RCAAP Repository

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Objectives: At Santa Marta Hospital, Ross Surgery was performed for the first time in 1999. Twenty years later, we feel it is desirable to evaluate the mid and long-term results of our experience, as well as estimate the future of this procedure. Methods: Between March 1999 and June 2016, 23 Ross procedures were performed at our institution. We did a retrospective analysis of the patients´ data, results of the surgery, complications, freedom from reoperation and mortality. Results: The majority (36,4%) of the patients had aortic stenosis, 22,7% had aortic regurgitation and 27,3% had aortic stenosis and regurgitation. Sub-valvular stenosis was present in 13,6% of patients. The mean follow-up is 15 years. The overall mortality was 9%, without early mortality. In our series, 83% of the patients are free from reoperation. Eighty percent (n=16) of the survivors are in NYHA class I, with the remaining 20% (n=4) in class II. Conclusion: Ross surgery has strict indications and in this group of patients the advantages are undeniable and the outcomes, according to our results (with 83% of patients free from reoperation, at a mean follow-up of 15 years), are positive and encouraging.

Introduction: Lung cancer has a high mortality rate with an overall survival of 18% at 5 years. Surgical treatment is the gold standard for early stages and is associated with high rates of resolution with a 5-year survival of 80% reported in large studies. Purpose: To determinethe survival of patients with non-small cell lung cancer (NSCLC) in stage IA (T1N0M0) undergoing surgical treatment with curative intent in our center. Methods: We performed a retrospective review of the clinical records of all patients with pathological stage T1a-c N0 (stage I) who underwent thoracic surgery with curative intent from 2010 and 2017 in our center. Overall survival and lung cancer-specific survival was estimated by the Kaplan-Meier method. Results: 87 patients (54 men and 33 women) with a median age of 66 years (range 36 to 83 years) were included. Lobectomy with systematic lymph node dissection was performed in 67 patients (77%). Adenocarcinoma was the predominant histological subtype (n=69; 79%). Overall survival at 5th years was 86,7%. Patients submitted to limited resection (segmentectomy or wedge resection) had lower overall survival compared to those submitted to lobectomy (66,4% vs 88,7%; p=0.008). Conclusions: Our results show a high 5-year overall survival rate, in agreement with results from larger series studies. Lung cancer screening, although not yet widely implemented, has been shown to reduce mortality associated with lung cancer. These results reinforce the importance of screening programs for specific populations in order to identify patients in early stages and improve overall survival.

Introduction and Objectives: COVID-19 pandemic forced a change in health care resources and provision due to the emergence of a new group of patients, requiring extraordinary protective measures and the adoption of new organization for the treatment of urgent or priority COVID-19 negative patients. We reviewed our practice during the first pandemic period to evaluate our surgical outcomes and identify if patients COVID-19 negative submitted to thoracic surgery had an increased risk of being infected or die. Methods: We retrospectively reviewed our surgical results between 11th March and 15th May 2020. Thirty patients underwent thoracic surgery at the Department of Cardiothoracic Surgery of Centro Hospitalar Universitário de São João. Results: None of the patients was COVID-19 positive and cross-transmission of the disease was not recognized. The majority of patients were admitted from home, with a high priority indication, namely an oncological disease. There was only one case of in-hospital mortality. Conclusion: During the first wave of the pandemic it was safe to be admitted and submitted to thoracic surgery at CHUSJ. Our patients, including oncological patients, received the adequate surgical treatment without an increase of risk of death or infection.

Objectives: To analyse the safety and outcomes of endovascular procedures in an ambulatory practice. Methods: Data were collected from a cohort of patients admitted in an ambulatory unit for an endovascular procedure for lower limb (LL) arterial occlusive disease during a one year period. Results: A total of 168 procedures were carried out in 134 patients. Patients’ mean age was 67 (39-91) years and 78% were male. Most patients presented with lower limb ulcer or gangrene (43%) or disabling claudication (40%). Most frequent comorbidities included hypertension (75.4%), dyslipidemia (72.4%) and diabetes mellitus (57.5%). The preferred vascular access for the procedures was the common femoral artery (52%), superficial femoral artery (24%) and humeral artery (21%). Global complication rate was 19% but only one major, non-fatal complication was identified. The most common complication was arterial dissection (8.3%), none compromising blood flow. One-year amputation rate was 6.7%, and one-year mortality was 3.0%. Factors significantly associated with procedure complications were female sex, hypertension and dyslipidemia. Conclusion: Ambulatory endovascular procedures for PAD are safe and effective in selected patients. Both the low rate and low severity of complications make them an attractive option in the prospect of diminishing the burden of these patients on the health-care system while improving patient comfort.

Introduction: The abdominal aortic aneurysm (AAA) is a nosological entity whose main complication is rupture, being associated with a high mortality rate. The early identification of this pathology in groups at risk through an ultrasound screening program can have benefits based on elective surgical repair before the rupture occurs, preventing death. In Portugal, no screening program for this aneurysm is implemented. Our goal is to review the impact of screening among risk groups on the global and aneurysm-related mortality rates, quality of life, cost-effectiveness and its applicability in Portugal. Materials and methods: We performed a narrative review of the literature on screening for AAA. Results: There is evidence that screening is effective in reducing aneurysm-related mortality in men aged 65 and over, but not in reducing overall mortality. In addition, the implementation of a screening program in several countries appears to be cost-effective in at-risk populations. Discusssion and conclusion: Data from epidemiological studies on AAA suggests that the implementation of an AAA screening program, based on ultrasound, in men aged 65 and over, can bring health benefits and be cost-effective. Even so, taking into account that all the studies took place outside Portugal, the possibility of generalizing the results to the portuguese population is not clear.

The transaxillary (TAX) approach for transcatheter aortic valve implantation (TAVI) results in comparable short and long-term clinical results compared to the transfemoral (TF) approach. However, adequate closure of the axillary artery is the most critical issue when performing the percutaneous approach. Compared to surgical transaxillary approach, the percutaneous approach was used only in selected cases due to this closure limitation. In the present paper, we aim to demonstrate the feasibility of implanting the CoreValve Evolut Pro transcatheter heart valve via percutaneous transaxillary approach and make a literature review of procedure particularities and outcome. We describe the case of a patient with severe aortic stenosis in the presence of small calibre and severely calcified femoral arteries. A CoreValve Evolut Pro 26 was successfully implanted percutaneously through the left axillary artery. Percutaneous transaxillary transcatheter aortic valve implantation is a feasible and safe alternative in patients who have suboptimal iliofemoral vessels.

Sixteen months after the replacement of the ascending aorta an 80-year-old lady was referred to our center for a presternal pulsatile mass. Computed tomography scan showed an ascending aorta pseudaneurysm extended through the sternum and filling the subcutaneous space. Surgical correction was successful. Specific surgical considerations of this case are discussed.

Primary carcinoid tumours of the lung are rare tumours and when typical are associated with a benign behaviour and should be classified as low-grade neuroendocrine tumour/carcinoma. A 67-year old HIV-positive female was admitted due to a typical carcinoid tumour on the distal third of the main left bronchus, occupying two thirds of the lumen. Given she was HIV positive, had a moderately compromised lung function and in order to minimize surgical events, postoperative complications and to maximize postoperative lung function, the authors opted for a bronchoplasty using a patch. The surgery was uneventful and as the resected area of the bronchus was small, patency was assured and the distortion was minimal. During extubation, resistance was felt upon trying to the remove the bronchial blocker. After performing bronchoscopy it was seen that the loop at the end of the bronchial blocker was caught in the patch suture. Fortunately it was possible to cut the loop, freeing the blocker and avoiding a redo surgery. There were several possible options, ranging from left pneumonectomy, superior left lobe sleeve lobectomy, resection of the left main bronchus with a Y bronchial reconstruction or a bronchoplasty using a patch. The chosen technique has several advantages: From an oncological standpoint a typical carcinoid is indolent and needs only a clear resection margin. From a functional standpoint lung tissue resection was prevented. From a surgical standpoint it is less challenging, easy to perform and less prone to surgical events, essential considering the particular case of an AIDS patient.

Ectopic thoracic kidney corresponds to less than 5% of all renal ectopia. An asymptomatic 81-year-old woman performed an x-ray which demonstrated a heterogeneous opacity in the right hemithorax. An ultrasonography showed a thoracic right kidney, and a computed tomography demonstrated the right kidney in her right hemithorax through Bochdalek foramen. Physicians must be aware that asymptomatic patients do not need any treatment or invasive procedures due to this malformation, although surgical interventions may be due in severe cases.

Thoracic origin of a single renal artery with a normal position of the kidney is a very rare anatomical variant with just a dozen cases depicted in the medical literature. In this case report we describe an incidental finding of a main renal artery arising from the thoracic aorta at the 11th thoracic vertebral level in an asymptomatic 57 year-old man in a routine computed tomography (CT) on follow-up for chronic pancreatitis.

62 year-old man admitted in ICU post myocardial infarction with ventricular septal defect (VSD) and cardiogenic shock due to anterior descending artery stenosis. VSD corrected percutaneously after intra-aortic Figure 1 Transthoracic echocardiography with Doppler showing VSD after myocardial infarction due to anterior descendent stenosis. balloon pump insertion, resulting in iatrogenic tricuspid regurgitation. Tricuspid valvuloplasty, VSD correction and CABG performed after patient stabilization. Discharge after 26 days.

A 66-year-old male with an aspergiloma in the upper left lobe was submitted to a wedge resection in December 2019. Pneumostasis was performed using biological glue and afterward the test of submersion in water showed no significant alveolopleural leak. In the immediate postoperative period, the patient presented an expanded lung parenchyma and moderate alveolopleural leakage that gradually decreased. A month later the patient was readmitted in intensive care unit with an acute respiratory distress after a sudden episode of coughing with abundant and purulent sputum and significant increase in alveolopleural leakage. Intraoperatively it was found that the pulmonary parenchyma covering the segmental bronchi was necrotic.

Recurrent lymphocele after repair of crural hernia without resolution after several aspirations and injections of sclerosing agents. Reintervention with lymphatic marking (injection of patent blue dye at the interdigital level, Figure 1 a) Lymphatic marking through injection of patent blue dye at the interdigital level. b) Surgical approach of the inguinal region. Figure 1), followed by en bloc removal of the ganglia of the saphenofemoral junction and the lymphocele capsule (Figure 2). No evidence of recurrence at 24 months of follow- up.

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Introduction: Papillary fibroelastomas (PFE) are a rare primary cardiac neoplasm, out of which multifocal PFE constitute a small minority of cases. These benign masses are commonly found on valvular surfaces, particularly the aortic valve. Clinical case: We present a patient with a history of embolic stroke and intra-cardiac masses. Multimodal imaging revealed multiple nodules with extensive intra-cardiac distribution. All nodules were successfully removed without valve dysfunction. Conclusion: This is a unique case of multiple PFE involving intracardiac cavities as well as all valvular structures.

We report the clinical case of a 38 weeks gestational age neonate, antenatally diagnosed with a left large macrocystic pulmonary malformation conditioning dextrocardia. At birth, he presented with respiratory distress requiring non-invasive ventilation with high-flow nasal cannula (HFNC). A left inferior lobectomy was performed via thoracotomy on day 21 of life. Histological features of the lesion were compatible with congenital pulmonary airway malformation (CPAM) type I with muci- nous cell clusters. No surgical complications were reported and the neonate was discharged six days after surgery. Follow-up two months after surgery was unremarkable.

Lemierre's syndrome refers to infectious thrombophlebitis of the internal jugular vein developed as complication of an oropharyngeal infection. It is a rare syndrome, affecting otherwise healthy young adults, which may lead to sepsis complicated by septic embolization. Although there is a characteristic clinical picture, many modern physicians are unaware of this syndrome, leading it to be termed ‘the forgotten disease’. The authors report a case of late diagnosis due to initial suspicion of COVID-19 and highlight the pitfalls on its diagnosis.

Arteriovenous malformations (AVMs) involving the upper limb constitute 10% of the total AVMs. In the upper limb, AVMs are more frequent in the hand than in the arm, being the hand one of the body’s regions more frequently associated with AVMs, coming after the head and neck. The total prevalence of the upper limb AVMs remains unknown and there is currently no definitive consensus for the treatment of upper limb AVMs. The purpose of this study was to review thebest evidence of the treatment for the upper limb AVMs and describe their clinical characteristics and diagnosis. The majority of patients with asymptomatic AVMs follows a conservative management. In the symptomatic patients, the treatment with surgery and or chemical embolization is beneficial. The amputation can be necessary in the case of life-threatening and massive AVMs, constituting the first step in patient's rehabilitation. Although the most common option for the management of symptomatic or functional AVMs is the embolo-sclerotherapy combined with surgery, different outcomes should be taken into account to plan the treatment, specially the presence of symptoms, bleeding and heart failure.

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