Minimally Invasive Mitral Valve Repair: From Total Endoscopic To Closed-Chest Robotic.

Minimally invasive cardiac surgery has evolved over the past few decades, thanks to advancements in technology and surgical techniques. These advancements have allowed surgeons to perform cardiac interventions through small incisions, reducing surgical trauma and improving patient outcomes1. However, despite these advancements, thoracoscopic mitral repair has not been widely adopted by the cardiac surgery community, possibly due to the lack of familiarity with video-assisted procedures1. Over the years, various minimally invasive mitral valve surgery (MIMVS) techniques have been developed to achieve comparable or better results while minimizing surgical trauma. These techniques have evolved from direct-vision procedures performed through a right thoracotomy with a rib retractor to video-directed approaches using long-shafted instruments1. Robotic surgery, introduced in the late 90s, has also played a significant role in mitral valve repair. The da Vinci system, the only robotic platform currently used for cardiac surgery, provides surgeons with enhanced dexterity and high-definition 3D visualization, allowing for precise and accurate procedure2, and is now the preferred approach for mitral repair in many programs3. The first mitral repair using the da Vinci system was performed in Europe by Carpentier and Mohr in 1998, followed by the first mitral replacement by Chitwood in the USA in 20002-4. The advantages of robotic technology allow surgeons to perform complex repair techniques such as papillary muscle repositioning and sliding leaflet plasty4. Studies have shown that robotic mitral surgery results in shorter ICU and hospital stays, better quality of life postoperatively, and improved cosmesis compared to conventional surgery5,6. In our experience, we have also observed significant benefits with robotic surgery, including reduced blood loss and the need for transfusions. This can be attributed to the closed-chest technique, which eliminates the need for a thoracotomy and rib retractor, reducing the risk of bleeding associated with these approaches7. In this article, we will compare the surgical steps of endoscopic and robotic mitral valve repair, providing detailed information on patient selection, operative techniques, and the requirements for building a successful program. By understanding the advantages and challenges of both approaches, surgeons can make informed decisions and provide the best possible care for their patients. Combined ablation and multivalvular procedures are mostly performed in few centers by minimally invasive techniques.

Redo mitral valve replacement through minithoracotomy on ventricular fibrillation: Bailout for a nightmare Redo.

A 56-year-old woman entered the emergency department due to worsening dyspnea. Severe mitral regurgitation and pulmonary artery dilation with flow compatible with fistula were observed by transthoracic and transesophageal echocardiography. The patient had history of an ALCAPA (anomalous left coronary artery from pulmonary artery) syndrome having undergone coronary artery bypass grafting (saphenous venous graft to left anterior descending artery) 30 years before. Coronary angiography and computed tomography revealed patency of the graft, with the dilated vein running across the front of the ascending aorta and being responsible for the perfusion of the left anterior descending artery and circumflex artery. We resent this case for discussion of which surgical strategy/options are available in order to treat the mitral valve and avoid injuring the patent graft.

Epidemiology of Trigger Finger: Metabolic Syndrome as a New Perspective of Associated Disease.

Objective: The aim of this study was to identify the main diseases related to trigger finger. Methods: A retrospective, observational study was performed with data obtained through a computerized record of 75 patients with trigger finger diagnosis between July 2011 and October 2015. The diagnosis of metabolic syndrome was performed following National Cholesterol Education Program Adult Treatment Panel III (2001). Results: Patients' ages ranged from 50 to 84 years, with a mean age of 63 years. The ring finger was the most affected, followed by the middle finger, index finger, and little finger. Most had a grade 2 trigger finger classified by Green; the right hand involvement was more prevalent, as was the dominant hand. The incidence in women was twice as high as in men. Arterial hypertension, diabetes mellitus, and dyslipidemia were shown to be important associated diseases, but metabolic syndrome was the main association found. Conclusions: Metabolic syndrome in the group of patients studied in this scientific article seems to be the main associated disease.

Concomitant procedures using minimally access.

Alongside the mitral repair or replacement, a considerable number of concomitant procedures can be performed with the minimally invasive mitral valve surgical approach. Some of these concomitant procedures comprise the tricuspid valve repair or replacement, left atrial appendage (LAA) exclusion, Interatrial septum defects correction and atrial fibrillation (AF) ablation.

Long-term Outcomes in Octogenarians Following Isolated Aortic Valve Replacement.

INTRODUCTION: Isolated aortic valve replacement (AVR) in elderly patients is associated with increased operative risk, due to higher prevalence of associated risk factors and other comorbidities, making outcome prediction essential. In patients with symptomatic severe aortic disease, advanced age is often a reason for a transcatheter rather than surgical aortic valve replacement. In the era of TAVI, there has been renewed interest in the outcomes of conventional AVR for high and intermediate risk patients. This study evaluates the short and long-term outcomes of elective AVR in elderly patients. METHODS: Between July 2011 and May 2015, 100 patients, aged 80 years or older, underwent elective AVR in our unit. The notes of these patients were retrospectively reviewed and follow-up information was obtained from their cardiologists and general practitioners. The average age was 82.8±2.3 years, 53.0% were female, 96.0% had severe aortic valve stenosis and their mean EuroSCORE II was 4.1±3.2 (intermediate risk). Preoperatively, 35.0% of patients were in NYHA class III or IV. Statistical analyses were done using IBM SPSS version 24. RESULTS: Median UCI and hospital stay was 2.0±3.7 and 7.0±9.5 days, respectively. Post-operatively, 2 patients required insertion of a permanent pacemaker, 3 patients suffered an ischemic stroke without sequelae, 3 required temporary renal replacement therapy, 7 required resternotomy for bleeding, 3 had sternal wound infections. No myocardial infarction was observed. In-hospital mortality was 4.0%, which was in accordance with the mean EuroSCORE II (4.1±3.2, p>0.05). One- year survival was 85.0%, three-year survival was 81.4% and five-year survival was 59.4%. At follow-up, 96.0% of patients were New York Heart Association (NYHA) Class I or II and 2 late endocarditis occurred and were medically treated. Structural valve deterioration was observed in 2 patients at 3 years follow-up. CONCLUSION: The outcome after AVR in octogenarians is satisfactory; the operative risk is acceptable and might even be reduced with an individual approach to perioperative management in high-risk patients. Patient age should not be the primary exclusion for conventional cardiac surgery for aortic valve disease.

Analgesia Management for Mitral Valve Repair Via Minithoracotomy - A Case Report.

INTRODUCTION: Minimally invasive cardiac surgery (MICS), via minithoracotomy, is thought to be a fast track to extubation and recovery after surgery. Chronic pain, due to intercostal nerve injury, develops in up to 50% of postthoracotomy patients.A number of regional anaesthesia and analgesia techniques may be employed, and the anaesthesiologists play a key role in facilitating optimal outcomes after surgery. METHODS: We report a case of postoperative pain management with a local anesthetic infiltration for MICS. RESULTS: A 63-year-old woman, 80kg, American Society Anaesthesiology (ASA) physical status 3 [arterial hypertension, atrial fibrillation (AF), rheumatic mitral stenosis and class II NYHA heart failure] was presented for an elective minimally invasive mitral valve repair through a minithoracotomy and cryoablation of AF. No relevant facts were found on pre-operative evaluation. Calculated EuroScore II was 1.55%. After premedication with intravenous (IV) midazolam 1.5mg, radial arterial and jugular central venous catether were placed. General anaesthesia was induced with IV remifentanil 1mcg/kg/h, propofol 50mg, rocuronium 1mg/ kg. A transesophageal echocardiography probe was inserted atraumatically, which revealed thickened mitral valve leaflets. ASA standard, invasive blood pressure, central venous pressure, depth of anaesthesia and cerebral oximetry monitoring were used. Urine output and arterial blood gas were measured periodically. A right lateral minithoracotomy was performed. After cardiopulmonary bypass (CPB) by femoral cannulation, cryoablation was performed followed by placement of the mechanical prosthesis. Total bypass time was 186min including 139min aortic cross-clamping time. At the ending of CPB, there was no need for inotropic support. Analgesia with paracetamol 1g, tramadol 100mg and morphine 10mg was performed after protamine reversion. Immediately before closure of skin, catheter was placed nearly to intercostal space (figures 1, 2) and ropivacaine 0,75% 75mg was administered. Anaesthesia and surgery were uneventful. Patient was shifted to intensive care unit (ICU), being extubated 3 hours after surgery. There was no need for additional bolus of ropivacaine during 2 days of ICU stay. She was discharged home on the 4th postoperative day, without complications. In a telephone interview 3 weeks after surgery, the patient referred no pain and good satisfaction with analgesia management. CONCLUSION: Thoracotomy incisions are associated with severe pain, leading to a decrease in pulmonary function, an increase in metabolic and hormonal activity and increased cardiac morbidity. Regional analgesia techniques have an opioid-sparing effect, reducing stress response and pain chronification. The local infiltration through catheter with local anaesthetics allows excellent analgesia for 8-12 hours, providing a route of additional analgesia according to pain control.

Evaluación in vitro de la rugosidad superficial y la alteración de color de dos tipos de ionómeros de vidrio, luego de ser sometidos a diferentes bebidas / Avaliação in vitro da rugosidade superficial e alteração de cor de dois tipos de ionômeros de vidro, depois de ter sido submetido a bebidas diferentes / in vitro evaluation of surface roughness and color alteration of two types of glass ionomers, after being subjected to different beverages

El objetivo de este estudio in vitro fue analizar la rugosidad superficial y la alteración de color de dos tipos de ionómeros vítreos luego de ser sometidos a diferentes soluciones. En una matriz de teflón (8x2mm), fueron confeccionados 60 cuerpos de prueba con 2 tipos de ionómeros fotopolimerizables: 30 para el Fuji II LC (M1) y otros 30 para el Ketac N100 (M2). El aparato utilizado fue el Elipar Freelight 2 3M Espe. La fotopolimerización se realizó por 20 segundos cada cuerpo de prueba. Luego de la confección, los sesenta cuerpos de prueba fueron mantenidos en gasa humedecida por 24 hs en estufa a 37ºC y luego se clasificaron y luego se dividieron en tres grupos de 10 cada uno para ser sometidos a 3 tipos diferentes de soluciones: agua destilada (S1), bebida carbonatada (S2) y jugo cítrico (S3) por 90 segundos diariamente durante 14 días. Las lecturas de la alteración de color, obtenidas a través de un colorímetro, y las de rugosidad superficial, realizadas por medio del rugosímetro, fueron realizadas a las 48 hs. (T0) y luego a los 14 días (T1). Los resultados obtenidos fueron sometidos al test ANOVA y Tukey (p≤0.05). Los resultados mostraron que; a) La bebida carbonatada (S2) tuvo mayor media de alteración de color (ΔE*) en relación a las otras soluciones, b) que Ketac N100 (M2) tuvo mayor media con respecto a la rugosidad superficial en la interacción material por solución. Por tanto, se concluyó que trascurrido determinado período de tiempo las propiedades estéticas y físico-mecánicas de los materiales estudiados se ven afectados.

O objetivo deste estudo in vitro foi analisar a rugosidade superficial e a alteraçã o de cor de dois tipos de ionômeros de vidrio após serem submetidos a diferentes bebidas. Em uma matriz de te ón (8x2mm), foram confeccionados 60 corpos de prova com 2 tipos de ionômeros fotopolimerizáveis: 30 para o Fuji II LC (M1) e outros 30 para o Ketac N100 (M2). O aparelho utilizado foi o Elipar Freelight 2 3M Espe. A fotopolimerização foi realizada por 20 segundos em cada corpo de prova. Após a confecçã o, os 60 corpos de prova foram mantidos em gaze umedecida por 24 hrs em estufa a 37o C e divididos em 3 grupos de 10 cada um, para ser submetidos a 3 tipos diferentes de soluçõ es: água destilada (S1), bebida carbonatada (S2) e suco cítrico (S3) por 90 segundos diariamente durante 14 dias. As leituras de alteraçã o de cor, obtidas através de um colorímetro, e das de rugosidades superficial, realizadas por meio do rugosímetro, foram realizadas após 48 hs. (T0) e após 14 dias (T1). Os resultados obtidos foram submetidos à test ANOVA e Tukey (p≤0.05). Os resultados mostraram que; a) a bebida carbonatada (S2) teve maior media de alteraçã o de cor (ΔE*) em relaçã o às outras soluçõ es, b) que Ketac N100 (M2) teve maior media com respeito a rugosidade superficial na interaçã o material pela soluçã o. Podemos concluir que a partir de determinado período de tempo as propriedades estéticas e físico-mecânicas dos materiais estudados são afetadas.

The aim of this in vitro study was to examine the surface roughness and discoloration of two types of glass ionomer had been subjected to different solutions. In a matrix of Teflon (8x2mm), 60 test bodies were prepared with 2 types of resin modified glass ionomers: 30 for Fuji II LC® (M1) and the other 30 for Ketac N100® (M2). The apparatus was Freelight two 3M ESPE Elipar. Photopolymerization was carried out for 20 second each test body. After the preparation, the seventy-two specimens were kept in gauze soaked for 24 hours in an oven at 37°C and then were sorted and divided into three groups of 12 each to be subjected, for 90 seconds each day at 3 different types of solutions: distilled water (S1), carbonated beverage (S2) and citrus juice (S3) for 14 days. Readings from discoloration, obtained through a colorimeter, and the surface roughness made using the profilometer were performed after 48 hours (T0) and after day 14 (T1). The results were submitted to ANOVA and Tukey test (p ≤ 0.05). The results showed that: a) The carbonated beverage (S2) had higher mean discoloration (ΔE *) compared to the other solutions, b) Ketac N100®(M2) had higher mean with respect to the interaction surface roughness material solution. Therefore, it was concluded that certain period of time elapsed aesthetic properties and physico-mechanical properties of the material studied are affected.

A Modified Nance Palatal Arch for the Treatment of Ectopically Erupting Permanent First Molars.

Permanent teeth that remain impacted could lead to the early loss of primary teeth and cause space problems in dental arches. We present two cases of ectopic eruption of the permanent maxillary first molars treated with soft distal movements using a modified Nance palatal arch (NPAm). The wire was soldered to the band and positioned distally to serve as support for the elastic chain, which was attached to a bonded button on the occlusal surface. After a few months, the ectopic eruption was corrected, preserving the adjacent primary teeth and restoring the occlusion. An NPAm is a viable option for distalization and space recovery in the maxillary arch.

[Incidence of atrial fibrillation after cardiac surgery: Influence of the type of surgery, cardiopulmonary bypass and preoperative and perioperative predictive factors]. / Incidência De Fibrilação Auricular Pós Cirurgia Cardíaca: Influência Do Tipo De Cirurgia, Da circulação Extracorporal E De Fatores Pré E Intraoperatórios.

BACKGROUND: Atrial fibrillation (AF) is the arrhythmia with higher incidence in postoperative period after cardiac surgery. In individuals undergoing valve replacement surgeries (VRS) it occurs in about 64% and in individuals undergoing coronary artery bypass grafting (CABG) it can occurs in about 30-40%. Its incidence in postoperative period can still be influenced by pre and perioperative risk factors. AIM: To study the incidence of AF after cardiac surgery, its association with the type of surgery, cardiopulmonary bypass (CPB), and with the main pre and perioperative risk/predictive factors. METHODS: Longitudinal retrospective observational study of individuals undergoing CABG and VRS in 2014, in a central hospital in the northern region. Cardiac rhythm was evaluated in four moments of postoperative period (end of CPB, Intensive Care Unit (ICU)/hospitalization, pre-hospital discharge, follow-up). The association of cardiac rhythm and preoperative risk/predictive factors (size of the atria, cardiomegaly, left ventricular hypertrophy (LVH)) and intraoperative risk factors (type of surgery, duration of CPB, aortic clamping time and cardioplegia administration) were explored through Odds ratio (OR). RESULTS: We studied 416 individuals, 73.6 % male, mean age 66.8±10.5 years old. VRS showed incidence values of AF in all evaluation moments, and CABG only in ICU/internment and pre-hospital discharge. The incidence of AF was higher in ICU/internment in all types of surgery, ranging from 3.7% (CABG with CPB) to 71.4% (mitral VRS). Preoperative predictive factors with an OR>1 were age upper 65 years old (2.51 end of CPB, 10.62 pre-hospital discharge), dilation of the right atrium (RA) (1.08 follow-up, 3.41 pre-hospital discharge), and LVH (1.68 end of CPB, 2.78 pre-hospital discharge). Perioperative predictive factors with an OR>1 were CPB (2.74 ICU/interment, 3.37 pre-hospital discharge), and cardioplegia (2.93 ICU/internment, 5.40 pre-hospital discharge). CONCLUSIONS: VRS were the type of surgery with higher incidence of AF. CABG had a higher incidence of AF in surgeries without CPB. Age upper 65 years old, RA dilation and LVH were the preoperative predictive factors with positive association with AF incidence in all evaluation moments.

Transapical aortic valve and mitral valve in ring prosthesis implantation - a new advance in transcatheter procedures.

Transcatheter valve implantation offers a new treatment modality to those patients whose general condition makes conventional surgery very risky. However, the transcatheter option has only been available for the aortic valve. We describe a case of a successful implantation of two Edwards SAPIEN(®) 26 and 29 mm transapical valves, respectively, in aortic and mitral positions, on a 74-year-old patient with severe aortic and mitral stenosis. The procedure progressed uneventfully. Predischarge echocardiogram showed a peak aortic gradient of 20 mmHg, mild periprosthetic regurgitation, peak and mean mitral gradients of 12 and 4, respectively, and moderate (II/IV) periprosthetic regurgitation. Indications for transapical valve implantation will rapidly increase in the near future. It is essential to individualize the treatment be applied for each patient, in order to optimize the success of the procedure.

[Patency of Coronary Artery Bypass Graft]. / Permeabilidade dos Bypass Aorto-Coronários.

INTRODUCTION: Coronary heart disease is the leading cause of death and disability in the U.S. and Europe. When significant, the coronary disease can be treated medically or surgically. The medical treatment is performed in the catheterization laboratory and consists in the re-permeabilization of the coronary arteries by percutaneous approach, whereas the surgical myocardial revascularization consists in performing aorto-coronary bypass using arterial or venous conduits. OBJECTIVE: This study is sought to assess the patency and longevity of bypass in patients requiring new catheterization after surgery for recurrence of ischemic heart disease and to evaluate its relationship with factors such as the type of bypass, cardiovascular risk factors and left ventricular ejection fraction. METHODS: This study retrospectively analysed a sample of 260 surgically revascularized patients who required a new catheterization at the Hospital of Vila Nova de Gaia - Espinho between 2007 and 2012, for recurrence of ischemic heart disease. The degree of patency of the bypass was evaluated and sought a relationship with other variables such as gender, age, cardiovascular risk factors, left ventricular ejection fraction, the time interval between bypass surgery and the new catheterization. RESULTS: The patency of the arterial bypass using the left internal mammary artery proved to be superior to the venous conduit bypass. There was no statistically significant relationship between the patency of the bypass, the cardiovascular risk factors and the left ventricle ejection fraction. CONCLUSION: In this study we found a greater patency of the arterial bypass compared to the venous bypass.

Complex ventricular septal rupture with dissection of the right ventricular wall in ischemic context.

A 72-year-old man was admitted to the local hospital with non-ST elevation myocardial infarction. In the first 24 hours, a new onset apical murmur was heard. Transthoracic and transesophageal echocardiography showed interventricular septal (IVS) rupture and dissection of the right ventricle (RV) wall forming an echolucent pseudocavity that partially occupied the RV and communicated with the true RV cavity. Multislice computed tomography characterized in detail the IVS and RV wall dissection, and further showed the right coronary artery in the outer border of the RV and pseudocavity, excluding pericardial fluid. Despite surgical correction, progression to cardiogenic shock and death occurred 33 days after admission.

Successful implantation of a CoreValve prosthesis through direct aortic access via ministernotomy.

The use of tanscathether aortic valve implantation (TAVI) to treat severe aortic valve disease is increasing exponentially. Peripheral vascular access for TAVI is not always possible, and when transapical approach is contraindicated, other access options can be considered like the central transaortic access. The authors describe a successful implantation of a CoreValve prosthesis through direct aortic access via ministernotomy, addressing particular attention to the implantation procedure, potencial complications, advantages and limitations of the method.

A rare cause of acute heart failure.

We describe a rare clinical case of ruptured sinus of Valsalva aneurysm (RSVA) into the right ventricle, complicated with severe aortic regurgitation (AR) and myocardial ischaemia. The AR was caused by a hemodynamic effect solely, in which the shunt of blood flow through the ruptured site pulled the right aortic cusp away from closure. The pathological mechanism of the AR was clearly visualized by transesophageal echocardiography. Early successful primary closure of the RSVA resulted in resolution of the associated AR without any additional procedure.

Syphilitic aneurysm of the ascending aorta.

Syphilitic aortic aneurysm is a rare occurrence in the antibiotic era, making the diagnose assumption even more infrequent. Nonetheless, this pathology can appear and should be suspected in patients with aortic aneurysm. We report a case of a 57-year old patient who presents with neurosyphilis and, in the following study, a large ascending aorta aneurysm is identified. The authors discuss the diagnostic challenge, the epidemiologic concerns, surgical indication and treatment and subsequent follow-up.

Fratura dos metacarpianos e falanges / Fracture of metacarpals and phalanges

O presente trabalho procura dar uma orientaçäo aos médicos, que possam vir a se deparar com mäos traumatizadas. Mostra a classificaçäo das fraturas dos metacarpianos e falanges, faz uma abordagem, acerca dos tratamentos básicos preconizados e tece consideraçöes suscintas sobre as complicaçöes advindas, tanto relativas aos tratamentos como conseqüentes às próprias fraturas

Tratamento das patologias ósseas tumorais e infecciosas por método näo convencional / Treatment of tumoral infectious pathologies by non-conventional method

Os autores relatam quatro casos operados no Hospital Naval Marcílio Dias, portadores de Patologia Tumorais Osseas e Infecciosas que foram submetidos a ressecçäo segmentar com substituiçäo por endopróteses näo convencionais. A execuçäo desse procedimento impede que se mutile o paciente, permitindo a preservaçäo da funçäo do membro doente