Portuguese Journal of Cardiac Thoracic and Vascular Surgery

Long-Term Impact Of Permanent Pacing After Mitral Valve Surgery: A Scoping Review Of Current Literature

Mon, 04 Aug 2025 00:00:00 -0700

Background: Conduction disorders after mitral valve surgery (MVS) are frequent with a considerable percentage of patients requiring the implantation of a permanent pacemaker (PPM). This has been associated with prolonged hospital length of stay and increased resource utilization. In this scoping review, we consolidate the current evidence on the impact of PPM on late outcomes after MVS in terms of heart failure and mortality.

Methods: A comprehensive electronic literature search was conducted on Medline, EMBASE, Cochrane, ClinicalTrials.gov, and Google Scholar using the keywords (‘mitral valve repair’, ‘mitral valve replacement’, ‘pacemaker implantation’). The search was performed in November 2023. Studies were included if they involved adults ≥18 years old who underwent MVS, reported the long-term outcomes of PPM implantation, and were observational or randomized control trials. Exclusion criteria included case series, case reports, conference abstracts, and non-English studies.

Results: Literature search identified 2263 citations, of which, four studies, with a total of 49,006 patients (of which, 38,063 underwent mitral valve procedures) were ultimately included in this review. The incidence of PPM after MVS ranged between 4.2-11.8%. Factors associated with higher PPM risk, including advanced age, concomitant surgical procedures, pre-existing atrial fibrillation, conduction disorders, and ischemic heart disease, were chosen for their consistent identification across multiple studies. Data was not conclusive on whether there was a correlation between PPM implantation and an increased risk of late congestive heart failure or mortality.

Conclusions: We did not find enough evidence to suggest that permanent pacing may have negative impact on late outcomes after mitral valve surgery. This may be explained by the heterogeneity of the included studies and the complex nature and multi-factorial etiology of post-surgical electric conduction disorders.

Prosthetic Graft Infection in Femoropopliteal Bypass

Mon, 04 Aug 2025 00:00:00 -0700

Introduction: Peripheral artery disease, a manifestation of systemic atherosclerosis, often necessitates surgical revascularization in advanced stages, with femoropopliteal bypass serving as a primary intervention to restore adequate lower limb perfusion. When autologous vein grafts are not available, prosthetic conduits are commonly used. However, these heterologous materials carry an increased risk of infectious complications, which, although rare, are associated with substantial morbidity and mortality. This study aims to review the current literature on prosthetic graft infections in femoropopliteal bypass surgeries, focusing on epidemiology, risk factors, microbiology, diagnostic methods, treatment strategies, and preventive measures.

Materials and methods: A narrative review of the literature was conducted using databases such as PubMed to identify relevant studies on vascular prosthetic infections, particularly in femoropopliteal bypass surgeries.

Results: Prosthetic graft infections occur in approximately 2.6% of femoropopliteal bypass surgeries. Staphylococcus epidermidis is the most commonly isolated pathogen. Other relevant Gram-positive bacteria include Staphylococcus aureus, and Gram-negative bacteria such as Pseudomonas aeruginosa. Accurate identification of the etiological agent through microbiological and diagnostic methods is essential for improving clinical outcomes. Early diagnosis is crucial to enable timely and effective treatment, which generally combines antibiotic therapy with surgical intervention, often necessitating graft removal. Furthermore, adopting preventive measures, such as perioperative antibiotic prophylaxis, is fundamental to reducing the incidence of these complications and minimizing the morbidity and mortality associated with prosthetic graft infections.

Conclusion: Prosthetic graft infections in femoropopliteal bypass surgeries remain a challenging complication. A multidisciplinary approach encompassing early detection, evidence-based treatment, and targeted prevention strategies is essential to improve outcomes, preserve limb function, and mitigate long-term morbidity.

Surgical Repair Of Severe Mitral And Tricuspid Valve Regurgitation In Patient With Left Ventricle Noncompaction - A Case Report

Mon, 04 Aug 2025 00:00:00 -0700

Left ventricular non-compaction (LVNC) cardiomyopathy is a rare congenital cardiomyopathy which is characterized by prominent and extensive trabeculation and deep intertrabecular recesses communicating with left ventricular cavity. Here we present a rare case report of patient with severe secondary Mitral regurgitation (MR) and severe tricuspid regurgitation (TR) in LVNC cardiomyopathy who underwent MV Repair using ring annuloplasty with #28 CG future ring and kay’s suture annuloplasty for severe TR and its postoperative management. Patient recovered well after surgery and was discharged with improved hemodynamics. The valve surgery in patients with such cardiomyopathy is very rare. This case will add to the small growing literature of surgery in severe secondary Mitral regurgitation in LVNC and the problems we faced while coming off bypass and its postoperative management.

Orogastric Tube Use in Patients Undergoing Cardiac Surgery, A Pilot Study

Mon, 04 Aug 2025 00:00:00 -0700

Objectives: This pilot study investigated the potential impact of using orogastric tube (OGT) on the immediate post- operative outcomes in adult patients undergoing coronary artery bypass graft procedures.

Design: A prospective non-blinded randomised study.

Setting: At a single University Hospital.

Participants: Seventy-eight consecutive adult patients that underwent coronary artery bypass graft surgery were included.

Interventions: Thirty-nine patients received an OGT, and thirty-nine patients did not (control group).

Measurements: Primary outcomes included: the incidence of postoperative nausea and vomiting, opiate use for pain, prolonged ventilation, and gastric dilatation on x-ray. Secondary outcomes included: the incidence of major adverse cardiac and cerebral events, major respiratory, gastrointestinal, and renal complications, and total hospital length of stay.

Main Results: There were non-significant trends towards higher incidence of post-operative nausea (n=2/39; 5.1%; p=0.156) and vomiting (n=1/39; 2.6%, p=0.314) in the OGT group compared to the non-OGT group (n = 0). There was a significant increase in opiates use for pain in the OGT group (n = 13/39; 33.3%) compared to the non-OGT group (n = 3/39, 7.7%) (p=0.0054), indicating that OGT may contribute to the development of postoperative pain or discomfort. There was no difference in the incidence of major postoperative outcomes.

Conclusions: In this pilot study, the use of OGT did not impact the immediate postoperative outcomes after coronary artery bypass surgery. However, it was significantly associated with higher use of opiates in these patients.

Influence Of Clinical Presentation Of Diabetic Patients With Chronic Limb Threatening Ischemia Submitted To Distal Revascularization

Mon, 04 Aug 2025 00:00:00 -0700

Objective: The purpose of this article was to evaluate the clinical impact of diabetic foot ulcer (DFU) severity in patients with chronic limb-threatening ischemia (CLTI) who underwent distal open revascularization.

Methods: This study included a single-center retrospective analysis of diabetic patients with CLTI who underwent distal revascularization between January 2012 and December 2019. The sample was divided into two groups according to DFU severity; group 1 was defined if observed Wound grade ≥ 2 and Infection grade ≥ 1 and group 2 was defined if observed Wound grade < 2 and Infection grade < 1, according to Wound, Ischemia, and foot Infection (WIfI) classification. The primary endpoint was achieving freedom from CLTI at 1 year. Secondary endpoints encompassed the recurrence of CLTI, limb salvage, amputation-free survival, overall survival, and primary patency over a 4-year follow-up period.

Results: A total of 258 distal bypasses were performed in diabetic patients with CLTI. Among these, 95 patients had infected major foot lesions (group 1), while the remaining 163 limbs comprised group 2. Group 1 patients were slightly younger, with a median age of 72 years (IQR 14), compared to 74 years (IQR 14) in group 2 (p=0.045). Most of the patients achieved freedom from CLTI at 12 months (82%), with no significant differences between groups (HR 0.75, CI 0.53-1.04, p=0.084; aHR 0.77, CI 0.54-1.08, p=0.130). At 4 years of follow-up, recurrence rates of CLTI and limb salvage were no different between groups (HR 0.68, CI 0.34-1.35, p=0.266; aHR 0.71, CI 0.34-1.48, p=0.355 and HR 1.18, CI 0.63-2.24, p=0.591; aHR 1.81, CI 0.80-4.11, p=0.155, respectively). Survival-related end points were not different between groups, except when adjusted for baseline characteristics and graft type (survival: HR 1.50, CI 0.96-2.33, p=0.072; aHR 2.49, CI 1.54-4.05, p<0.001; amputation-free survival: HR 1.37, CI 0.97-1.92, p=0.071; aHR 2.03, CI 1.40-2.93, p<0.001).

Conclusion: The present study emphasizes the value of distal revascularization in limb salvage of patients with diabetic foot, independently of the DFU severity. However, these results suggest a lower survival in patients with infected major foot lesions. Further studies are needed to assert these findings.

Hot Topic In Thoracic Surgery: Can Sublobar Anatomical Resections Be Non-Inferior To Lobectomies For Small, Peripheral Non–Small-Cell Lung Cancer (NSCLC)? 9 Year Experience In A Single Center

Mon, 04 Aug 2025 00:00:00 -0700

Background: Technological advances and widely spread screening programs enabled the discovery of ever smaller lesions. As such, in the last years, the tendency has shifted towards lung-sparing procedures. The role of limited surgical excision for small peripheral nodules is currently a topic of heated debate.

Aim: In our work, we try to answer whether the segmentectomy could adequately treat the peripheral NSCLC staged as Tis/1a-bN0M0.

Materials and methods: Our analysis is a single-center retrospective study based on the 8-year experience of our department. We identified 73 lobectomy patients and 16 segmentectomy patients. However, the lack of similarity between the two groups made it inadequate to draw satisfactory conclusions, therefore we reduced the lobectomy group and selected only those patients who could be paired with corresponding patients in the segmentectomy group. The established parameters of similarity were age (weighted at 15%), size of the lesion (50%), and follow-up (35%), and the input values were normalized. With this method, we could compare two samples of the most similar patients. 32 cases were included in the final analysis. The inclusion criteria were: NSCLC histology, size up to 2 cm, no visceral pleura invasion, N0 disease, and performed segmentectomy or lobectomy between Jan/2015 and Dec/2022. We analyzed the disease-free time and relapse rate.

Results: Data refers to a total of 32 patients distributed in two groups: group A with 16 segmentectomies (S6, S1+2 or S1) and group B with 16 lobectomies. The mean time of follow-up was 30 months (1-85) for group A and 32 months (1-91) for group B. The disease-free survival was 27 months for group A and 31 months for group B. The relapse rate was 19% for segmentectomies and 12.5% for lobectomies.

Conclusions: In conclusion, while this article presents our center's experience with segmentectomy, we believe further studies with larger sample sizes are needed to establish its non-inferiority. Nevertheless, our experience indicates that segmentectomy offers significant benefits, including lung preservation and the potential for future resections.

Real World Applicability Of Voyager-Pad According To Oac3pad Score

Mon, 04 Aug 2025 00:00:00 -0700

Introduction: Lower extremity peripheral artery disease (PAD) is associated with a high risk of cardiovascular and limb adverse events. Optimal post intervention antithrombotic strategy may significantly impact medium to long-term outcomes. The VOYAGER PAD trial showed a clinical benefit of combining low dose rivaroxaban plus aspirin by reducing cardiovascular and limb major adverse events. However, safety of this dual pathway inhibition (DPI) may be questionable. Current European Society for Vascular Surgery guidelines on this subject suggest DPI for symptomatic PAD patients undergoing invasive treatment, in the absence of high bleeding risk. However, real-world patients differ from those enrolled in the VOYAGER PAD trial, especially chronic limb threatening ischemia (CLTI) patients. The OAC3PAD score is a novel risk stratification tool to assess bleeding risk in PAD patients that may help balance the benefits and risks of antithrombotic therapy.

Methods: Single center retrospective study analyzing data all patients admitted for lower limb revascularization procedures between 2020 and 2023. The primary objective was to evaluate the proportion of patients, as categorized into the different categories of the OAC3PAD score, eligible for DPI, according to the VOYAGER PAD trial criteria.

Results: A total of 652 patients were included in this study. Mean age of the patients was 69,6 ±10,3 years, and 76,8% were male. Out of the 652 patients, 12% were classified as high bleeding risk, 23% as intermediate to high bleeding risk, 46% as low to moderate bleeding risk, and 19% as low bleeding risk. Based on the VOYAGER PAD trial criteria, 441 patients (67,6%) were identified as potential candidates for low-dose rivaroxaban therapy. Eligibility for DPI varied significantly (p<0.001) across OAC3PAD scores, with the highest proportion of patients observed in the low to intermediate bleeding risk patients, while the lowest was in the high bleeding risk patients.

Conclusion: Current evidence points to a higher bleeding risk of PAD patients than previous stated, especially when CLTI patients are being considered. Despite showing promising results, DPI with low dose rivaroxaban plus aspirin may require special caution in almost 50% of CLTI patients due to bleeding risk. This is a more frail and older population were adverse cardiovascular and limb events are more common and would benefit the most from strategies to reduce such events.

Tracheal Surgery - a 10-year Center Experience

Patricia M. Castro, Cátia Silva, António Lima, José Miranda, Miguel Guerra — Mon, 04 Aug 2025 00:00:00 -0700

Background: Tracheal surgery is a specialized field in which many disciplines work jointly due to the variety of indications and the extended topography. The main indications for surgery include inflammatory (generally post-intubation), congenital or post-traumatic stenoses, benign or malignant neoplasms and tracheal lacerations, whether iatrogenic or traumatic. The purpose of this study is to review the management of one institution's approach to a wide variety of tracheal lesions over the last 10 years.

Methods: We retrospectively analyzed data of all subjects submitted to tracheal surgery in our center, between January 1, 2014 and December 31, 2023. The preoperative and postoperative data were retrospectively evaluated through the consultation of the clinical files and the computer registry system.

Results: We included 24 patients, mean age of 53 years (min 19; max 87), 54% being female. The most frequent indication for surgery was post-intubation tracheal stenosis (16, 67%) followed by tracheal laceration (6, 25%) and pleomorphic adenoma of the trachea (2, 8%). The mean operative time was 148 minutes (min: 80; max. 205). The mean tracheal length resected was 2,14 cm (min: 1; max: 3,2). Postoperative complications included: vocal cord paralysis (2, 8%), surgical wound site infection (2, 8%), anastomotic dehiscence (1, 4%) and mediastinitis (1, 4%). Re-stenosis occurred in 1 patient who was treated with prosthesis placement via bronchoscopy and 1 patient required definitive tracheostomy due to vocal cord paresis. Median chin stitch duration and median length of stay was 10 and 15 days, respectively. In-hospital mortality was 8% (2 cases). Overall mortality during mean follow-up time (51 months) was 8% (2 cases).

Conclusions: Tracheal surgery seems a valid and safe technique in selected patients and can be performed safely with low morbidity and mortality, according to our center results.

Using Pedal Acceleration Time To Predict Ischemic Wound Healing In Diabetic Patients

Eduardo Silva, Joana Iglésias, Pedro Lima, Luís F. Antunes, Manuel Fonseca — Mon, 04 Aug 2025 00:00:00 -0700

Aim: Diabetes Mellitus is one of the main factors for peripheral arterial disease (PAD), while also being associated with medial arterial calcification, thus limiting the use of the ankle-brachial index. Pedal acceleration time (PAT), has emerged as a diagnostic alternative, by measuring the systolic acceleration in the arteries of the foot, with higher PAT values corresponding to a worse prognosis and with the literature suggesting a cut-off of 180 ms as a predictor of wound healing. We aimed to confirm whether we could use PAT to predict wound healing, need for revascularization and amputation in diabetic patients and whether this cut-off was valid in our population.

Methods: A retrospective cross-sectional study was carried on diabetic patients referred to our department with PAD and lower limb wounds. Each limb was assessed individually in case of bilateral wounds. Limbs with unmeasurable PAT were excluded. Limbs were assessed on follow-up and classified as: healed wounds (HW), non-healed wounds (NHW), revascularized or amputated. PAT cut-off for wound healing was measured with ROC curve. Significance was defined at p≤0.05.

Results: A total of 88 patients and 100 limbs were included, mostly males (80.68%) with a median age of 75 years. Cut-off for wound healing was validated at 180.5 ms. Among the assessed limbs, 26% HW, 31% NHW, 33% revascularized limbs and 7% amputations. Mean PAT in each group was 159.81 ms (HW), 199.32 ms (NHW), 239.18 ms (revascularized), 279.14 ms (amputated). When comparing the HW and NHW groups, 61.3% of NHW had PAT >180ms versus 19.2% HW, p<0.001 (OR=6.65; 95%CI [1.98-22.39]). In the sub-set of NHW we further analysed whether the wound was clinically better or worse: wounds with a positive healing process had a mean PAT of 189.96 ms vs 231.43 ms (p=0.14) in wounds with worse evolution.

Conclusion: The results of our study validate the cut-off of 180 ms and reinforce using PAT as a predictor for wound healing, even among diabetic patients. In our analysis, only patients with HW had mean PAT ≤180 ms, with higher values of PAT being associated with worse outcomes (need for revascularization/amputation). Furthermore, in NHW patients, those with a PAT closer to 180 ms were associated with more favourable wound healing outcomes.

Thoracic Surgery - Notes on Its History in Brazil

Roger Normando, João Pedro Normando — Mon, 04 Aug 2025 00:00:00 -0700