Full-text · Article · Sep 2014 · Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology
[Show abstract][Hide abstract] ABSTRACT: We present the case of a 47-year-old man with hypertension for over 20 years, referred to our hospital due to mild aortic dilatation detected on a transthoracic echocardiogram. On physical examination weak lower limb pulses and a blood pressure differential of >50 mmHg between arms and legs were detected. Complete interruption of the aortic arch below the left subclavian artery was diagnosed by computed tomography angiography. With this case we aim to draw attention to aortic coarctation and interrupted aortic arch as potential causes of hypertension and to highlight the importance of the physical examination in the diagnosis of secondary causes of hypertension.
No preview · Article · Jul 2014 · Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology
[Show abstract][Hide abstract] ABSTRACT: Apresentamos o caso de um homem de 47 anos, com hipertensão arterial desde há mais de 20 anos, referenciado ao nosso hospital por dilatação ligeira da aorta ascendente detetada em ecocardiograma transtorácico. No exame físico constatou-se que os pulsos femorais eram pouco amplos e existia um diferencial de pressões superior a 50 mmHg entre os membros superiores e inferiores. Por angiotomografia computorizada do tórax diagnosticou-se uma interrupção completa do arco aórtico abaixo da artéria subclávia esquerda. Com este caso pretendemos relembrar a coartação da aorta e interrupção do arco aórtico como potenciais causas de hipertensão e realçar a importância do exame físico no diagnóstico de causas secundárias de hipertensão.
[Show abstract][Hide abstract] ABSTRACT: Superior Vena Cava Syndrome (SVCS) occurs when there is a reduction or blockage of blood flow through the superior vena cava (SVC) and may be associated with debilitating clinical manifestations. Although classically associated with malignant etiologies, increasing number of intravenous procedures (central venous catheters, pacemakers) have raised the percentage of cases of benign etiology, which currently account for 40%. Endovascular management of SVCS has gained increasing popularity, although it is not always feasible or leads to long-term clinical improvement, so sometimes surgical treatment is necessary.
The authors present a patient with superior vena cava syndrome due to pacemaker leads. After unsuccessful attempt of endovascular treatment, the patient underwent surgical reconstruction with resolution of symptoms.
[Show abstract][Hide abstract] ABSTRACT: Introduction: Mitral valve repair is feasible for all patients with mitral regurgitation and its advantages are well documented; however, there is general agreement that it is technically demanding and that success rates are related to volume/ experience centers. The aim of this study was to evaluate the clinical and echocardiographic mid-term outcomes of patients who underwent a mitral repair in a low-volume hospital. Methods and Results: Between 2009 and 2014, 55 patients (23 female) with mitral regurgitation underwent mitral repair. The mean age was 60.7±11.4 years (range, 21-81 yr). The most prevalent cardiovascular risk factors were: hypertension 61.8%, dyslipidemia 47.3% and diabetes 21.8%. Nine patients (16.4%) were in class III-IV of NYHA and ten (18.2%) had atrial fibrillation. Repair procedures included mitral ring annuloplasty (n=55), quadrangular resection (n=20), chordal replacement (n=13) and commissuroplasty (n=5). Postoperative complications included atrial fibrillation 16.4%, check bleeding 3.6%, wound infection 1.8% and renal failure 1.8%. The hospital mortality rate was 1.8%. Follow-up echocardiography (median 19±5 months) revealed trivial or no mitral regurgitation in 38.2%, mild (1+) in 34.5% and severe (3+) only in 3 patients. Conclusion: In the current era, patients undergoing successful mitral valve repair have low mortality and morbidity even in low-volume hospitals.
[Show abstract][Hide abstract] ABSTRACT: Transcatheter aortic valve implantation (TAVI) is the standard treatment for patients with severe aortic stenosis and unacceptable surgical risk. These are usually elderly patients with multiple comorbidities. We report the case of a 20-year-old man with mandibuloacral dysplasia, an extremely rare premature ageing syndrome, and severe symptomatic aortic stenosis, referred to our center for TAVI after being considered unsuitable for surgical aortic valve replacement. TAVI by a transfemoral approach was performed successfully. Severe acute respiratory failure that did not respond to optimal conventional treatment led us to employ venovenous extracorporeal membrane oxygenation. The device was removed after 10 days, and the patient was discharged home 27 days later. At one-year follow-up he is in NYHA class I with full functional autonomy. To the best of our knowledge, this is the youngest patient to undergo TAVI reported in the literature.
[Show abstract][Hide abstract] ABSTRACT: Case report description: A 32-years old male patient presented to the emergency department with progressive weakness, weight loss and hoarseness in the last 4 months. He was a previous drug addict (now on detoxification program), smoker and excessive alcohol consumer. Haemogram, blood chemistry and coagulation tests were unremarkable. Nasofibroscopy revealed paralysis and atrophy of the left vocal cord and chest radiography showed widening of the mediastinum and a mass in the zone of the aortic arch with a right shift of the trachea.
A mutidetector computed tomography angiography of the chest was then performed showing dilatation of the ascending aorta (44 mm maximum diameter) and proximal aortic arch with diffuse thickening of their walls, together with five saccular aneurysms with intramural thrombosis. Four aneurysms were located in the ascending aorta and the largest one, with a 70 x 44 mm size, was located on the posterior side of the aortic arch, at the level of the left common carotid emergency, compressing the trachea and esophagus. The transthoracic echocardiogram showed moderate aortic regurgitation and preserved systolic function of both ventricles.
The patient tested positive on serological tests for syphilis – TPHA ≥ 1/5120 and VDRL = 1/64. Viral markers were negative for human immunodeficiency virus (HIV) 1 and 2, hepatitis B and C. Diagnosis of tertiary syphilis with cardiovascular involvement was made and the patient initiated a cycle of antibiotic therapy with benzylpenicillin. Surgical treatment was then performed with replacement of the ascending aorta and proximal aortic arch by a 26 mm x 15 cm vascular graft. Histopathology of the aneurysmal walls was compatible with the diagnosis of syphilitic aneurysms, with marked reduction of muscular and elastic fibers and lymphocytic infiltration with predominant plasma cells in relation to the vasa vasorum ("endarteritis obliterans").
Discussion and conclusion: Cardiovascular syphilis is a rare clinical entity nowadays in developed countries. It occurs in a late stage (tertiary syphilis), usually in the 5th or 6th decades of life, 10 – 30 years after untreated primary infection. This case reports a rare form of presentation of cardiovascular syphilis in a young patient with multiple saccular aneurysms of the aorta. The majority of cases described in the literature are seen in older patients with isolated aortic aneurysms. Although far rarer than in past decades, syphilis must be recognized as a potential source of aneurysmal disease, because it warrants antibiotic therapy and screening of involvement of other organs.
Preview · Article · Aug 2013 · European Heart Journal
[Show abstract][Hide abstract] ABSTRACT: Coronary artery aneurysms are uncommon but potentially hazardous entities found on a small percentage of coronary angiograms. The best management strategy remains to be determined; the coexistence of obstructive coronary artery disease is the main determinant of prognosis. We report the case of a middle-aged woman with mixed aneurysmal and obstructive coronary artery disease presenting as an acute myocardial infarction, probably due to atherosclerosis. The unusual severity and complexity of the angiographic presentation of this case, with involvement of all major coronary arteries, raises important issues in terms of the patient's treatment options.
[Show abstract][Hide abstract] ABSTRACT: Complete revascularization is considered superior to incomplete revascularization (IR), with better long-term survival and
a lower rate of reintervention. However, it has yet to be established whether this difference is due directly to IR as a surgical
strategy or whether this approach is merely a marker of more severe coronary disease and more rapid progression. We believe
that IR is a prognostic marker for a more complex coronary pathology, and adverse effects are probably due to the preoperative
condition of the patient. In fact, although IR may negatively affect long-term outcomes, it may be, when wisely chosen, the
ideal treatment strategy in selected high-risk patients. IR can derive from a surgical strategy of target vessel revascularization,
where the impact of surgery is minimized to reduce perioperative mortality and morbidity, aiming to achieve the best feasible
Full-text · Article · Nov 2011 · Interactive Cardiovascular and Thoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: Intraoperative aortic dissection is a rare but potentially fatal complication of cardiac surgery. In this report, we present a case of intraoperative aortic dissection during a Bentall operation for annulo-aortic ectasia repair combined with mitral valve replacement. The aorta was successfully repaired using another dacron tube graft after profound hypothermic circulatory arrest.
No preview · Article · Jul 2011 · Revista portuguesa de cirurgia cardio-toracica e vascular: orgao oficial da Sociedade Portuguesa de Cirurgia Cardio-Toracica e Vascular
[Show abstract][Hide abstract] ABSTRACT: Intraventricular pressure gradients have been described between the base and the apex of the left ventricle during early diastolic ventricular filling, as well as, their increase after systolic and diastolic function improvement. Although, systolic gradients have also been observed, data are lacking on their magnitude and modulation during cardiac dysfunction. Furthermore, we know that segmental dysfunction interferes with the normal sequence of regional contraction and might be expected to alter the physiological intraventricular pressure gradients. The study hypothesis is that systolic and diastolic gradients, a marker of normal left ventricular function, may be related to physiological asynchrony between basal and apical myocardial segments and they can be attenuated, lost entirely, or even reversed when ventricular filling/emptying is impaired by regional acute ischemia or severe aortic stenosis.
Animal Studies: Six rabbits will be completely instrumented to measuring apex to outflow-tract pressure gradient and apical and basal myocardial segments lengthening changes at basal, afterloaded and ischemic conditions. Afterload increase will be performed by abruptly narrowing or occluding the ascending aorta during the diastole and myocardial ischemia will be induced by left coronary artery ligation, after the first diagonal branch.Patient Studies: Patients between 65-80 years old (n = 12), both genders, with severe aortic stenosis referred for aortic valve replacement will be selected as eligible subjects. A high-fidelity pressure-volume catheter will be positioned through the ascending aorta across the aortic valve to measure apical and outflow-tract pressure before and after aortic valve replacement with a bioprosthesis. Peak and average intraventricular pressure gradients will be recorded as apical minus outflow-tract pressure and calculated during all diastolic and systolic phases of cardiac cycle.
We expect to validate the application of our method to obtain intraventricular pressure gradients in animals and patients and to promote a methodology to better understand the ventricular relaxation and filling and their correlation with systolic function.
Full-text · Article · May 2011 · Journal of Cardiothoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: Thoracic splenosis is a rare clinical condition consisting in the heterotopic autotransplantation of pieces of splenic tissue into the chest, following a previous trauma, with spleen and diaphragm laceration. In this paper, the authors report the clinical case of a thoracic splenosis in a 26 years old male, who had suffered a severe thoraco-abdominal trauma in childhood, leading to an emergency splenectomy. The patient, with the previous diagnosis of malignancy, namely pleural fibrotic tumors, underwent surgical management for removal of some nodular tumors of the pleura. Pathological studies confirmed the diagnosis of thoracic splenosis. The clinical diagnosis of thoracic splenosis should be suspicious facing asymptomatic patients, with a history of previous thoraco-abdominal trauma and nodular peripheral tumors in the chest x-rays.
No preview · Article · Jul 2010 · Revista portuguesa de cirurgia cardio-toracica e vascular: orgao oficial da Sociedade Portuguesa de Cirurgia Cardio-Toracica e Vascular
[Show abstract][Hide abstract] ABSTRACT: Staged or combined carotid endarterectomy (CEA) offers the potential benefit of decreased neurological morbidity during and after cardiac surgery; however, the strategy for treating unstable high-risk patients, who need urgent coronary artery surgery, remains unresolved. We report in-hospital and 30-day outcomes of 23 consecutive patients admitted with unstable angina, who underwent carotid angioplasty and stenting (CAS) immediately prior to urgent coronary artery surgery, from October 2007 to October 2008. Aspirin and unfractioned heparin were administrated during carotid stenting and clopidogrel was only started after cardiac surgery. All patients remained event-free during and immediately after the carotid stenting procedure. One patient died due to sepsis 22 days after cardiac surgery. There was neither stroke nor myocardial infarction at follow-up. No patient needed a cardiac or carotid re-intervention. This new approach (combined carotid stenting and coronary artery surgery) provides a less radical intervention, can be performed with a low periprocedural complication rate and may become a valuable alternative in the treatment of high-risk patients with combined carotid and cardiac disease.
Preview · Article · Jun 2009 · Interactive Cardiovascular and Thoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to investigate the operative results and the clinical outcomes of Portuguese octogenarians who underwent cardiac surgery. Records of 339 consecutive octogenarians who had had cardiac operations between 2003 and 2005 were reviewed. The effect of cardiac and operative risk factors on mortality was evaluated. Selected variables included risk factors, cardiac status, preoperative hemodynamics and surgical procedures were collected on all patients. The mean age was 82.4+/-2.4 years-old (range 80-94) and 51.9% were male. Octogenarians had often diabetes (23.6%), renal failure (5.9%), cerebrovascular disease (8.3%), peripheral vascular disease (16.5%) and chronic lung disease (10.0%). The surgical priority was elective for 206 patients, urgent for 120 patients and it was emergent for 8 patients. Coronary artery bypass grafting was performed in 46.9%of patients, valve surgery was performed in 31.6% and combination of these in 19.5% of patients. Overall hospital mortality was 10.0%. Operative mortality for coronary artery bypass and valve surgery were 9.4% and 8.0%, respectively. Combined surgery (16.7%), diabetes (15.7% vs 9.3%, p<0.05), and urgent/emergent (14.3% vs 7.3%, p<0,05) increased significantly operative mortality. In conclusion, cardiac surgery can be performed within acceptable limits of risk and an acceptable mortality. Several factors might help both in case selection and in perioperative decisions.
No preview · Article · Apr 2009 · Revista portuguesa de cirurgia cardio-toracica e vascular: orgao oficial da Sociedade Portuguesa de Cirurgia Cardio-Toracica e Vascular
[Show abstract][Hide abstract] ABSTRACT: Transcatheter aortic valve implantation has been increasingly reported as an alternative to the surgical management of aortic stenosis in patients who are contraindicated for surgery. Transcatheter technical limitations for vascular access in some patients created the need for alternative approaches as is the case of the subclavian artery access. The authors report their experience and results in a group of four patients treated with transcatheter aortic valve implantation through subclavian artery access.
No preview · Article · Apr 2009 · Revista portuguesa de cirurgia cardio-toracica e vascular: orgao oficial da Sociedade Portuguesa de Cirurgia Cardio-Toracica e Vascular
[Show abstract][Hide abstract] ABSTRACT: Multiple strategies to achieve some degree of myocardial revascularization are available. In some, less complete revascularization is accepted to limit invasiveness, mostly in older, high-risk patients and patients with unsuitable coronary anatomy.
Patient and operative data were collected retrospectively for all patients with three-vessel coronary artery disease who had off-pump coronary artery bypass surgery from January 2003 through December 2005. In-hospital outcomes, preoperative risk, survival and postoperative complications were compared between patients with complete (n = 89) and incomplete (n = 61) revascularization.
The mean follow-up was 20.2 +/- 4.6 months. Patients with incomplete revascularization tended to be older (76.8 +/- 1.4 years) than those with complete revascularization (66.3 +/- 1.0 years) and were more likely to have diabetes (43% versus 30%), cerebrovascular disease (18% versus 11%) and peripheral arterial disease (20% versus 9%), poorer ejection fraction (34.7 +/- 1.7% versus 50.8 +/- 1.5%) and greater EuroSCORE risk (9.7 +/- 2.1 vs. 5.1 +/- 1.3). In-hospital (3.3% versus 3.4%) and 6-month (4.9% versus 5.6%) mortality were not statistically different in the two groups, nor was recurrence of angina (3.3% versus 1.1%) or need for repeat revascularization (percutaneous or surgical) (4.9% versus 3.3%).
In high-risk patients with three-vessel coronary artery disease, the potential benefits of less invasive surgery should be considered. Surgical outcomes depend on preoperative condition rather than incomplete revascularization. Medium-term mortality and cardiac-related events associated with this surgical strategy are not increased.
No preview · Article · Nov 2008 · Revista portuguesa de cardiologia: orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology: an official journal of the Portuguese Society of Cardiology