The roadmap to transcatheter aortic valve implantation.

Nearly 300 years after the first description of aortic valve obstruction, it has taken less than two decades of randomized clinical trials (RCTs) for transcatheter aortic valve implantation (TAVI) to become a recognized strategy for patients with aortic stenosis. The high density of recent publications makes it easy to ignore the history that led to the development of this procedure. Knowing the evolution of a diagnostic or therapeutic technique improves critical reasoning, prevents repeated mistakes, paves the way for future research and contributes to an insightful perspective on the subject. Nevertheless, it should not overshadow the findings of recently published RCTs, which still are the mainstay of clinical practice. In this timeline review, the authors aim to recap the development of TAVI, combining the pathophysiology of aortic stenosis and the initial concept of TAVI with the roadmap of clinical trials that led to the generalization of the TAVI procedure.

Correction of adult-type VSD causing aortic valve endocarditis through aortotomy.

Ventricular septal defects are the most common congenital abnormality diagnosed in children but account for only 10 percent of congenital heart defects in adults. Although many defects close spontaneously before adulthood, many others persist, predisposing to endocarditis, and other complications. Herein, we report a case of a known, asymptomatic, perimembranous ventricular septal defects that has complicated at 53 years of age with the need for surgery due to native aortic valve endocarditis and concomitant severe aortic regurgitation. We opted to surgically repair the ventricular septal defects with a pericardial patch through the necessary aortotomy used for aortic valve replacement (Figure 1 and 2). The surgery was straightforward. Postoperative course was only marked by the need of a permanent pacemaker implantation due to a sick sinus syndrome, which was diagnosed before the surgery. Thus, we emphasize the role of surgery in repairing ventricular septal defects and the importance of choosing the appropriate approach, especially when concomitant heart lesions are present.

As comunicações interventriculares são a lesão congénita mais comummente diagnosticada em idade pediátrica mas representam apenas 10% dos defeitos cardíacos congénitos em idade adulta. Apesar da maioria das comunicações interventriculares encerrarem espontaneamente antes da idade adulta, muitas persistem predispondo a endocardite e outras complicações. Apresentamos um caso de comunicação interventricular perimembranosa assintomática até à idade adulta, que complicou aos 53 anos com endocardite da válvula aórtica nativa associada a regurgitação aórtica severa, necessitando, por isso, de correção cirúrgica. Optamos pela correção cirúrgica implantando um retalho de pericárdio heterólogo através da aortotomia necessária para a substituição valvular aórtica (Figure 1 and 2). A cirurgia decorreu sem intercorrências. De referir apenas, no pós-operatório, a necessidade de implantação de um pacemaker permanente dado existência prévia de doença do nó sinusal. É de salientar a importância do papel da cirurgia na correção de comunicações interventriculares e a necessidade de escolher a abordagem cirúrgica mais apropriada, especialmente, quando existem lesões cardíacas concomitantes.

[Euthanasia: Are there several types?] / Eutanásia: existirão vários tipos?!

Euthanasia has been discussed since Antiquity. Euthanasia and assisted suicide should be considered under the term "euthanasia" and under the same definition of "active and intentional death on demand of the patient, due to administration of medication, resulting from the decision of the physician, being independent of the executor", before being suithanasia, where the administration of medication was performed by the patient, or homothanasia, in the case of the doctor. The designations direct, active and voluntary, currently related to euthanasia should fall into disuse, because it assumes various kinds, of what is false. Greater openness of mindset and broader dialogue, based on scientific evidence and the clarification of definitions and objectives, are essential in the process of liberalizing euthanasia.

A eutanásia está em debate desde a Antiguidade. A eutanásia e o suicídio assistido devem ser considerados sob a mesma designação de "eutanásia" e sob a mesma definição de "morte activa e intencional, a pedido do doente, devida a administração de medicação, resultante da deliberação do médico, sendo independente do executor", estando perante suitanásia, caso a administração da medicação fosse executada pelo doente, ou homotanásia, no caso do médico. As designações directa, activa e voluntária, actualmente relacionadas com a eutanásia devem cair em desuso, pois pressupõem vários tipos desta, o que é falso. Uma maior abertura de mentalidade e um diálogo mais alargado, baseado na evidência científica e na clarificação de definições e objectivos, são essenciais no processo de liberalização da eutanásia.

Isolated tricuspid valve Staphylococcus lugdunensis endocarditis in patient with a KBG syndrome.

Both KBG syndrome (approximately 50 patients worldwide) and isolated tricuspid valve Staphylococcus lugdunensis endocarditis are very rare entities. The KBG syndrome is a multiple congenital anomaly characterized by short stature, distinctive craniofacial features, and neurologic/developmental/cognitive delay and is only associated to congenital heart defects in 9% of patients. Staphylococcus lugdunesis is an aggressive cause of infective endocarditis. Herein is described a case of a patient presenting both diseases, despite the absence of any known infection, congenital heart defect, heart device or any other entry port which could explain this scenario. The unusual findings in this young patient raised questions regarding the, as-yet unexplained, etiopathogenesis of the KBG syndrome, the possibility of it being related to this rare and concerning clinical presentation and the unclear and undefined management and surgical approach associated to right side endocarditis.

O síndrome KBG (aproximadamente 50 casos a nível mundial) e a endocardite tricúspide isolada causada por Staphylococcus lugdunensis são entidades raríssimas. O síndrome KBG é uma anomalia congénita caracterizada por baixa estatura, características craniofaciais típicas e atrasos neurológicos, cognitivos e de desenvolvimento. Apenas 9% estão associados a patologia cardíaca congénita. O Staphylococcus lugdunesis é um agente associado a quadros de endocardite infeciosa com péssimo prognóstico. O presente caso clínico refere-se a um jovem adulto com ambas as patologias, apesar de não apresentar nenhuma lesão, anomalia ou dispositivo cardíaco, infeção ou outra porta de entrada que justificasse este desenvolvimento clínico. Estes achados incomuns levantaram questões quanto à, ainda mal esclarecida, etiopatogenia do síndrome KBG, a possibilidade deste estar associado ao quadro de endocardite e qual a melhor abordagem médica e/ou cirúrgica aquando de uma infecção limitada às câmaras direitas.

[In dubio pro malum - a clinical case to reflect]. / In dubio pro malum ­ um caso clínico para reflectir.

Patients with cardiac pathology alone are already complex, when this is associated with oncologic pathology, or it's mere suspicion, the patient becomes even more complex. We present a clinical case of a patient with severe aortic stenosis with suspected cancer disease, whose diagnostic study could not be performed due to the patient's clinical condition. The option to intervene surgically was widely debated, never being a consensus among surgeons. There are many doubts about a clinical case of this type, and it is not easy to make a decision to operate. In case of doubt, the decision must always be in favor of the patient: in dubio pro malum.

Se os doentes com patologia cardíaca, por si só, já são doentes complexos, quando a esta se associa patologia oncológica, ou a sua mera suspeição, o doente torna-se ainda mais complexo. Apresentamos um caso clínico de um doente com estenose aórtica severa, com suspeita de doença oncológica, cujo estudo diagnóstico não se poderia realizar devido ao facto de o estado clínico do doente não permitir tolerar o mesmo. A opção de intervir cirurgicamente foi uma opção amplamente debatida, nunca se encontrando um consenso entre os cirurgiões. São imensas as dúvidas levantadas perante um quadro clínico deste tipo, não sendo fácil a tomada de decisão de operar. Em caso de dúvida, a decisão deve ser sempre a favor do doente: in dubio pro malum.

[Papillary muscle rupture as a manifestation of SLE in the puerperium]. / Rotura de Músculo Papilar como Manifestação de Lupus Eritematoso Sistémico no Puerpério.

Systemic Lupus Erythematosus (SLE) and Antiphospholipid Syndrome (APS) are two autoimmune diseases that may have serious cardiovascular manifestations, especially when associated. We report the clinical case of a young female, in the puerperium, with SLE in acute phase, who developed a sudden heart failure due to rupture of the papillary muscle. She underwent emergent cardiac surgery, with replacement of the mitral valve by a biological prosthesis. The postoperative course had no major intercurrences. Catastrophic SAF was concluded as a final diagnosis, due to the presence of anti-phospholipid antibody, to the attainment of multiple organs by thromboembolic phenomena, with histological documentation of micro-thrombi in cardiac tissue. This condition has a mortality rate of about 50%, despite treatment.

O Lúpus Eritematoso Sistémico (LES) e a Síndrome Antifosfolípido (SAF) são duas doenças auto-imunes que podem ter manifestações cardiovasculares graves, principalmente quando associadas. Apresentamos o caso clínico de uma doente jovem, puérpera, com LES em fase de agudização, que desenvolveu um quadro súbito de insuficiência cardíaca grave, por ruptura de músculo papilar. Foi submetida a cirurgia cardíaca emergente, com substituição da válvula mitral por prótese biológica. O período pós-operatório decorreu sem intercorrências de relevo. Como diagnóstico final concluiu-se SAF catastrófica, devido à presença de anticorpo anti-fosfolípido, ao atingimento de múltiplos órgãos por fenómenos trombo-embólicos, com documentação histológica da presença de micro-trombos no tecido cardíaco. Esta condição tem uma taxa de mortalidade de cerca de 50%, apesar do tratamento.

Aortic Valve Replacement With Perceval® Bioprosthesis: Initial Single-Center Experience.

INTRODUCTION: Aortic valve replacement (AVR) is the gold standard for the treatment of severe or symptomatic aortic valve stenosis. Less invasive procedures have been developed as an alternative to the conventional technique of full sternotomy approach with stented prosthesis. The Perceval® aortic valve (LivaNova, Milan, Italy) is a sutureless bioprosthesis, of which several reports have shown promising results in terms of mortality, morbidity and hemodynamic performance, especially with a less invasive approach. METHODS: Between March 2016 and September 2017, 43 patients underwent AVR with Perceval® bioprosthesis. The mean age was 74.3±6.8 years, 24 (55.8%) patients were female, and the mean EuroSCORE II was 4.1±0.6. Concomitant procedures were CABG (n=11; 25.6%), mitral valve surgery (n=2; 4.7%) and tricuspid valve surgery (n=1; 2.4%). RESULTS: Isolated AVR were performed in 31 patients (72%), with a less invasive approach in 29 cases (67%), of which 20 patients with upper ministernotomy and 9 patients with right anterior mini-thoracotomy. Cardiopulmonary bypass and cross- clamp times were 69.8±26.6 and 49.2±18.1 minutes for isolated AVR and 106.1±32.6 and 82.9±24.9 minutes for combined procedures, respectively. Preoperative peak and mean gradients were 81.6±24.8 and 49.7±16.1 mmHg, decreasing to 22.4±10.2 and 11.9±5.8 mmHg, respectively, during follow up (mean 9.1±6.0 months). The mean effective orifice area improved from 0.77±0.18 to 1.83±0.45 cm2, and mean left ventricular ejection fraction from 55.0±10.0 to 55.2±8.4%; mean left ventricular mass decreased from 221.6±55.7 to 180.2±42.4 g/m2. Trivial paravalvular leakage occurred in 2 patients, without clinical relevance. Five patients (11.6%) needed pacemaker implantation because complete heart-block before discharge (in 4 patients postdilation modelling wasn't performed). In-hospital mortality was 9.3% (n=4), all non-valve related (mean EuroSCORE II of 9.15±4.0). CONCLUSION: AVR with the Perceval bioprosthesis is associated with low mortality rates and excellent hemodynamic performance. Sutureless technology may reduce operative times, especially in combined procedures, making minimally invasive AVR more easily reproducible.

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.

Trifecta Bioprothesis for Aortic Valve Replacement: Our Experience.

INTRODUCTION: Bioprosthesis are increasingly used for aortic valve replacement (AVR), as a result of increasing elderly patients, as well as, continuous improvements in durability and hemodynamic performance of pericardial prosthesis. The Trifecta aortic prosthesis is a latest-generation trileaflet stented pericardial valve designed for supra-annular placement in the aortic position. This study establishes the safety and early clinical and hemodynamic performance of the Trifecta valve. METHODS: We retrospectively analyzed the data of 373 consecutive patients that underwent surgical implantation of the pericardial stented aortic prosthesis (Trifecta valve; St Jude Medical, St Paul, Minn) at our institution from March 2014 (first implant) to March 2017 (3 years). Pre-operative, operative and post-operative parameters and clinical outcomes, as well as, echocardiography data were evaluated. RESULTS: The mean age was 73,96 years ± 51, 176 (47,18%) patients were male, mean body mass index of 28,14 ± 12 and 75 (20,11%) were 380-years old. Concomitant procedures were performed in 123 (32,98%) patients. Isolated AVR was undertaken through conventional sternotomy (62,5%), partial sternotomy (35%) or anterior right minithoracotomy (2,5%). Prosthesis sizes implanted were: 19 mm (n=37), 21 mm (n=138), 23 mm (n=196) and 25 mm (n=2). The overall follow-up included 669 late patient-years. Early (≤ 30 day) mortality occurred in 20 patients (5.36%), and there were 4 (1.07%) late (≥ 31 days) deaths yielding a linearized mortality rate of 2.98% per late patient-year. For isolated AVR, mortality occurred in 12 (3.22%) patients. The incidence of new onset atrial fibrillation/flutter was of 28.95% (n=108). Five patients had necessity for implantation of postoperative permanent pacemaker (1,34%), and four mediastinitis/ sternal dehiscence (1.07%) and thirty nine cases of major bleeding required surgery (10.46%). There were 2 early thromboembolic events, including 1 (0,27%) stroke and 1 (0,27%) systemic embolic event. There were no instances of early valve thrombosis, endocarditis, or clinically significant haemolysis. There were no late thromboembolic events or valve structural deterioration. In total, there was 1 late valve explant due to an endocarditis. Overall, freedom from valve explant was 99,77% per late patient- -year. At postoperative echocardiography, average mean gradients across all valve sizes was 10.63mmHg. Mean follow-up was 4± 2 months. No severe aortic regurgitation was observed. CONCLUSION: The present systematic review demonstrated that AVR with this prosthesis provided excellent early safety and hemodynamic outcomes with acceptable mean gradients; nevertheless, their timing, pathological characteristics, and clinical presentation mandate continued follow-up.

Surgical management of primary spontaneous pneumothorax: 11-years experience.

INTRODUCTION: Primary spontaneous pneumothorax (PSP) is a pathology with a high recurrence rate. Surgical treatment allows the resolution of the acute episode and prevention of its recurrence. The main objective of the present study was to evaluate the outcomes of patients submitted to surgery due to PSP. METHODS: A retrospective case series review was undertaken on all patients submitted to thoracotomy or video-assisted thoracoscopic surgery (VATS) for PSP at our thoracic surgery center between January 2005 and December 2016. RESULTS: A total of 319 surgeries were performed in 298 patients with a mean age of 29.0±12.7 years. Surgical approach was thoracotomy in 30 surgeries and VATS in 289 procedures. Surgical technique included bullectomy or apical resection in 98.1% of the surgeries in combination with some kind of pleurodesis, mainly partial parietal pleurectomy plus pleural abrasion in 38.9% and only pleural abrasion in 38.9%. Median postoperative stay was 4 days. Postoperative complications occurred in 14.7% of cases, primarily due to persistent air leak (30 of the 47 complications). Recurrence rate was 4.7% (15 cases). There was no association between surgical approach or surgical technique and recurrence. CONCLUSION: Surgical treatment remains one important cornerstone for definitive treatment of PSP. Our study demonstrated that a VATS approach, particularly uniportal VATS, to perform bullectomy or apical wedge resection along with pleural abrasion can be a safe and efficient choice in the treatment and prevention of recurrence of the PSP.

Introdução: O pneumotórax espontâneo primário (PEP) é uma patologia com uma elevada taxa de recorrência. O trata- mento cirúrgico possibilita a resolução do episódio agudo e previne a sua recorrência. O principal objectivo do presente estudo foi avaliar os resultados cirúrgicos dos doentes submetidos a cirurgia devido a PEP. Métodos: Foram revistos retrospectivamente todos os doentes submetidos a toracotomia ou cirurgia vídeo-assistida (VATS) para o tratamento de PEP no nosso centro cirúrgico no período compreendido entre Janeiro de 2005 e Dezembro de 2016. Resultados: Um total de 319 cirurgias foram realizadas em 298 doentes com idade média de 29,0±12,7 anos. A abordagem cirúrgica utilizada foi toracotomia em 30 cirurgias e VATS em 289 cirurgias. A técnica cirúrgica incluiu a ressecção de bolhas enfisematosas ou ressecção atípica do ápex pulmonar em 98,1% das cirurgias, em combinação com uma técnica de pleurodese, principalmente pleurectomia parietal parcial associado a abrasão pleural em 38,9% dos casos e apenas abrasão pleural em 38,9% dos casos. O tempo mediano de internamento foi 4 dias. Ocorreram complicações pós operatórias em 14,7% dos procedimentos, sobretudo fuga aérea prolongada (30 dos 47 casos de complicações). A taxa de recorrência foi de 4,7% (15 casos). Não foi encontrada nenhuma associação estatisticamente significativa entre a abordagem ou técnica cirúrgica e a ocorrência de recorrência de PEP. Conclusão: O tratamento cirúrgico é uma das opções fundamentais no tratamento definitivo de PEP. O nosso estudo demonstrou que a VATS, sobretudo a VATS uniportal, para a realização de ressecção de bolhas enfisematosas ou ressecção atípica do ápex pulmonar associada a abrasão pleural pode ser considerada uma escolha segura e eficaz para o tratamento e prevenção de recidiva de PEP.

Circumflex Coronary Artery Lesion and Consequent Papillary Muscle Rupture after Chordal Sparing Mitral Valve Replacement.

Ischemic iatrogenic lesions can complicate surgical procedures on the mitral valve. One of the causative mechanisms is direct injury to or distortion of structures that lie in close proximity to the valve, such as the circumflex coronary artery. We report a case of iatrogenic circumflex coronary artery lesion after mitral replacement causing muscle wall dyskinesia, wall aneurism and papillary muscle rupture. We emphasize the role of post-operative echocardiography in the diagnosis of such complications by demonstrating a 25mm flail of a ruptured papillary muscle remaining sutured to the ring of the mitral prosthesis and moving freely inside the left ventricle intruding the aortic valve during systole.

As lesões isquémicas iatrogénicas são complicações possíveis durante a abordagem cirúrgica da válvula mitral. Um dos mecanismos é a lesão direta e/ou distorção de estruturas próximas, como a artéria coronária circunflexa. Reportamos um caso de lesão iatrogénica da artéria coronária circunflexa após cirurgia de substituição valvular mitral, tendo como consequência discinesia e aneurisma da parede ventricular, bem como ruptura do músculo papilar. Salientamos o papel do ecocardiograma como ferramenta diagnóstica destas complicações demonstrando imagens interessantes como por exemplo o "flail" do músculo papilar, suturado ao anel da válvula protésica, que se move livremente dentro do ventrículo e em sístole se insinua através da válvula aórtica.

Paraplegia due to spinal cord infarction following cardiac surgery.

Paraplegia is an extremely rare complication following any surgery, especially cardiac surgery. The underlying mechanisms remain poorly understood and even though spinal infarction has been reported previously, it is almost always associated with the use of intra-aortic balloon pump. We report the clinical case of a 75 year-old male, who developed paraplegia secondary to spinal infarction, following cardiac surgery (coronary artery bypass grafting and aortic valve replacement) in whom the intra-aortic balloon pump was not used and few other predisposing factors were present that could anticipate that complication.