Repositório RCAAP

Objectives: The goal of this study is to establish the relation between aortic bio prosthesis, patient prosthesis mismatch (PPM) and short-term mortality and morbidity as well as and long-term mortality. Methods: This is a single center retrospective study with 812 patients that underwent isolated stented biologic aortic valve replacement between 2007 and 2016. The projected indexed orifice area was calculated using the in vivo previously published values. Outcomes were evaluated with the indexed effective orifice area (iEOA) as a continuous variable and/or nominal variable. Multivariable models were developed including clinically relevant co-variates. Results: In the study population 65.9% (n=535) had no PPM, 32.6% (n=265) had moderate PPM and 1.5% (n=12) severe PPM. PPM was related with diabetes (OR:1.738, CI95:1.333-2.266; p<0.001), heart failure (OR:0.387, CI95:0.155-0.969; p=0.043) and older age (OR:1.494, CI95:1.171-1.907; p=0.001). iEOA was not an independent predictor of in-hospital mortality (OR 1.169, CI 0.039-35.441) or MACCE (OR 2.753, CI 0.287-26.453). Long term survival is significantly inferior with lower iEOA (HR 0.116, CI 0.041-0.332) and any degree of PPM decreases survival when compared with no PPM (Moderate: HR 1.542, CI 1.174-2.025; Severe HR 4.627, CI 2.083-10.276). Conclusions: PPM appears to have no impact on short-term outcomes including mortality and morbidity. At ten years follow-up, moderate or severe PPM significantly reduces the long-term survival.

Objectives: To study the incidence of acute kidney injury (AKI) in the postoperative period of cardiac surgery in patients without preoperative renal insufficiency who underwent cardiac surgery with cardiopulmonary bypass (CPB), and to explore the association between the incidence of AKI and predictors related to CPB. Methods: Observational, cross-sectional study. Participants were divided in two groups, those who developed AKI in the postoperative period and those who did not develop AKI. Kidney Disease: Improving Global Outcomes - Clinical Practice Guideline for Acute Kidney Injury (KDIGO) classification was used to characterize AKI. The analysis included preoperative variables (anthropometric data, cardiovascular risk factors and blood parameters), as well as the type of surgery, intraoperative variables related to CPB, and postoperative creatinine variation. Association between variables was studied with binary logistic regression. Results: We have included 329 patients, of which 62 (19%), developed AKI. There were statistically significant differences between the groups in age (p<0.001; OR (95%)-1.075 (1.037-1.114)), duration of CPB (p=0.011; 1.008 (1.002-1.014)), urine output during CPB (p=0.038; 0.998 (0.996-0.999)), mannitol and furosemide administration during CPB, (respectively, p=0.032; 2.293 (1.075-4.890) and p=0.013; 2.535 (1.214-5.296)). Conclusions: A significant number of patients developed AKI in the postoperative period of cardiac surgery and this incidence was influenced by factors related to CPB, namely: age, duration of CPB, urine output during CPB, mannitol and furosemide administration during CPB.

Introduction: Colorectal cancer is the third most common malignancy, being associated with metastatic disease in 50% of cases. The lung is the second organ most affected by metastasis in colorectal cancer. In this study, we aim to review the cases submitted to resection of pulmonary colorectal metastasis at Hospital Pulido Valente, comprised in the period from the 1st of January to the 31st of December 2017. Methods: Retrospective analysis. Data were collected from clinical records. Results: There were 21 patients operated during this period, with a total of 22 surgeries performed, all with curative intent. Data were collected regarding age, gender, site of primary tumour, number of resected lesions, surgical approach, performed procedure, disease-free interval, presence of bilateral disease and existence of extra-pulmonary metastasis. Conclusion: Lung metastases are frequent in colorectal cancer. Pulmonary metastasectomy is currently accepted as a potentially curative therapy as part of a multimodal approach to metastatic colorectal cancer.

A high percentage of patients presenting for lung surgery are either current or former smokers, which is typically associated with many anatomical and physiological pulmonary changes. The influence of tobacco on postoperative pulmonary complications remains controversial. The main goal of this study was to analyse the effects of smoking on the risk of post-operative complications and morbidity in patients submitted to lung resection surgery through uniportal VATS. Peri-operative data on all cases of anatomical lung resection surgery through single-port VATS performed between December 2013 and July 2018 at three Portuguese institutions were collected and retrospectively reviewed Demographic data, diagnosis, pre-operative lung function tests, in-hospital length of stay (LOS) and intra and post-operative drainage levels were registered. Patients were divided in two groups according to tobacco exposure. Post-operative complications and morbidity were compared through statistical analysis. We performed 313 procedures, 303 of which were evaluated in regard to outcome. Mean age at time of surgery was of 62,85 years (SD=12,24). One hundred and sixty patients (52,81%) had a history of tobacco use, while 47,19% (n=143) had never smoked. Non-smokers had significantly better lung function than smokers (p<0,05). Smoking history showed a contribution to post-operative prolonged air leaks (p=0,025) morbidity (p=0,05), 2-day longer LOS (μ=5,36 days vs. μ =7,53 days; p<0,05), longer operative times and higher intra and post-operative drainage levels. A history of smoking during a patient’s life negatively impacts morbidity in patients submitted to uniportal VATS for anatomical lung resection, increasing early post-operative complications and prolonging in-hospital stays.

Introduction: Hostile anatomic characteristics in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) may lead to technical non-success, late complications, reintervention or death. Objective: To analyze specific anatomical features of abdominal aortic aneurysms and to study the association with postoperative endoleak and survival. Methods: Retrospective review of all consecutive elective EVARs between 2010 and 2016, with available data, at one institution, for infra-renal aortic aneurysms. Patients comorbidities and preoperative computed tomography scans were analyzed considering characteristics of the proximal and distal landing zones, the aortic aneurysm and eventual concomitant iliac aneurysm or peripheral occlusive disease. Outcomes were endoleak development and survival. Results: We analyzed 56 patients, 54 (96%) male with a mean age of 78 (min 61, max 89) years. During a mean of 3.4 years of follow up, 12 (21%) patients developed endoleak (10 type II and 2 type I) and 18 (32%) died. The adjusted analysis showed a significant association between aneurysm angulation (p=0.044), patency of the inferior mesenteric artery and the lumbar arteries (p=0.044) and aneurysm diameter (p=0.009) with endoleak development. All except one endoleak were diagnosed within the first year after EVAR. None of the deaths that occurred during the follow up period were correlated to post intervention aneurysm enlargement or rupture. Conclusion: Unfavorable aneurysm morphologic characteristics for EVAR may predict complicated endograft placement or higher incidence of post intervention endoleak, which should be taken into consideration. For such clinical cases, complementary endovascular procedures or a surgical approach should be considered.

Background: Type B aortic dissection (TBAD) is associated with high morbidity and mortality. The DISSECT classification aims to reunite clinical and anatomical characteristics of interest to clinicians involved in its management. This paper aims to characterize a cohort of patients admitted for type B aortic dissection in a tertiary institution. Methods: This is a retrospective study that included all patients admitted to the hospital due to TBAD from 2006 to 2016. The computerized tomographic angiography that enabled the TBAD diagnosis were reevaluated using DISSECT classification. Results: Thirty-two patients were included in this case series. As to DISSECT classification, 79.3% were acute (Duration), 66% had a primary Intimal tear location in aortic arch, the maximum aortic diameter was 44±13mm (Size), 60% extended from aortic arch to abdomen or iliac arteries (Segmental Extent), 28% presented with Complications, and 28% had partial Thrombosis of false lumen. Six patients underwent intervention during the follow-up period. At 12 months, overall survival was 75.4%±8.3% and survival free of aorta-related mortality was 87.0±6.1%. Survival free of aortic dilatation was 82.6±9.5%. In univariate analysis, the presence of complications and chronic kidney disease associated with increased overall and aorta-related mortality rates. Hypertension was associated with aortic dilatation. Conclusions: The outcomes after TBAD in a Portuguese center are reported. All interventions in TBAD were performed due to complications. The presence of complications and chronic kidney disease was associated with overall mortality and aorta-related mortality and hypertension with aortic dilatation. DISSECT classification was possible to apply in all patients.

Persistant left superior vena cava is a rare systemic venous anomaly that can be associated with agenesis of the right superior vena cava. It is usually assymptomatic and discovered incidentally during surgery or other procedures. The authors present the case of a 72-year-old male submitted to an aortic valve replacement surgery. After sternotomy, persistant left superior vena cava and absence of the right superior vena cava were identified. The patient developed complete atrioventricular block after surgery, requiring the implantation of a definitive cardiac pacemaker through the brachiocephalic vein and coronary sinus. This case highlights and ilustrates the clinical implications of the described systemic venous anomalies, discussing the necessary management both in the perioperative and intraoperative periods.

Introduction: Mechanical prosthetic valve thrombosis (PVT) and obstruction is a lifethreatening event. The significant morbidity and mortality associated with this condition warrants rapid diagnostic evaluation and treatment. Case report: A 66-year-old female patient with a history of aortic valve replacement 13 years before, was admitted to our intensive cardiac care unit with symptoms and signs of prosthetic aortic valve dysfunction. During cardiac angiography, she collapsed and fluoroscopy showed an immobile disc, stopped in an open position and causing free aortic regurgitation. Cardio-pulmonary resuscitation (CPR) was initiated and a VA-ECMO was inserted as a bridge to emergent cardiac surgery. Surgery was then performed and the patient was successfully discharged with no neurological impairment. Discussion: We present a case where Veno-Arterial Extracorporeal Membrane Oxygenation (VA- ECMO) was successfully used as a bridge to emergent surgery in a cardiac arrest patient due to prosthetic valve thrombosis. Conclusions: This case illustrates how a relative contraindication (severe aortic insufficiency) to VA-ECMO may, in the end, be an indication in a very particular scenario.

We report the case of a 44 year-old patient with complex ACHD, admitted with acute decompensated heart failure (ADHF) in hemodynamic profile B. He had a single ventricle with pulmonary atresia, previously submitted to three modified Blalock-Taussig shunts (mBTs) at the age of 2, 12 and 19 years old. Despite conventional treatment with diuretics, β-blockers (BB) and isosorbide dinitrate the patient progressed to profile C and the transthoracic echocardiogram disclosed a reduced systolic function. Likewise, levosimendan was commenced and an appropriate decongestion and a marked reduction in the NT-proBNP were seen. Treatment with angiotensin-converting-enzyme inhibitor, BB, ivabradine and mineralocorticoid receptor was optimized. The patient was discharged home after 26 days in NYHA class III and referred for heart transplant after right heart catheterization. To our knowledge, this is the first report of successful levosimendan’s use in ADHF in a mBTs long- -term survivor.

Mucormycosis is a life-threatening fungal infection that occurs mainly in immunocompromised patients. Its occurrence isolated in the lung rare and carries a high mortality risk if untreated. We report the case of a 76-year old male immunocompetent patient, under treatment for pulmonary tuberculosis, admitted to the emergency department with hemoptysis. Bronchoscopy was performed and active bleeding from the middle lobe bronchus was found. Chest CT scan identified a solitary cavitary lesion in the middle lobe. The patient was proposed for urgent open middle lobectomy. Postoperative period was uneventful. Pulmonary mucormycosis was confirmed and adjuvant therapy with Amphotericin B was performed for 30 days. Despite its rarity, mucormycosis prevalence is expected to raise together with increasing number of immunocompromised patients. A high level of suspicion is recommended as early diagnosis can be determinant.

Ephitelioid Hemangioendothelioma (EHE) is a rare type of tumor with vascular and sarcomatous components. There's only another case published of an internal jugular vein (IJV) EHE. A case of a 50 years-old woman with a palpable and pulsatile mass on the left cervical area is reported. Doppler ultrasound and magnetic resonance imaging showed an IVJ' 4 cm mass. Cytology was inconclusive. Surgical treatment was therefore decided and during surgery a mass inside the left IJV, with local nonsuspicious lymph nodes, was confirmed. The mass was resected including a segmental resection of the IJV and one affected tributary vessel. Lymphadenectomy of the adjacent cervical levels was performed. Histologic examination depicted an EHE without metastatic lymph nodes. Tumor was staged as pT1bN0M0 and a multidisciplinary sarcoma group proposed surveillance. Patient remained well, without evidence of disease and without complications in a twenty-four months follow-up period.

Pulmonary sequestration (PS) is a rare congenital malformation, even more when its arterial supply is a coronary artery. We present a case of a 68-year-old man admitted in the emergency room with an acute coronary syndrome and no evidence of significant coronary disease. Instead, he had an abnormal branch from the circumflex coronary artery nourishing a mass in the left lower pulmonary lobe. A coronary steal phenomenon was proposed to explain the clinical presentation. An anterior left thoracotomy with ligation of the abnormal branch and atypical resection of the lung segment comprising the sequestration was performed.

A 63-years-old female developed shock after cardiac myxoma excision. Echocardiography identified inferior vena cava (IVC) stenosis and re-intervention with atrial and septal patch augmentation was attempted. The patient maintained hemodynamic instability as well as high IVC gradient and intraluminal thrombus. IVC percutaneous stenting was achieved and enabled full hemodynamic recovery.

A 72 year-old men admitted for a two week old myocardial infarction had a septal intra-myocardial cavity at first echocardiographic evaluation (A,B). Cardiac magnetic resonance showed extensive no-reflow on the septum (C). Owing to clinical stability, a conservative strategy was decided. Without a complete VSD (D), fibrosis filled the gap in two weeks (E), followed by a septal remodelling scar (F).

We present the case of a 56-year-old man involved in a motorcycle accident. The thoraco-abdominal examinations revealed multiple rib fractures, pneumohemothorax; left diaphragmatic hernia containing the stomach and colon and splenic lacerations. These lesions were addressed surgically by repositioning the stomach, placing a left thoracic drain and suturing the diaphragm.

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