Simultaneous thoracoscopic approach in a patient with long-standing persistent atrial fibrillation and primary lung cancer: the first described case

Abstract Cardiac rhythm disorders are common in many patients with cancer. The management of synchronous long-standing persistent atrial fibrillation and pulmonary lesions remains a serious surgical dilemma due to the lack of clinical data and surgical guidelines. To the best of our knowledge, this is the first described case of simultaneous thoracoscopic pulmonary segmentectomy and left atrial posterior wall and pulmonary vein isolation combined with left atrial appendage resection in a patient with early-stage primary lung cancer and long-standing persistent atrial fibrillation.

Right atrium tumor extension through the inferior vena cava. considerations about nine cases operated under cardiopulmonary bypass

Abstract Introduction: Adrenocortical and renal cell carcinomas rarely invade the right atrium (RA). These neoplasms need surgical treatment, are very aggressive and have poor prognostic and surgical outcomes. Case series: We present a retrospective cohort of nine cases of RA invasion through the inferior vena cava (four adrenocortical carcinomas and five renal cell carcinomas). Over 13 years (2002-2014), nine patients were operated in collaboration with the team of urologists. Surgery was possible in all patients with different degrees of technical difficulty. All patients were operated considering the imaging examinations with the aid of CPB. In all reported cases (renal or suprarenal), the decision to use CPB with deep hypothermic circulatory arrest (DHCA) on surgical strategy was decided by the team of urological and cardiac surgeons. Conclusion: Data retrospectively collected from patients of public hospitals reaffirm: 1) Low incidence with small published series; 2) The selected cases did not represent the whole historical casuistry of the hospital, since they were selected after the adoption of electronic documentation; 3) Demographic data and references reported in the literature were presented as tables to avoid wordiness; 4) The series highlights the propensity to invade the venous system; 5) Possible surgical treatment with the aid of CPB in collaboration with the urology team; 6) CPB with DHCA is a safe and reliable option; 7) Poor prognosis with disappointing late results, even considering the adverse effects of CPB on cancer prognosis are expected but not confirmed.

Mid-Term Results of Surgical Treatment of Atrial Fibrillation in Valvular Heart Disease Assesed by Speckle Tracking Echocardiography / Resultados em Médio Prazo do Tratamento da Fibrilação Atrial na Doença Valvular Cardíaca Avaliados por Ecocardiografia com Speckle Tracking

Abstract Background: Atrial fibrillation frequently affects patients with valvular heart disease. Ablation of atrial fibrillation during valvular surgery is an alternative for restoring sinus rhythm. Objectives: This study aimed to evaluate mid-term results of successful atrial fibrillation surgical ablation during valvular heart disease surgery, to explore left atrium post-ablation mechanics and to identify predictors of recurrence. Methods: Fifty-three consecutive candidates were included. Eligibility criteria for ablation included persistent atrial fibrillation <10 years and left atrium diameter < 6.0 cm. Three months after surgery, echocardiogram, 24-hour Holter monitoring and electrocardiograms were performed in all candidates who maintained sinus rhythm (44 patients). Echo-study included left atrial deformation parameters (strain and strain rate), using 2-dimensional speckle-tracking echocardiography. Simultaneously, 30 healthy individuals (controls) were analyzed with the same protocol for left atrial performance. Significance was considered with a P value of < 0.05. Results: After a mean follow up of 17 ± 2 months, 13 new post-operative cases of recurrent atrial fibrillation were identified. A total of 1,245 left atrial segments were analysed. Left atrium was severely dilated in the post-surgery group and, mechanical properties of left atrium did not recover after surgery when compared with normal values. Left atrial volume (≥ 64 mL/m2) was the only independent predictor of atrial fibrillation recurrence (p = 0.03). Conclusions: Left atrial volume was larger in patients with atrial fibrillation recurrence and emerges as the main predictor of recurrences, thereby improving the selection of candidates for this therapy; however, no differences were found regarding myocardial deformation parameters. Despite electrical maintenance of sinus rhythm, left atrium mechanics did not recover after atrial fibrillation ablation performed during valvular heart disease surgery.

Resumo Fundamento: A fibrilação atrial frequentemente afeta pacientes com doenças das valvas cardíacas. A ablação da fibrilação atrial durante a cirurgia das válvulas é uma alternativa para restaurar o ritmo sinusal. Objetivos: Este estudo teve como objetivos avaliar resultados em médio prazo da ablação cirúrgica bem sucedida da FA durante cirurgia para doença valvar, para explorar a mecânica do AE após a ablação e identificar preditores de recorrência. Métodos: Foram incluídos 53 candidatos consecutivos. Os critérios de elegibilidade para ablação foram fibrilação atrial persistente <10 anos e diâmetro do átrio esquerdo < 6 cm. Três meses após a cirurgia, foram realizados ecocardiografia, Holter por 24 horas, e eletrocardiografias em todos os candidatos que mantiveram o ritmo sinusal (44 pacientes). O estudo eco incluiu parâmetros de deformação ao átrio esquerdo (strain e taxa de strain) usando ecocardiografia bidimensional com speckle tracking. Simultaneamente, 30 indivíduos sadios (controles) foram analisados com o mesmo protocolo para o desempenho do átrio esquerdo. Um valor de P < 0,05 foi considerado significativo. Resultados: Após um período médio de acompanhamento de 17 ± 2 meses, 13 novos casos de fibrilação atrial no pós-operatório foram identificados. Um total de 1245 segmentos do átrio esquerdo foi analisado. O grupo pós-cirúrgico apresentou dilatação grave do átrio esquerdo, e as propriedades mecânicas do átrio esquerdo não se recuperaram após a cirurgia quando comparadas com valores normais. O volume do átrio esquerdo (≥ 64 mL/m2) foi o único preditor independente de recorrência de fibrilação atrial (p = 0,03). Conclusões: O volume do átrio esquerdo foi maior nos pacientes com fibrilação atrial recorrente, e desponta como o principal preditor de recorrência, melhorando, assim, a seleção de candidatos para essa terapia. No entanto, não foram encontradas diferenças em relação aos parâmetros de deformação do miocárdio. Apesar da manutenção elétrica do ritmo sinusal, a função mecânica do átrio esquerdo não se recuperou após a ablação da fibrilação atrial realizada durante a cirurgia para doença da valva cardíaca.

Resection of left atrial myxoma in a patient with retrosternal gastric tube: a case report

Abstract The median sternotomy remains the standard approach in cardiovascular surgery but, in some conditions, it can be considered difficult to perform, especially in patients with history of esophagectomy. This case report describes a successful resection of a left atrial myxoma through a right anterolateral thoracotomy approach in a patient with a previous retrosternal gastric tube reconstruction. The decision for the best surgical approach was made after a heart surgery team discussion. Through this surgical access, a safe and excellent exposure of the left atrium was possible, and a complete resection of the myxoma was performed without any injury to the gastric tube.

Registro de arritmias em pacientes com marcapassos e doença renal crônica de leve a moderada (RYCKE): resultados de um estudo de coorte observacional / Register of arrhythmias in patients with pacemakers and mild to moderate chronic kidney disease (RYCKE): results from an observational cohort study

O presente estudo examinou pacientes submetidos a implante de marcapasso dupla-câmara em decorrência de doença do nó sinusal ou bloqueio atrioventricular de 3o ou 2o graus do tipo 2 na doençarenal crônica em estágios 2, 3 e 4. O estudo teve como objetivo registrar os eventos arrítmicos durante 12 mesesde acompanhamento e comparar a incidência e a gravidade deles nas diferentes fases da doença renal crônica.Método: No total, 305 pacientes foram avaliados a cada 4 meses até 12 meses de acompanhamento. Os eventosarrítmicos foram avaliados em cada visita de acompanhamento. Resultados: Dentro do mesmo grupo de estágio da doença renal crônica não houve diferença entre as causas doença do nó sinusal e bloqueio atrioventricular, a respeito da ocorrência de qualquer arritmia. No entanto, menor incidência de taquicardia atrial/fibrilação atrial foi observada para todas as comparações entre todos os pacientes e os mesmos subgrupos em pacientes no estágio 2 (total: 58%; doença do nó sinusal: 63%; bloqueio atrioventricular: 51%), comparativamente aos estágios 3 (total:87%, P < 0,0001; doença do nó sinusal: 89%, P = 0,0020; bloqueio atrioventricular: 84%, P = 0,0019) e 4 (total: 85%, P < 0,0001; doença do nó sinusal: 81%, P = 0,0409; bloqueio atrioventricular: 90%, P < 0,0001). Em relação à taquicardia ventricular não sustentada/taquicardia ventricular sustentada, foi observada incidência mais elevada para todas as comparações entre todos os pacientes e os mesmos subgrupos em pacientes no estágio 4 (total: 32%; doença do nó sinusal: 16%; bloqueio atrioventricular: 16%), comparativamente aos estágios 3 (total: 11%, P = 0,0007; doença do nó sinusal: 9%, P = 0,0110; bloqueio atrioventricular: 14%, P = 0,0441) e 2 (total: 3%, P < 0,0001; doença do nó sinusal: 3%, P < 0,0001; bloqueio atrioventricular: 4%, P < 0,0001). Conclusão: Nossos resultados sugerem que quanto mais avançado o estágio da doença renal crônica maior a incidência de arritmias malignas...

The present study evaluated patients who had received a dual chamber pacemaker implant due to sinus node disease or 3rd/2nd degree type 2 atrioventricular block in chronic kidney disease stages 2, 3 and 4. The study was aimed at registering arrhythmic events for 12 months of follow-up and comparing their incidence and severity in different stages of chronic kidney disease. Method: Three hundred and five patients were evaluated every 4 months up to 12 months of follow-up. Arrhythmic events were assessed at each follow-up visit. Results: Within the same chronic kidney disease stage group there was no difference between the causes ofsinus node disease and atrioventricular block for the occurrence of any arrhythmia. However, a lower incidence of atrial fibrillation/tachycardia was observed for all comparisons among all patients and the same subgroups in stage 2 patients (total: 58%; sinus node disease: 63%; atrioventricular block: 51%) compared to stages 3 (total: 87%,P < 0.0001; sinus node disease: 89%, P = 0.0020; atrioventricular block: 84%, P = 0.0019) and 4 (total: 85%,P < 0.0001; sinus node disease: 81%, P = 0.0409; atrioventricular block: 90%, P < 0.0001). Regarding nonsustained/ sustained ventricular tachycardia, a higher incidence was observed for all comparisons among all patients and the same subgroups in stage 4 patients (total: 32%; sinus node disease: 16%; atrioventricular block: 16%) compared to stages 3 (total: 11%, P = 0.0007; sinus node disease: 9%, P = 0.0110; atrioventricular block: 14%, P = 0.0441) and 2 (total: 3%, P < 0.0001; sinus node disease: 3%, P < 0.0001; atrioventricular block: 4%,P < 0.0001). Conclusion: Our findings suggest that the more advanced the stage of chronic kidney disease, thegreater the incidence of malignant arrhythmias...

Simplified method for esophagus protection during radiofrequency catheter ablation of atrial fibrillation - prospective study of 704 cases / Método simplificado para proteção do esôfago durante a ablação por radiofrequência da fibrilação atrial - estudo prospectivo de 704 casos

Abstract Introduction: Although rare, the atrioesophageal fistula is one of the most feared complications in radiofrequency catheter ablation of atrial fibrillation due to the high risk of mortality. Objective: This is a prospective controlled study, performed during regular radiofrequency catheter ablation of atrial fibrillation, to test whether esophageal displacement by handling the transesophageal echocardiography transducer could be used for esophageal protection. Methods: Seven hundred and four patients (158 F/546M [22.4%/77.6%]; 52.8±14 [17-84] years old), with mean EF of 0.66±0.8 and drug-refractory atrial fibrillation were submitted to hybrid radiofrequency catheter ablation (conventional pulmonary vein isolation plus AF-Nests and background tachycardia ablation) with displacement of the esophagus as far as possible from the radiofrequency target by transesophageal echocardiography transducer handling. The esophageal luminal temperature was monitored without and with displacement in 25 patients. Results: The mean esophageal displacement was 4 to 9.1cm (5.9±0.8 cm). In 680 of the 704 patients (96.6%), it was enough to allow complete and safe radiofrequency delivery (30W/40ºC/irrigated catheter or 50W/60ºC/8 mm catheter) without esophagus overlapping. The mean esophageal luminal temperature changes with versus without esophageal displacement were 0.11±0.13ºC versus 1.1±0.4ºC respectively, P<0.01. The radiofrequency had to be halted in 68% of the patients without esophageal displacement because of esophageal luminal temperature increase. There was no incidence of atrioesophageal fistula suspected or confirmed. Only two superficial bleeding caused by transesophageal echocardiography transducer insertion were observed. Conclusion: Mechanical esophageal displacement by transesophageal echocardiography transducer during radiofrequency catheter ablation was able to prevent a rise in esophageal luminal temperature, helping to avoid ...

Resumo Introdução: Apesar de rara, a fístula átrio-esofágica é uma das complicações mais temidas na ablação por radiofrequência da fibrilação atrial pelo alto risco de mortalidade. Objetivo: Este é um estudo prospectivo controlado, realizado durante a ablação por radiofrequência da fibrilação atrial regular, para testar se o deslocamento do esôfago ao manipular o transdutor de ecocardiografia transesofágica poderia ser usado para a proteção de esôfago. Métodos: Setecentos e quatro pacientes (158 mulheres e 546 homens [22,4%/77,6%]; 52,8±14 [17-84] anos), com EF média igual a 0,66±0,8 e com fibrilação atrial refratária ao tratamento medicamentoso, foram submetidos à terapia híbrida com ablação por radiofrequência (isolamento convencional das veias pulmonares e ninhos de fibrilação atrial e ablação de taquicardia de background) com deslocamento do esôfago o mais longe possível do alvo da radiofrequência por manuseio do transdutor de ecocardiografia transesofágica. A temperatura luminal esofágica foi monitorada com e sem deslocamento em 25 pacientes. Resultados: O deslocamento esofágico significativo foi de 4 a 9,1 centímetros (5,9±0,8 cm). Em 680 dos 704 pacientes (96,6%), isso foi o suficiente para permitir a entrega completa e segura de radiofrequência (30W/40ºC/cateter irrigado ou 50W/60ºC/cateter de 8 milímetros) sem sobreposição do esôfago. As alterações médias de temperatura luminal esofágica com e sem deslocamento de esôfago foram de 0,11±0,13ºC versus 1,1±0,4ºC, respectivamente, P<0,01. A radiofrequência teve que ser interrompida em 68% dos pacientes sem deslocamento de esôfago devido ao aumento da temperatura luminal esofágica. Não houve nenhum caso, suspeito ou confirmado, de fístula átrio-esofágica. Foram observados apenas dois sangramentos superficiais causados por inserção do transdutor de ecocardiografia transesofágica. Conclusão: O deslocamento mecânico do esôfago pelo transdutor de ecocardiografia transesofágico durante ...

Comparison of superior septal approach with left atriotomy in mitral valve surgery / Comparação da abordagem septal superior com atriotomia esquerda em cirurgia valvar mitral

Objective: In this study, we aimed to compare clinical outcomes of superior transseptal approach with the conventional left atriotomy in patients undergoing mitral valve surgery. Methods: Between January 2010 and November 2012, a total of 91 consecutive adult patients (39 males, 52 females; mean age: 54.0±15.4 years; range, 16 to 82 years) who underwent mitral valve surgery in the Division of Cardiovascular Surgery at Koşuyolu Training Hospital were included. The patients were randomized to either superior transseptal approach (n=47) or conventional left atriotomy (n=44). Demographic characteristics of the patients, comorbidities, additional interventions, intraoperational data, pre- and postoperative electrophysiological study findings, and postoperative complications were recorded. Results: Of all patients, 86.7% (n=79) were in New York Heart Association Class III, while 12 were in New York Heart Association Class IV. All patients underwent annuloplasty (42.9%) or valve replacement surgery (57.1%). There was no significant difference in pre- and postoperative electrocardiogram findings between the groups. Change from baseline in the cardiac rhythm was statistically significant in superior transseptal approach group alone (P<0.001). There was no statistically significant difference in mortality rate between the groups. Permanent pacemaker implantation was performed in 10.6% of the patients in superior transseptal approach group and 4.5% in the conventional left atriotomy group. No statistically significant difference in bleeding, total length of hospital and intensive care unit stay, the presence of low cardiac output syndrome was observed between the groups. Conclusion: Our study results suggest that superior transseptal approach does not lead to serious or fatal adverse effects on sinus node function or atrial vulnerability, compared to conventional approach. .

Objetivo: O objetivo deste estudo é comparar os resultados clínicos da abordagem septal superior com a atriotomia esquerda convencional em pacientes submetidos à cirurgia valvar mitral. Métodos: Entre janeiro de 2010 e novembro de 2012, foi incluído um total de 91 pacientes adultos consecutivos (intervalo de 16 a 82 anos, média 54,0±15,4 anos; 39 homens, 52 mulheres) submetidos à cirurgia valvar mitral no Serviço de Cirurgia Cardiovascular no Hospital Training Koşuyolu. Os pacientes foram randomizados para abordagem septal superior (n=47) ou atriotomia esquerda convencional (n=44). Foram registradas características demográficas dos pacientes, comorbidades, intervenções adicionais, dados intraoperatórios, achados do estudo eletrofisiológico pré e pós-operatório e complicações pós-operatórias. Resultados: Do total de pacientes, 86,7% (n=79) estavam na Classe III e 12 na Classe IV da New York Heart Association. Todos os pacientes foram submetidos à anuloplastia (42,9%) ou cirurgia de troca valvar (57,1%). Não houve diferença significativa nos resultados do eletrocardiograma pré e pós-operatórios entre os grupos. Mudança da linha de base no ritmo cardíaco foi estatisticamente significativa apenas no grupo abordagem septal superior (P<0,001). Não houve diferença estatisticamente significativa na taxa de mortalidade entre os grupos. Marca-passo definitivo foi implantado em 10,6% dos pacientes no grupo abordagem septal superior e em 4,5% dos pacientes no grupo atriotomia esquerda convencional. Não houve diferença estatisticamente significativa no sangramento, tempo total de internação e de permanência na UTI, tendo sido observada síndrome de baixo débito cardíaco entre os grupos. Conclusão: Nossos resultados sugerem que a ...

Tratamento cirúrgico da fibrilação atrial crônica com eletrocautério convencional em cirurgia valvar mitral / Surgical treatment of chronic atrial fibrillation with conventional electrocautery in mitral valve surgery

OBJETIVO: Avaliar os resultados do tratamento cirúrgico da fibrilação atrial por ablação da parede posterior atrial esquerda utilizando o eletrocautério, em cirurgia valvar mitral. MÉTODOS: De maio de 2004 a dezembro de 2006, 23 pacientes foram submetidos a correção cirúrgica de valvopatia mitral e ao tratamento da fibrilação atrial utilizando o eletrocautério convencional para a realização de linhas de ablação no endocárdio atrial esquerdo. A idade média dos pacientes era de 59 anos, sendo 60,8% do sexo feminino. A média do diâmetro atrial esquerdo era de 50,3 ± 5,09 mm e a fração de ejeção do ventrículo esquerdo de 53,6 ± 11,03%. RESULTADOS: O tempo médio de circulação extracorpórea foi de 52,5 ± 13,3 min; pinçamento aórtico, 35,6 ± 12,9 min; ablação do endocárdio atrial, 3,05 ± 0,16 min. Todos os pacientes estavam livres de fibrilação atrial após o procedimento; na alta hospitalar, 69,5%; no 6º mês, 91,3%; no 12º mês, 76,4%; no 18º e 24º meses, 68,4%. No 12º mês, a média do diâmetro atrial esquerdo era de 42,1 ± 3,5 mm; a fração de ejeção do ventrículo esquerdo era de 59,2 ± 3,48%; e a contração atrial esquerda estava presente em 68,8 por cento de todos os pacientes. CONCLUSÃO: O tratamento cirúrgico da fibrilação atrial com eletrocautério, em cirurgia valvar mitral, foi capaz de determinar a reversão dessa arritmia a um número significativo de pacientes durante um seguimento clínico de curto e médio prazo, sem mortalidade e com baixa morbidade.

OBJECTIVE: To evaluate the results of the surgical treatment of atrial fibrillation for ablation of the posterior left atrial wall using electrocautery in mitral valve surgery. METHODS: From May 2004 to December 2006, 23 patients underwent surgical correction of mitral valve disease and treatment of atrial fibrillation using the conventional electrocautery for the accomplishment of lines of endocardial ablation in the left atrium. The mean age of the patients was 59 years, and 60.8% were female. The left atrium mean diameter was 50.3 ± 5.09 mm and the left ventricular ejection fraction was 53.6 ± 11.03%. RESULTS: The mean time of extracorporeal circulation was 52.5 ± 13.3 min; aortic clamping, 35.6 ± 12.9 min; atrial ablation, 3.05 ± 0.16 min. All the patients were free of atrial fibrillation after the procedure; on hospital discharge, 69.5%; at 6 months, 91.3%; at 12 months, 76.4%; at 18 months, and at 24 months, 68.4%. At 12 months, left atrium mean diameter was 42.1 ± 3.5 mm; left ventricular ejection fraction was 59.2 ± 3.48%; In addition, left atrial contraction was present in 68.8% of the patients. CONCLUSION: The surgical treatment of the atrial fibrillation with electrocautery in mitral valve surgery was capable to determine the reversion of this arrhythmia in a significant number of patients during short- and middle-term clinical follow-up without mortality and fewer complications.

Criocoagulación de venas pulmonares como tratamiento complementario de la fibrilación auricular en cirugía valvular / Cryoablation of pulmonary veins as complementary treatment of atria I fibrillation in valvular surgery

Background: The Cox MAZE III operation for the treatment of atrial fibrillation (AF) is complex and consumes significant operative time. Cryoablation of the pulmonary veins (CPV) is a simpler alternative for patients that require concomitant valvular surgery. Aim: To evaluate CPV in patients with AF submitted to valvular surgery. Patients and Methods: Twenty one patients had simultaneous valvular surgery and CPV, 81 percent of them had permanent AFfor an average of 5 years. Twenty patients had mitral valve disease. The etiology was rheumatic in 14. Average left atrial diameter was 60 mm. In 7patients the mitral valve was replaced, in 5 it was repaired, in 7 both mitral and aortic valve were replaced, in 1 the mitral valve was repaired and the aortic valve was replaced and in 1 only the aortic valve was replaced. A combined transeptal and superior approach was used for all patients. The CPV was performed after the valvular procedure with cryothermy at -60°C for 2 minutes with two 15 mm cryoprobes applied simultaneously. Results: CPV increased surgical time by 10 to 20 minutes. Operative mortality was 4.8 percent (1 patient). One patient developed a pericardial effusion and another a complete heart block that required a permanent pacemaker. All patients improved their functional class. At the end of an average 10.5 months of follow-up, 50 percent of patients were in normal sinus rhythm and 25 percent persisted in AF. The remaining patients were in some type of regular rhythm. Conclusions: CPV as a complementary procedure in patients with AF undergoing valvular surgery had good results to abate AF. It restored normal sinus rhythm in 50 percent of the cases, with low morbidity and mortality and little increment in surgical time.