Portuguese Journal of Cardiac Thoracic and Vascular Surgery

Ventricular Septal Rupture After Acute Myocardial Infarction – Can Va-Ecmo Give Us Extra Time?

Sara Teixeira, Inês Mendonça, Rita Ferreira, Sérgio Gaião, José Artur Paiva — Tue, 29 Apr 2025 00:00:00 -0700

Ventricular septal rupture (VSR) after myocardial infarction (MI) is a rare but life-threatening complication. Although surgery is the gold standard treatment, best surgical timing is still a matter of debate. Studies are showing a tendency towards survival improvement with delayed intervention on the assumption that scarring of the infarcted tissue may facilitate patch suturing and avoid relapse of the defect. Mechanical circulatory support (MCS) may be useful, not only for hemodynamic stabilisation and optimization before surgery, but also as a bridge to decide best surgical timing. Allowing myocardial recovery into a resistant scar, recurrence of VSR may be reduced and promotes a longer-lasting surgical repair.

The aim of this case report is to share the outcomes and management of two MI-associated VSR patients submitted to delayed surgery after VA-ECMO stabilisation. Although VSR repair failed, VA-ECMO allowed the patient's stabilisation, time for decision and became a bridge for successful heart transplant.

Chest Wall Intramuscular Myxoma : A Rare Tumor

Tue, 29 Apr 2025 00:00:00 -0700

Intramuscular myxomas are rare benign soft-tissue tumors. The myocardium is the most common site for myxomas, while extracardiac myxomas are commonly localized in the musculature (broad muscle), upper extremities (shoulder and arm), thighs and gluteal muscles. We report the case of a 68-year-old with an extremely rare intramuscular myxoma localized in the chest wall.

Difficulties include differentiation from sarcomas, intramuscular lipomas, hematomas and desmoid tumors.

Heparin Induced Thrombocytopenia In The Setting Of Urgent Cardiac Surgery: Can Bivalirudin Be A Safe Option? – A Case Report

Bárbara Alves, Joana Veiga, Inês Morais, Fátima Lima, Nelson Paulo — Tue, 29 Apr 2025 00:00:00 -0700

Unfractionated heparin is the main anticoagulant employed in the context of cardiovascular surgery. When a patient with heparin induced thrombocytopenia (HIT) is proposed for cardiac surgery, the anticoagulation management is challenging.

Bivalirudin is an alternative to heparin in the perioperative setting. We present a rare case of a patient with HIT and cardiogenic shock that required bivalirudin use in the perioperative period of an urgent reoperation of recurrent mitral valve dysfunction.

Although infrequent, the use of bivalirudin can be safe in high risk patients if adequate measures follow institutional protocols, as reported in this case.

Endobronchic Follicular Dendritic Cell Sarcoma: An Exceptionnal Endobronchic Tumour

Tue, 29 Apr 2025 00:00:00 -0700

Follicular dendritic cell sarcoma is a very rare entity subject of few studies, we report a case of endobronchial site manifested by a total atelectasis of the right lung managed by initial endobronchic desobstruction and surgical excision with successful results.

Hemodynamic Predictors And Changes During Carotid Endarterectomy Under Regional Anesthesia

Tue, 29 Apr 2025 00:00:00 -0700

Objectives: Carotid endarterectomy (CEA) is the standard treatment for carotid stenosis, but it can lead to cerebral hypoperfusion and hemodynamic stroke. Regional anesthesia (RA) and light sedation allow continuous monitoring of intraoperative neurological function. However, the relationship between perioperative hemodynamic management and neurological dysfunction has yet to be thoroughly investigated. This study aims to identify hemodynamic patterns that are associated with intraoperative cerebral ischemia in CEA under RA.

Material and Methods: Patients who underwent CEA at an academic tertiary referral center between January 2012 and December 2019 were included. Cases were individuals who developed intraoperative neurological deficits (ND). Consecutive controls without ND were sampled in 1:1 ratio.

Results: 154 patients were included, 78.6% male, and mean age was 70.1±9.1 years. Cases were on average older than controls (72.0 ± 9.90 vs 68.3 ± 8.3 years, p=0.012). Baseline systolic blood pressure (SBP) values were higher in the ND group (154.6 ± 31.8 vs 141.8 ± 41.2 mmHg, p=0.035), alongside pulse pressure (98.1 ± 24.0 vs. 87.4 ± 32 mmHg, p=0.023). The ND group also had a statistically significant higher mean arterial pressure at the 3rd-minute post-clamp (108.3 ± 19.7 vs 101.1 ± 20.2 mmHg, p=0.028) and a smaller drop in SBP between the pre-clamp and the 1st and 3rd minutes post-clamp (11.95±16.19 vs. 19.79±24.01 mmHg, p=0.021 and 11.12±21.83 vs 19.42±26.78 mmHg, p=0.039, respectively).

Conclusions: Intraoperative ND showed no characteristic predictive pattern, besides higher SBP. Hemodynamic management could be key for preventing unwanted deficits.

Surgical Aortic Valve Replacement For Bicuspid And Tricuspid Valve Disease: 7-Year Outcomes In >1100 Patients

Tue, 29 Apr 2025 00:00:00 -0700

Introduction: Bicuspid aortic valve affects 0.5-2% of the population in developed countries. Given uncertainties about the best aortic valve replacement (AVR) option in this often younger, low-risk, population, it is important to understand how newer bioprostheses perform in these patients. The primary objective of this analysis was to compare 7-year outcomes of surgical AVR (SAVR) with the Avalus bioprosthesis between patients with a congenital bicuspid or tricuspid valve.

Methods: This prospective, non-randomized study included 1132 patients with aortic valve stenosis or chronic severe aortic regurgitation who underwent successful SAVR with the Avalus bioprosthesis. Patients were categorized into bicuspid (n=339) and tricuspid (n=775) groups; 18 patients had unknown etiology. Kaplan-Meier analyses estimated valve-related adverse events over 7 years. Multivariable Cox proportional hazard models with propensity score adjustments evaluated the association of valve etiology with clinical outcomes, and a multivariable analysis identified risk factors for all-cause mortality.

Results: Patients with a tricuspid valve were older with more advanced heart failure symptoms and a higher mean Society of Thoracic Surgeons risk score (P<0.01). At 7 years postimplant, mortality was lower [8.9% (95% CI: 5.9%-13.4%) versus 21.3% (95% CI: 18.1%-24.9%), P<0.01] and non-structural valve dysfunction was higher in the bicuspid cohort [2.9% (95% CI: 1.5%-5.5%) versus 0.6% (95% CI: 0.2%-1.6%), P<0.01]. Other safety parameters were not significantly different. In the bicuspid and tricuspid cohorts, the respective mean effective orifice area was 2.0±0.5 and 2.0±0.5 at 7 years, and the respective mean aortic gradient was 13.6±6.4 and 14.1±5.7. Reintervention rates were low [6.8% (95% CI: 4.1%-10.9%) versus 5.4% (95% CI: 3.7%-7.8%), P=0.54] in both cohorts.

Conclusions: SAVR with the Avalus bioprosthesis yielded excellent 7-year outcomes for patients with either a congenital bicuspid or tricuspid valve. Hemodynamic performance and reintervention rates were similar between cohorts with low rates of other valve-related adverse events.

Oncological Outcomes Of Radical Surgery With And Without Induction And Adjuvant Chemotherapy In Mesothelioma Patients – 8-Year Experience In A Single Center

Tue, 29 Apr 2025 00:00:00 -0700

Introduction: Mesothelioma is a devastating, insidious disease with a long latency period. Its peak incidence occurs in the 5th and 6th decades of life, up to 40 years after asbestos exposure which is strongly related to the disease. The optimal treatment is the object of an intense discussion.

Aims: The established outcomes were disease-free survival (DFS) and 1-year survival analyzed in the context of neoadjuvant chemotherapy with subsequent surgery, surgical intervention without any systemic treatment, an upfront surgery and adjuvant chemotherapy and surgical intervention with both neo- and adjuvant therapy to establish the most advantageous treatment in terms of oncological results.

Materials and Methods: We analyzed our center’s surgical experience with radical surgery for mesothelioma, evaluating the disease-free time and 1-year survival in relation to the treatment scheme. A search of the department’s surgical database for mesothelioma cases between January 2016 and December 2020 revealed 16 cases, which were included in the final analysis. The established outcomes were disease-free survival and 1-year survival.

Results: The 3 patients treated with surgery without any systemic treatment had a median follow-up period (MFUP) of 7 months (3- 12), 67% of recurrence, DFS of 6 months (0-12), and 1-year survival of 33%. The 6 patients treated with neoadjuvant chemotherapy, surgical resection, and adjuvant therapy, had an MFUP of 45 months (8-82), 67% of recurrence, DFS of 32 months (2-82), and 1-year survival of 83%. The 1 patient, treated with neoadjuvant chemotherapy and subsequently, surgery had a follow-up of 29 months with DFS of 20 months and he was alive at the time of submission of this article. The 6 patients treated with an up-front surgery and adjuvant chemotherapy had an MFUP of 20 months (8-33), 67% of recurrence, DFS of 15 months

(6-33), and 1-year survival of 67%.

Conclusion: Despite the limitations of the study, the multimodal approach with both neoadjuvant and adjuvant chemotherapy demonstrated the longest MFUP, DFS, and 1-year survival. The worst results were observed in patients treated only with radical surgery, while the sequence of systemic treatment did not influence the rate of recurrence.

Arterial Injuries In Lower Extremity Trauma – Outcomes Of A Single Center Study

Tue, 29 Apr 2025 00:00:00 -0700

Objectives: Femoropopliteal artery injury is a common and potentially life-threatening form of arterial injury in the lower extremities. Despite advancements in its management, there is still a considerable risk of amputation and death associated with these injuries.

Methods: We conducted a retrospective analysis on the patients who received treatment for lower limb trauma and concomitant arterial injury at a Level 1 Trauma Center and aimed to compare patient characteristics, injury severity scores, time to surgery, vascular repair methods, presence of fractures, and sequence of vascular and orthopedic repairs between groups: limb salvage vs amputation and survival vs death. We also aimed to identify factors contributing to amputation and death.

Results: Between January 2020 and June 2023, 21 patients, 71.4% male and 28.6% female patients were treated. 95.2% of the injuries were caused by blunt trauma, and the most commonly injured artery was the popliteal artery, in 61,9% of the cases. MESS scores were significantly higher in patients who died (p=0.012) and the presence of an exposed fracture was more common in patients who underwent amputation (p=0.004). 23,8% of patients were submitted to above knee amputation and a death rate of 19% was observed.

Discussion/Conclusion: When dealing with multiple injured limbs, the treatment approach and priorities are still under discussion, typically customized based on individual clinical situations. Our study underscores the significance of promptly performing vascular repair, reducing time delays, and taking into account bone and soft tissue injuries in the treatment strategy.

Open Surgical Repair of a Popliteal Vein Aneurysm in a Patient with Varicose Veins

Henrique Guedes da Rocha, Daniel Mendes, Carolina Vaz, Rui Machado — Tue, 29 Apr 2025 00:00:00 -0700

Unseen Impact: A Bullet Lodged in an Unexpected Location

Patricia M. Castro, Cátia Silva, Paulo Ponce, Daniel Martins — Tue, 29 Apr 2025 00:00:00 -0700

Two-Staged Treatment of Symptomatic Complex Type 2 Thoracoabdominal Aneurysm with Unconventional EVAR, TEVAR, and iBEVAR

Henrique Guedes da Rocha, Paulo Almeida, Carolina Vaz, Rui Machado — Tue, 29 Apr 2025 00:00:00 -0700

Concerning the TNM 9th edition - Go forth and validate

Filipe Leite — Tue, 29 Apr 2025 00:00:00 -0700