 pts), treated between January 2014 and September 2017. All survivors are periodically followed up in our outpatient clinic with CT or MRI angiography. RESULTS: The average follow-up period is 18,7 ± 12,2 months. In the first stage (FET) - the left subclavian was conserved in all cases. In six of these pts, after an average period of 37 days, a TEVAR was performed, to complete the exclusion of the aneurysmal sac or the false lumen in the descending aorta. In 2 pts, the interval was longer and in the same intervention, a fenestrated endoprosthesis was implanted in the abdominal aorta by the vascular team. After TEVAR, mean ICU time was 16 hours and hospitalization was 5,2 days. One pt died in the 1st month post-intervention TEVAR + EVAR fenestrated. The remaining pts are stable and asymptomatic, in Class I NYHA, without endoleaks and with the expected involution of the aneurysmal sac and positive remodeling of the aorta. There were no cases of paraplegia or other neurological complications documented. CONCLUSION: This strategy is safe and effective. Clinical follow- -up associated with close postoperative imaging surveillance is required not only to determine the optimal interval between the two stages, which is dependent on the anatomy and underlying pathology of each patient, but also to identify possible complications. The quality of life of these pts in the medium-term is excellent.

Ascending Aorta Aneyrysms Over 70mm.

INTRODUCTION: Current guidelines suggest that patients with aortic diameter over 55-60 mm should undergo ascending aorta replacement, depending on associated valve pathology and other comorbidities. Studies show that the risk of aortic rupture over 60 mm is over 30%. Even though, we still receive in our practice patients that present with aneurysms of greater dimensions. The aim of our study is to evaluate the surgical outcomes of patients presenting with ascending aorta with diameter larger than 70 mm. METHODS: We performed a retrospective observational study. We collected data from patients operated on by our team between January of 2012 to September of 2017. We performed univariate logistic regression and survival analysis to construct Kaplan Meier survival curves. RESULTS: We analysed data from 430 patients, and 31 patients fulfilled the inclusion criteria. 64.5% of the patients were male. The mean age was 67.9 ± 12.9 years. The preoperative comorbidities were hypertension (64.5%), dyslipidaemia (45.2%), aortic valve disease (35.4%), renal impairment (9.7%) and COPD (3.2%). The average diameter was 82.3 ± 18.6 mm, with values ranging from 70 to 160 millimeters. As for the procedures performed the majority was interposition of prosthetic graft (45.2%), followed by aortic valve replacement and graft interposition (35.5%), Frozen Elephant Trunk (12.9%), tube interposition and combined CABG (3.2%) and aortic root replacement with graft interposition (3.2%). 9.7% of the procedures were reoperations and 9.7% were performed as urgent. In-hospital mortality was 3.2% and 1-year survival was 83.9%. The mean survival time after surgery was 1135.9 ± 777.1 days. As for complications, 29% developed respiratory complications, 9.7% had cardiac complications, 6.5% had central nervous system complications and 3.2% developed renal and vascular complications. Greater diameter was not associated with early (p = 0.929) or late mortality (p = 0.987). CONCLUSIONS: These results show that patients with aneurysms greater than 70 mm can be safely operated on, with no increase in complications in the postoperative period or greater mortality.

Major Complications of Videomediastinoscopy and their Resolution - a 5 year experience.

INTRODUCTION: Videomediastinoscopy is an invasive procedure for mediastinal assessment, with low rates of morbidity and mortality. Despite the low risk of complications, they can be potentially lethal if not immediately controlled. OBJECTIVE: The goal of this study is to analyse the overall incidence of complications of videomediastinoscopies, performed in the last 5 years at our department, as well as their resolution and outcomes. METHODS: A retrospective review of all videomediastinoscopies performed at a single institution during a 5-year period was performed. Major complications were defined as life-threatening events. RESULTS: During the study period, from July 2012 to July 2017, were performed 160 mediastinoscopies, 67 were diagnostic and 93 for staging. There were 3 major complications (1.87%), of which a severe haemorrhage from a bronchial artery, a tracheal rupture, and a massive haemorrhage from an innominate artery laceration. In this 3 cases, the diagnosis were lung cancer in 2 patients and lymphoma in the other one. There were no intraoperative deaths. One patient died in the postoperative period due to mediastinitis and disease progression. The patient who suffered innominate artery laceration, had a stroke due to dissection of the right carotid artery. During follow-up, one patient died from progression of oncologic disease, and the other one is alive 4 years later. CONCLUSION: Although mediastinoscopy has a low rate of complications, these can be potentially lethal and the thoracic surgeon should be able to resolve them rapidly. Due to the scarcity of publications on this subject, it is important to describe potential complications of this surgical procedure and their clinical resolution.