Repositório RCAAP

A 20-year old male patient presented at the emergency department with occipital headache, chest pain and hemoptysis, following an accident while playing sports (fall after impact with another player). There was no known relevant patient history or usual medication. Initial work-up revealed an occipital hematoma and right lumbar pain, in the absence of rib fracture or subcutaneous emphysema. Crackles at the lower-third of the right hemithorax were noted at auscultation. No abnormalities were found on the cranial computed tomography (CT) or chest x-ray. Due to a new onset of hemoptysis, a chest CT was carried out showing a pulmonary subpleural, para-vertebral, air-filled lesion, measuring 1.2 x 7cm (axial x longitudinal diameter). Given the recent traumatic injury, a pneumatocele was suspected secondary to a discrete parenchymal laceration. An adjacent 5cm ground-glass opacity was seen, suggesting an associated alveolar hemorrhage (figure 1). Owing to clinical stability, the patient was not submitted to an emergency bronchoscopy and was admitted for a two-day surveillance. There was a complete symptomatic relief on the discharge day and re-evaluation following one month showed a total filling of the pulmonary parenchymal lesion (figure 2).

Congenital variation of right aortic arch (prevalence 0.05%), aberrant left subclavian artery (posterior to the oesophagus) and 28*26mm diameter Kommerell diverticulum (prevalence 0.4-2.3%), with tracheal deviation and extrinsic esophageal compression. Symptomatic or >55mm diameter Kommerell’s diverticulum should be considered for repair due to their risk of rupture.

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Takayasu’s arteritis (TA) is a rare inflammatory vascular disease, which causes a chronic progressive pan-endarteritis involving the aorta and its main branches, leading to persistent and uncontrolled hypertension and symptoms related to ischemia such as claudication, visual disturbances, stroke and transient ischemic attack. Limited information is available concerning anaesthetic management. We present the successful anaesthetic management of a 55 years old woman with TA scheduled for mitral valve replacement, tricuspid valve annuloplasty and coronary artery bypass grafting (CABG). The choice of anaesthetic technique took into consideration mainly the maintenance of blood pressure in the intraoperative and postoperative periods. According to our monitoring records, we can say that our choice enabled a safe and stable anaesthetic procedure.

Bioprosthetic valve thrombosis is a rare complication. Left atrial dilatation, atrial fibrillation, hypercoagulability and low cardiac output are known risk factors. We report the case of a patient undergoing a bioprosthetic mitral valve replacement who required postoperative circulatory support with extracorporeal membrane oxygenation and presented acute bioprosthetic valve thrombosis. Some aspects regarding pathogenesis, diagnosis and treatment are discussed.

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.

We report a rare case of an advanced stage thymoma with right superior pulmonary lobe, superior vena cava, innominate vein and pericardium invasion in a patient with Good’s syndrome. In a multidisciplinary discussion, surgical resection was deemed the best initial approach, since invaded structures could be safely managed. The tumor was fully resected and included partial resection of the superior pulmonary lobe, superior vena cava and innominate vein. The encircled right phrenic nerve was dissected from the tumor and preserved. The superior vena cava and innominate vein were reconstructed using autologous pericardium patch. Immunoglobulin replacement and radiotherapy were initiated afterwards. No signs of relapse at 6 months follow-up. In such advanced cases, aggressive surgical intervention should be considered as first line of treatment, as long as full resection can be anticipated, since complete resection is the leading factor for long-term prognosis.

Objective: determine whether patient transfer adversely affects the survival of ruptured abdominal aortic aneurysm (rAAA) patients after conventional surgery. Methods: We performed a retrospective review of all patients undergoing attempted repair of an rAAA at a tertiary center, over January 2008 and December 2014. Patients were divided into those presenting directly to our center and those transferred from another hospital. The main outcome variable was 24-hour or 30-day mortality, with secondary variables including time to surgical treatment, length of intensive care unit stay and total length hospitalization. Results: 78 patients (88% men) underwent attempted open repair of an rAAA during this period, 69% (54 cases) were transferred from another institution. Both groups were similar in terms of demographic characteristics, comorbidities and hemodynamic stability. The overall mortality rate was 51% at 30 days. Transferred patients took twice as long as direct patients to get to the operating room (median 7,9 vs. 3,9 horas, p < 0,05), Although the difference for surgery treatment, there was no difference in 24-hour and 30-day mortality between the transferred group and direct group (26% e 50% vs. 29% e 58%, p < 0,05). Mean intensive care unit stay (median, 12 vs. 4 dias, p = 0,04) and total hospitalization (median 11 vs. 4 dias, p = 0,04) were substantially superior in the transferred group. Conclusions: Transfer of patients with RAAA in this series results in a doubling of the time interval between initial patient presentation and arrival in the operating room. This, however, did not result in any disadvantage in the survival rate between the groups. The total length and resources consumption were higher in the transfer group. These results may be attributed to a pre-selection of patients (clinically stable) who are able to tolerate such a delay in surgical treatment, secondary to transfer.

The authors describe a clinical case of correction of a type 1A endoleak after EVAR using endo-anchors. An 85-year old female was referred due to an abdominal aortic aneurysm. The patient´s previous medical history included hypertension, dyslipidemia, renal insufficiency and multiple abdominal surgeries (appendicectomy, classic cholecystectomy and hysterectomy). The aneurysm had 7.5 cm diameter with an angulated short 14 mm neck extension. She underwent an uneventful EVAR with placement of a Medtronic® Endurant II stentgraft. One month after the procedure the abdominal computed tomographic angiography (CTA) revealed a type 1A endoleak. Correction of endoleak consisted of left renal artery stenting (the lowest one), placement of a proximal aortic cuff and 9 endo-anchors (APTUS® System) with satisfactory end result. The control CTA after re-intervention showed patency of the renal arteries and the stentgraft, aneurysm exclusion and absence of endoleaks.

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Background: Surgical repair is the standard treatment for complete atrioventricular septal defect. At our institution, this repair is performed by single patch, modified single patch or two patch techniques, according to the surgeon preferences and the surgical anatomy of the defect. The goal of this study was to evaluate our results from the last twelve years. Methods: From June 2006 to June 2018, 81 children with complete atrioventricular septal defect (without tetralogy of Fallot or unbalanced ventricles) were submitted to surgical repair at our institution. Data from all patients was retrospectively collected and evaluated. Results: The average age was 6.9 ± 13.7 months and 84% had Down syndrome. Eighty percent were symptomatic and 6 patients were previously submitted to pulmonary artery banding. No more that mild left atrioventricular valve insufficiency was found in 84% and 89% of the patients, at discharge and follow-up, respectively. Small residual septal defects were present in 27% at discharge; during follow-up, 41% of these closed spontaneously. Pulmonary hypertension at discharge and follow-up appeared in 3.7% and 1.3%, respectively. Permanente pacemaker was implanted in 3 patients. Left ventricle outflow tract obstruction was found in 3 patients and 2 needed surgical correction. At follow-up (40 ± 38 months), 90% of the patients presented NYHA functional class I. No significant differences in the main repair outcomes were found between techniques, with the exception of small residual septal defects, although the groups were unmatched. Conclusions: Overall and regardless of the technique used for the repair of complete AVSD, good early and midterm outcomes were achieved.