Repositório RCAAP

Introduction: The association between aortic valve disease and dilatation of the ascending aorta is well known and concomitant surgery is recommended when the aortic diameter is higher than 45mm. The use of the rapid deployment valves allows less cross-clamping and cardiopulmonary bypass times for both isolated and combined procedures in comparison to regular valves. We describe our initial experience of concomitant aortic valve and the ascending aortic replacement, using the rapid deployment valve Edward Intuity EliteTM. Case presentation: All patients were male, with a mean age of 72-years-old. The mean cross-clamping time was 48 minutes, with a mean cardiopulmonary time of 61 minutes. The mean time of ICU stay was 4 days. All the patients had follow-up 1 and 3 months after discharge and were doing well. Conclusions: The rapid deployment aortic valves have recognized advantages in aortic valve replacement. Our small experience reinforces that replacement the ascending aortic and aortic valve with this prothesis is one procedure that can benefits from generalization without increased risks and with potentially better clinical outcomes. Larger cohort studies would allow clarification over this subject.

Background: Patients under dialysis have a high cardiovascular risk and they are at increased risk when submitted to cardiac surgery. Aim of the study: to evaluate morbidity, early and late mortality, and predictive factors of mortality in patients under dialysis who underwent cardiac surgery. Methods: A retrospective observational study was performed including all dialysis dependent patients who underwent cardiac surgery (coronary, valvular or combined procedures) in our institution between 2007 and 2014. A population of 95 consecutive patients was obtained (no exclusions). Perioperative variables and predictors of mortality were analysed and the endpoints were early and late mortality. Propensity score matching, with a control group of patients with creatinine clearance >90mL/min, was performed by logistic regression, with a 1:1 matching. Kaplan Meier curves were performed for late mortality. Results: Early mortality was 9.4% (EuroSCORE II 4.1%). In univariate analysis, mean time of cardiopulmonary bypass (CPB) (p=0.016) and EuroSCORE II (p=0.02) were related with early mortality. In a multivariate analysis model, combined procedures (OR 138.09; CI95% 1.82-10498.4; p=0.03) and CCS (Canadian Cardiovascular Society) 3-4 (OR 70.951; CI 95% 1.32-3810.11; p=0.037) were predictors of mortality. In multivariable analysis, CPB time >152 min was a predictor of early mortality (p=0.001). After propensity score matching, 30 day, one year and late mortality were higher in the dialysis group. Conclusions: Early and late mortality were significantly higher in dialysis dependent patients. Predictive factors of mortality were CPB time and EuroSCORE II in univariable analysis, and CCS 3-4 and combined procedures in multivariable analysis.

Objective: To observe the impact of the use of capnography system adapted to cardiopulmonary bypass (CPB). To measure the concordance between values obtained from continuous monitoring of partial pressure of carbon dioxide in membrane oxygenator exhaustion (PeCO2) and the results observed on arterial blood gas test. Methods: Participated in this study 40 patients submitted to elective cardiovascular surgery with CPB. They were divided into two groups: Group 1, with 20 patients submitted to the surgical procedure using blood gas analysis at intermittent intervals (20 - 30 minutes); Group 2, with 20 patients operated with a capnography system adapted applied to membrane oxygenator exhaustion and blood gas test. A test was used to compare arterial partial pressure of carbon dioxide (PaCO2) from group 1 and group 2. In group 2, the strength of the correlation between PeCO2 and PaCO2 was evaluated by a linear regression test. The Bland-Altman method was used to determine the degree of agreement between the two variables. Results: Average and standard deviation of Group 1’s PaCO2 (34.6 ± 7.44) and Group 2’s PaCO2 / PeCO2 (36.5 ± 4.42) / (39.9 ± 3.98). There was no statistically significant difference in PaCO2 between the groups (P = 0.21). In group 2, PeCO2 and PaCO2 analyzed corrected for esophageal temperature obtained a positive linear correlation (r = 0.79, P <0.001), the degree of agreement presented an average 3.47 ± 2.70 mmHg. Conclusion: The continuous PeCO2 monitoring from cardiopulmonary bypass circuit has a positive impact on the result of PaCO2. This instrument confirms and maintains the carbon dioxide (CO2) values into reference parameters.

Introdução: Os aneurismas verdadeiros do membro superior são raros e o seu tratamento visa a prevenção de complicações como a embolização distal, a compressão de estruturas neurovasculares adjacentes ou a rotura. Objetivo: O objetivo deste estudo é rever a casuística de um serviço no tratamento cirúrgico de aneurismas verdadeiros do membro superior. Métodos: Foi realizado um estudo retrospetivo entre Janeiro de 2007 e Agosto de 2017. Resultados: De um total de onze doentes, nove eram do sexo masculino e dois do sexo feminino. Um dos doentes foi submetido a duas cirurgias por aneurismas consecutivos do membro superior. De um total de doze casos, dois tinham localização na artéria subclávia, um na axilar e nove na braquial. Três aneurismas eram de etiologia degenerativa/idiopática, um estava associado à presença de costela cervical e sete ocorreram no contexto de fístula arteriovenosa para hemodiálise e/ ou transplante renal. Cinco doentes foram submetidos a cirurgia em contexto de urgência e os restantes em contexto eletivo. Todos os pacientes foram submetidos a aneurismectomia. A morbilidade aos 30 dias correspondeu a dois hematomas, um síndrome do compartimento e duas oclusões precoces com um total de quatro pacientes a necessitarem de reintervenção. Durante o período de follow-up todos os doentes com o enxerto inicialmente preservado apresentaram permeabilidade dos enxertos. Não houve necessidade de cirurgia mutiladora. Conclusão: Neste estudo, a maioria dos aneurismas do membro superior ocorreram em doentes com fistulas arteriovenosas para hemodiálise e/ou transplantados renais. Apesar da necessidade de reintervenção em alguns casos, o tratamento cirúrgico dos aneurismas do membro superior acarreta uma baixa morbilidade.

Neointimal hyperplasia is a physiologic healing response to injury to the blood vessel wall, involving all the three arterial layers and it occurs in the presence of internal (endovascular) or external (surgical) injury. It is a highly complex process involving several tissues (perivascular, vessel wall, and blood) and numerous cell lineages with multiple molecular signaling networks. So, there is a number of possible targets for inhibition of this process. There are known risk factors for Intimal Hyperplasia, such as diabetes, female gender, presence of systemic inflammation, type of arteries treated, types of surgical and endovascular materials, presence of turbulent flow and genetic status. The present paper discusses the pathophysiology of neointimal hyperplasia and the strategies to prevention and treatment of it.

Lung herniation is an uncommon entity which was fully classified in 1845 after the study of several case reports. Acquired lung hernia, especially traumatic, is the most common etiology. In the absence of clear guidelines, management of lung hernia is made in a case-by-case basis. We present an asymptomatic middle lobe hernia perceptible on physical examination, but diagnosed initially by imaging studies. Patient medical history included a blunt bull trauma fourteen years before.

Cold agglutinins (CA) are autoantibodies whose clinical significance depends upon titer and thermal amplitude. Patients, which undergo cardio-pulmonary bypass and especially hypothermic cardioplegia myocardial protection, represent a challenge regarding operative management, as tissue temperature should be maintained above the threshold of agglutination. We report on a case in which the presence of CA was discovered during elective aortic valve replacement surgery, and managed with normothermic cardiopulmonary bypass and continuous retrograde warm blood cardioplegia administration.

Alkaptonuria is a rare genetic disorder related to tyrosine metabolism. The cardiovascular manifestations are rare being the aortic stenosis the most commonly reported. We present a case of 72-year-old women who underwent aortic valve replacement with intraoperative findings in the aortic valve and the aortic wall suggestive of Cardiac Ochronosis. Once it is a rare disease there are issues related to the natural history of the disorder that still unknown, namely the type of aortic prothesis in use. For this reason, we find essential the documentation and follow-up of all these rare cases.

Creating and maintaining a functional vascular access (VA) is a critical factor in the survival of a dialysis patient. It implies a creative attitude either to maintain its functionality or to build a new one wherever possible, being it autologous or synthetic. We describe the VA history of a 59 years-old male patient, with extreme obesity, which started in 2012 with failed attempts of VA construction in both forearms until a functional brachiocephalic arteriovenous fistula (AVF) in the right upper limb was achieved. However, it required ligation due to severe venous hypertension secondary to central venous disease related to previous CVC use. As he had no good superficial conduit in the left arm we decided to harvest the arterialized right cephalic vein and implant it in the left arm, creating an autologous arteriovenous shunt between the brachial artery and axillary vein (AV). Despite initial patency, it failed irreversibly approximately one year after creation. As no more superficial veins were available in the upper limbs, a prosthetic access was the next step. We decided for a hybrid graft (HG) between the left brachial artery and the AV because of the patient’s biotype and scarred axilla that impeded a safe re-intervention on the AV. This graft was used between 2015 and 2017 with multiple interventions to maintain patency. In 2017 a significant diffuse prosthesis deterioration and reduced AVF flow were noticed with no possible segmental reconstruction. We were then forced to proceed with subtotal graft substitution preserving the outflow stented segment of the HG, using an early cannulation graft to prevent CVC use. After this successful reconstruction, the patient started hemodialysis on the following day with no intercurrences registered.

Synovial hemangioma is a rare nonneoplastic vascular malformation of the synovial membrane described by Bouchut in 1856. Fewer than 200 cases have been described in the literature, corresponding to 1% of all hemangiomas. The presenting symptoms are often non-specific, which often leads to a delay in diagnosis of many years and can result in arthropathy if left undetected. The early diagnosis of a synovial haemangioma is important as recurrent haemarthrosis may lead to irreversible joint damage and chronic inflammatory synovitis. In practice, there is no consensus on the best treatment of synovial hemangiomas in children. Total resection of the tumor can be performed by arthroscopy in localized forms and for small lesions. Open resection associated with synovectomy is necessary when the hemangioma occupies most of synovial membrane.

A 77-year-old female Caucasian patient with known Takayasu’s arteritis diagnosed at 20 years of age was admitted to the emergency department due to diffuse sudden-onset abdominal pain. On physical examination, femoral pulses were feeble. Laboratory results were unremarkable. Abdominal CT angiography showed a long abdominal predominantly infra-renal aortic stenosis (Figures 1 and 2).

A 28 year old woman presented a painless pre-sternal mass since childhood. At 25 years old, after pregnancy, the mass turned painful and started growing. A percutaneous biopsy diagnosed osteochondroma (Figure 1). Figure 1 Figure 2 A B She underwent partial sternectomy (Figure 2 a) and closure of the sternal defect with a Marlex mesh (Figure 2 b). Histology revealed grade 1 chondrossarcoma with free surgical margins. After 8 months she is free from recurrence.

In the 1930-50s, before antimicrobial drugs, collapse therapy was the mainstream of treatment for cavitary pulmonary tuberculosis. We present an 78-year-old man with a history of pulmonary tuberculosis treated with plombage in 1962, who presented with axillary pleurocutaneous fistula (Figure 1). The patient was submitted to surgical extraction of 21 lucite balls, pleurocutaneous drainage and thoracoplasty (Figure 2).

Homem de 69 anos, hipertenso, fumador e com cardiomiopatia desenvolveu quadro de dor abdominal, retorragias e perda ponderal (10 kg), acompanhado de parestesias nos pés. Por doença arterial periférica grau III de Leriche-Fontaine e isquemia mesentérica crónica (Fig. 1) foi submetido a bypass aorto-bifemoral com extensão à artéria mesentérica superior (Fig. 2). Aos 4 anos de seguimento apresenta-se assintomático, com recuperação ponderal e bypass funcionante.

65 year-old man, admitted in ICU post cardiac surgery. Pleural drains removed in postoperative. Chest radiography showed bilateral pneumothorax, apparently extensive, needing drainage, with no clinical correlation. Exam repeated in better technical conditions eliminating skin folds: it confirms small pneumothorax with no need of pleural drainage, avoiding an invasive technique.

.

.

.

.

Background: In selected cases, aortic valve repair (RVAo) is an alternative to prostesic aortic valve replacement. Aim: To compare mid-term survival, need of reoperation and echocardiographic findings associated with RVAo. Methods: Retrospective single-center cohort study including consecutive patients younger than 70 years-old, with non-stenotic aortic valve disease, who underwent RVAo between 2012 and 2017. A comparison was made with a group of patients who underwent mechanical aortic valve replacement (SVAo) in the same period. The groups were characterized and compared using Chi-Square and t-tests for independent samples and survival and reoperation were analyzed using Kaplan-Meier curves and Cox regressions. Results: We included 72 patients submitted to RVAo. Mean follow-up time was 4 years, maximum 7. Although the mean age was relatively low (47±13 years), patients undergoing RVAo presented a lower prevalence of rheumatic etiology (3%). The cardiopulmonary bypass (148±74 minutes) and cross clamping aortic times (108±52 minutes) are the usual times for this type of surgery and similar to those of the comparing group (SVAo). In the echocardiographic follow-up (median of 3 months), we verified a left ventricular mass regression of 21% and a prevalence of aortic insufficiency of 4%. At 7 years, cumulative survival and freedom from reoperation of patients undergoing RVAo were 98.8% and 97.6%, respectively. Conclusion: RVAo can be a safe and effective alternative, with good mid-term results if patient selection is judicious.