Repositório RCAAP

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Aortic mural thrombus is a rare clinical finding in the absence of aneurysm or atherosclerosis but an important source of noncardiogenic emboli with a difficult diagnosis and a high rate of complications, including high mortality. It appears to occur more frequently in young adults usually with underlying pro-thrombotic disorder. With the increasing use of high resolution imaging, the asymptomatic mural thrombus became an increasingly frequent finding, but its potential for embolization or the best treatment are still a matter of debate. The management of mural thrombus in non-atherosclerotic aorta represents a challenge because no guidelines are available, and should be individualized. The therapeutic approach should include the triple aspects of aortic mural thrombus: primary disease anticoagulation treatment, surgical thrombectomy to solve embolic complications and endovascular/classical surgery to exclude the thrombus from the aorta. Historically therapeutic anticoagulation was proposed as first-line therapy and surgical intervention was reserved for mobile thrombus, recurrent embolism and contraindication for anticoagulation. However, it is associated with a 25-50% embolic recurrence rate, thrombus persistence in 35% and secondary aortic surgery in up to 31% of the cases. Recent data suggest that endovascular coverage of the aortic thrombus, when feasible, appears to be an effective and safe procedure with a low recurrence and re-embolization rates. In this article we review the published literature concerning this topic.

The concomitant presentation of lung cancer and severe heart disease requiring intervention is a scenario that many clinicians have to face. Its common physiopathological substratum is unknown and it is believed that tobacco plays a role. From a surgical point of view, these patients pose various technical challenges and medical literature is scarce in providing solid answers. The aim of this report is to review our experience with cases undergoing combined surgical treatment of both heart disease and lung cancer, aiming to analyse patients’ characteristics, operative technical considerations and related outcomes. A total of five patients were included, with two synchronous procedures, two cases with lung surgery being performed first and one case commenced with cardiac surgery. All cancers were non-small-cell lung carcinoma or carcinoid tumors and cardiac disease was mostly represented by severe aortic stenosis. Lobectomy was performed in two thirds of patients and minimally invasive techniques were used in 60% of the procedures. All valvular patients received a bioprosthesis. There was one immediate complication, with good recovery on follow-up, and there were no late events (median follow-up of 1,8 ±1,1 months). The analysis of these cases highlights the complex nature of these challenging patients and reinforces the importance of devoting efforts to offer the most suitable solutions for each scenario.

Backgroud: Primary focal hyperhidrosis affects between 1 to 4% of the general population, with a higher prevalence in teenagers and young adults. The condition is characterized by excessive sweating in 1 or more body part, most often the palms, face, armpits and soles. This condition causes a significant negative impact on patient’s quality of life. The pathophysiology of focal hyperhidrosis is believed to be due to excessive sympathetic stimulation, and videothoracoscopic sympathectomy is a recognized form of treatment. The aim of this study is to evaluate the post-operative quality of life of patients who underwent thoracoscopic sympathectomy. Materials and Methods: This is a retrospective study of fifty-four patients with primary focal hyperhidrosis submitted to bilateral thoracoscopic thoracic sympathectomy at the Center of Cardiothoracic Surgery of Casa de Saúde da Boavista, between January 2011 and December 2014. The Quality of Life questionnaire and the Hyperhidrosis Severity Scale questionnaire were used to evaluate the quality of life in the pre-operative period and 3 months after surgery. Further to this, data was collected regarding medium-term follow-up by telephone. All patients underwent general anesthesia and had bilateral video-assisted thoracoscopic resection of the sympathetic chain. Results: The majority of patients are females 59.3% (32). The mean age is 30.8 ± 7.70 (between 16 and 49 years). Prior to surgery, 85% of the patients had severe hyperhidrosis. 79.6% of respondents stated that general discomfort was promoted by the condition, with the Funcional-Social domain being the most affected aspect of their life (61.1%). The rates of peri-operative complications and major post-operative complications were null, and minor complications were 5.5%. After 3 months, improvement in patient’s quality of life and satisfaction level were of 100% and 96.3% respectively, however compensatory hyperhidrosis was observed in 53.7% of patients. 57.3% of the patients reported significant improvements in the Funcional-Social domain. Medium-term follow-up (mean=6 years) allowed for the evaluation of 31 patients (57.4% of the population), of whom 77.4% maintained compensatory hyperhidrosis. 93.5% reported to be highly satisfied with the surgical results and claimed to have improved their quality of life by 93.5%. 94% and 94.4% respectively of the patients evaluated in the medium term follow-up and after 3 months and in the medium term follow-up, recommend the surgery. Conclusion: Sympathectomy by video-assisted thoracoscopic surgery (VATS) is an effective and viable therapeutic option for primary focal hyperhidrosis patients. Despite compensatory hyperhidrosis being observed at time, this procedure produces very satisfactory results particularly in regard to the patient’s post-operative quality of life.

Introduction: A right aortic arch and agenesis of internal carotid artery (ICA) are both extremely rare vascular devel- opment anomalies. Etiology of the both anomalies might be associated with the abnormal regression of the dorsal aorta. Most cases of ICA are asymptomatic due to sufficient collateral circulation and it is usually an incident finding on head and neck imaging by color Doppler ultrasonography, computed tomography (CT) or magnetic resonance imaging (MRI). ICA agenesis has a significant association – 24-67% – with intracranial aneurysms and their early detection can spare the patient serious complications. Clinical case: A 28-year-old male had a single episode of hypertension that motivated the realization of several tests. During the investigation he was submitted to a duplex ultrasonography that revealed a diffuse narrowing of the left common carotid artery (CCA), with a markedly decrease in the peak systolic velocity and the absence of the left internal carotid artery (ICA) was suspected. Contrast-enhanced computed tomography (CT) demonstrated no abnormalities, such as cerebral infarc- tion or intracranial vascular malformations, but confirmed a right-sided aortic-arch, with anomalous origin of the left subcla- vian artery with a common origin of both CCAs and the absence of the left ICA. Examination of the head CT in bone window demonstrated an absence of the left internal carotid canal. Conclusion: This clinical case emphasizes the importance of recognizing this condition due to the associated hemody- namic changes and in order to discover and evaluate other additional vascular malformations (aneurysms, collateral channels) and their life threatening potential risks (subarachnoid hemorrhage or ischemia). Also, it has a special importance in case of planning carotid or trans-sphenoidal hypophyseal surgery. To our knowledge, only 8 cases have been reported right aortic arch associated with agenesis of the left internal carotid artery.

Objective: The preoperative factors determining the selection of anesthetic technique in patients submitted to TAVI were identified. The results of this procedure in our hospital were evaluated. Methods: Retrospective study in patients submitted to TAVI in Santa Marta Hospital (January 2010 to December 2016). Data collected from periprocedural records and stratified according to the anesthetic technique. Periprocedural complications were defined according to The Valve Academic Research Consortium 2. The preoperative factors determining the selection of anesthetic technique were identified through Chi-square test (categorical variables) and Student's t tests (continuous variables), followed by logistic regression. Results: Bad vascular access identified by TC was a preoperative determinant for general anesthesia selection. Arterial hypertension and previous acute myocardial infarction were determinants for selection of local anesthesia with sedation. From a total of 149 patients, 105 (70,5%) developed some postprocedural complication; the most common were arrhythmias (n=53; 35,6%), major bleeding (n=50; 33,6%) and vascular complications (n=36; 24,2%). Conclusion: There is no consensus regarding the best anesthetic technique to be performed in patients submitted to TAVI. It is the anesthesiologist decision which most appropriate anesthetic technique to select, considering technical aspects and objective evaluation of the patient. Local anesthesia with sedation showed some advantages: shorter duration of procedure and fewer patients requiring vasopressor drugs administration. TAVI is a highly complex procedure and a multidisciplinary approach is fundamental to its success.

Videobronchofibroscopy of a Chinese 74-year-old woman showing abundant whitish plaques in the vocal cords with antraconic lesions extending throughout the tracheal pathway and bronchial trees, predominantly in the upper left lobe, compatible with Endobronchial My- cobacterium tuberculosis. The evolution and prognosis varies, from complete resolution to severe endobronchial stenosis.

Introduction: Extracorporeal membrane oxygenation (ECMO) has evolved as a life-saving measure for patients requiring emergent support of respiratory and cardiac function. The femoral artery is the standard site for vascular access when initiating adult venoarterial (VA) ECMO. Cannulation-related complications are a known source of morbidity and it has been speculated that patients undergoing ECMO via femoral arterial cannulation are more likely to develop peripheral vascular complications (up to 70%). Methods: Retrospective institutional review of patients requiring ECMO (January 2011-August 2017). The primary outcome of this study was to investigate the prevalence of cannulation-related complications on VA ECMO and to determine its effect on patient morbimortality. Results: Eighty-two patients underwent ECMO during the period of study, 56,1% were male with a mean age of 55,8 years. The VA mode was used in 61 patients, 56 with peripheral cannulation. Femoral arterial access was established in 52 patients (73% percutaneously). Vascular complications were observed in 28,6% of the VA femoral ECMOs: 12 acute limb ischemias and 3 major hemorrhages. At the time of femoral cannulation, distal peripheral catheter (DPC) was placed in 5 patients and none developed limb ischemia. For those who developed limb ischemia, several interventions were performed: DPC placement in 9 cases, fasciotomy in 4 and 2 major amputations. Thirty patients underwent arterial cannulas open surgical removal: 8 underwent balloon catheter trombectomy and 5 needed femoral reconstruction. There was an association between PAD (p=0,03) and ischemic cardiopathy (p=0,02;OR 4,5) with the present of vascular complications after ECMO implantation. Conclusions: Cannulation of femoral vessels remains associated with considerable rates of vascular events (28.6%). PAD and ischemic cardiopathy are associated with vascular complications in this form of cannulation.

Introduction: Transcatheter aortic valve implantation has emerged as an effective alternative to the traditional method of surgical aortic valve replacement in high risk or inoperable patients. Infective endocarditis after transcatheter aortic valve implantation is a post-operative complication with a high rate of mortality, and thus far, very few cases of successful surgery have been reported. Case presentation: The authors report the case of a patient that underwent transcatheter aortic valve implantation and developed an infective endocarditis following the procedure. Corrective surgery for transcatheter aortic valve’s removal and aortic valve replacement was successfully performed. Conclusions: Given the increasing use of transcatheter aortic valve implantation, endocarditis will become increasingly relevant in the near future. As in conventional aortic prosthesis, for some cases, medical therapy alone is not enough. Under optimal conditions, surgery is a safe option and should be considered and discussed in a Heart Team, patient by patient.

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.

Background: Bartonella quintana is a facultative intracellular bacterium and the causative agent of trench fever. The disease was reported during the World Wars in pre-antibiotic era and is associated with louse infestation and poor hygiene conditions. Bartonella bacteraemia may result in endocarditis mostly in people with existing heart valve abnormalities. Case Report: We report a case of endocarditis caused by B. quintana in a 77-year-old woman with previous valvulopathy. This active endocarditis case was characterized by aortic root involvement 5 years after surgical aortic valve replacement. Although the initial serological tests had induced to a presumptive diagnosis of Q fever, B. quintana infection was confirmed by PCR and sequencing. Detection of Bartonella DNA in valvular and abscess specimens was determinant to confirm Bartonella infection in the absence of other associated risk factors. Conclusions: Bartonella infection should be considered in patients with pre-existing valvular disease and with a blood culture-negative endocarditis.

We present a 36 year-old female patient with a popliteo-femoral deep vein thrombosis whose further workup revealed a thigh tumor later diagnosed as hibernoma. Hibernoma is a very rare benign tumor stemming from vestigial remnants of fetal brown adipose cells, usually disclosed as a slow and painless growing, mass. It is impossible to distinguish it on clinical grounds from the more aggressive and ominous liposarcoma.

Renal artery aneurysm (RAA) is a rare entity with an estimated prevalence of 0.09%. The majority present asymptomatically and the diagnosis is made incidentally during an imaging test. Indications to treat have been subject of intense debate, nevertheless, there seems to be some consensus that RAA’s greater than 2 cm in diameter, expanding, with thrombus or in pregnant women should be treated. Treatment options vary between surgical or endovascular approach. Hilar RAA presents a therapeutic challenge because of their anatomic location and may require extracorporeal arterial reconstruction and auto-transplantation. We describe a 71-year-old woman, with an incidentally diagnosed complex RAA, following the study for an abdominal discomfort. Computed tomographic angiography revealed a 13mm, saccular aneurysm located at the right renal hilum. We performed hand-assisted laparoscopic nephrectomy with ex-vivo repair of the RAA. The intervention and postoperative course were uneventful. At six months of follow up the patient keeps a well-functioning auto-transplant. RAA may be nowadays more frequently diagnosed due to the increasing use of imaging techniques. Hand- -assisted laparoscopic nephrectomy with ex-vivo repair and auto-transplantation is a challenging but feasible option for treating hilar RAA.

Abdominal aortic aneurysm affects 5-9% of the population over the age of 65 years; is more common in male smokers and in patients with a positive family history of aortic aneurysms. Most patients are asymptomatic; rupture is the most common and dreaded complication. The classical triad of back pain, hypotension and pulsatile mass is the most common presentation but is present in only 25–50% of patients. Clinical presentation seems dependent on rupture site. Our report illustrate a rare clinical presentation for a serious clinical condition. Knowledge of different presentations can lead to timely diagnosis and management and decrease in rupture related morbidity and mortality.

A 68-year-old female presents with AV block after mitral repair surgery. Persistent left superior vena cava (PLSVC) was diagnosed during double chamber pacemaker implantation. PLSVC has a prevalence of 0.3-0.5% and may render cardiopulmonary bypass and device implantation more challenging. Nevertheless, evidence suggests it does not influence long-term follow-up.

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