Lesión cardíaca por arma blanca inadvertida durante la evaluación inicial en el servicio de emergencia / Missed cardiac stab injury during initial evaluation in the Emergency Department

Introducción. La incidencia reportada de traumatismo cardíaco es baja y su grado de resolución es variable, dependiendo de la causa, el mecanismo de la lesión, el lugar donde ocurra y las características del sistema sanitario. Su incidencia ha aumentado recientemente debido al incremento de los accidentes de tránsito y la violencia, predominando los traumatismos penetrantes asociados a heridas por armas cortopunzantes y de fuego. Los traumatismos cardíacos se acompañan de un alto grado de letalidad. Caso clínico. Mujer de 35 años que consultó a emergencia por trauma torácico penetrante ocasionado por arma blanca y fue intervenida de urgencia por derrame pleural izquierdo, sin mejoría hemodinámica. Fue reevaluada detectándose derrame pericárdico con taponamiento cardíaco, ocasionado por lesión cardíaca. Fue tratada quirúrgicamente con resultados satisfactorios. Resultados. Las manifestaciones clínicas en los traumatismos penetrantes generalmente son graves y fatales, pero en algunos casos puede no comprometer tanto la hemodinamia del paciente. Para consolidar el diagnóstico clínico pueden realizarse variados estudios, siendo la ecografía FAST extendida uno de los más recomendados por su elevada sensibilidad y especificidad. Dependiendo del adelanto tecnológico del centro hospitalario y la estabilidad hemodinámica del paciente, el tratamiento quirúrgico es el más indicado. Conclusión. El conocimiento del trauma cardíaco penetrante resulta de gran importancia, no solo para el médico del servicio de emergencia sino también para el médico general. Un diagnóstico rápido y acertado, unido a un manejo adecuado, pueden ser decisivos para salvar la vida del paciente.

Introduction. The reported incidence of cardiac trauma is low and its degree of resolution is variable depending on the cause, the mechanism of injury, the place where it occurs and the characteristics of the health care system. Their incidence has currently increased due to the increase in traffic accidents and violence, with a predominance of penetrating trauma associated with stab wounds and firearms. Cardiac trauma is accompanied by a high degree of lethality. Clinical case. A 35-year-old female patient, evaluated in the emergency room for penetrating thoracic trauma caused by stab wound. She underwent emergency intervention due to left pleural effusion, but without hemodynamic improvement. She was reevaluated and pericardial effusion with cardiac tamponade caused by cardiac injury was detected. She was treated surgically with satisfactory results. Results.The clinical manifestations generally described in penetrating cardiac trauma are severe and fatal, but in some cases and due to the characteristics of the injury caused, the patient's hemodynamics may not be so compromised. To consolidate the clinical diagnosis, several complementary studies can be performed, with FAST ultrasound being one of the most recommended due to its high sensitivity and specificity. Surgical treatment is still the most indicated, depending on the technological progress of the hospital and the hemodynamic stability of the patient. Conclusions.Knowledge of penetrating cardiac trauma is of great importance, not only for the emergency department physician but also for the general practitioner. A quick and accurate diagnosis, together with adequate management can be decisive in saving the patient's life.

Diagnosis and treatment of 131 adult patients with bronchopulmonary sequestration: A retrospective analysis / 中国胸心血管外科临床杂志

@#Objective    To explore the safety and feasibility of uni-portal video-assisted thoracic surgery (VATS) for the treatment of bronchopulmonary sequestration (BPS). Methods    The clinical data of BPS patients with surgical resection in Shanghai Pulmonary Hospital from February 2010 to June 2021 were reviewed. The patients were divided into a VATS group and a thoracotomy group according to the operation method. The operation time, intraoperative blood loss, hospital stay and postoperative complication rate were compared between the two groups. The VATS group was subdivided into a uni-portal VATS group and a multi-portal VATS group for subgroup analysis. Results    Finally 131 patients were enrolled, including 62 males and 69 females with an average age of 39.3±13.2 years. There were 103 patients in the VATS group and 28 patients in the thoracotomy group. A total of 104 patients were diagnosed with left lower BPS, 26 with right lower BPS and 1 with bilateral lower BPS. The main symptom was cough (88 patients, 67.2%). There were 119 patients diagnosed by thoracic enhanced CT before operation. Compared with the thoracotomy group, the operation time was not statistically different (P=0.717), but the blood loss was less, the rate of postoperative complication was lower and hospital stay was shorter in the VATS group (P<0.05). The rate of conversion to open surgery in the uni-portal VATS group and multi-portal VATS group was 11.8% and 13.5%, respectively. Meanwhile, patients in the uni-portal VATS group had shorter operation time and postoperative hospital stay, less blood loss and lower postoperative complication rate than those in the multi-portal VATS group (P<0.05). Conclusion     In order to improve the rate of diagnosis, the lung enhanced CT scan should be selected as an optimal noninvasive method in adult suspected patients (especially those with solid cystic and solid lesions in the lower lobe). Uni-portal VATS is a safe and feasible method for BPS which can be widely promoted.

Efetividade da terapia Reiki para ansiedade pré-operatória na cirurgia cardíaca: ensaio clínico randomizado / Efectividad de la terapia de reiki para ansiedad preoperatoria en cirugía cardíaca: ensayo clínico aleatorizado / Effectiveness of Reiki therapy for preoperative anxiety in cardiac surgery: a randomized clinical trial

Resumo Objetivo Avaliar a efetividade de um protocolo de Reiki nos níveis de ansiedade no período pré-operatório de cirurgia cardíaca. Métodos Ensaio clínico controlado e randomizado realizado em um hospital universitário de referência em cardiologia entre junho e dezembro de 2021. Foi realizada randomização em bloco e alocação por sorteio com envelopes selados opacos em dois grupos: Controle (n=44; não submetido a intervenção) e Intervenção (n=44; submetido a duas sessões de Reiki três dias antes e na véspera da cirurgia). Os desfechos principais (ansiedade, bem-estar e tensão muscular) foram avaliados ao longo das sessões usando um modelo de efeitos mistos. Para avaliar o tamanho do efeito foram calculados os valores parciais de eta quadrado (η2p). Resultados Foram determinadas as diferenças nos escores de ansiedade (+2,7 pontos a mais para o controle), bem-estar (-0,78) e tensão muscular (1,27), sendo consideradas estatisticamente significativas (p<0,001). Na análise do tamanho do efeito, o experimento distinguiu melhor a variação na variável ansiedade (η2p=0,74) que nas outras duas variáveis (η2p=0,14; η2p=0,23). Conclusão O estudo oferece evidência favorável para efetividade do Reiki no controle da ansiedade pré-operatória de cirurgia cardíaca.

Resumen Objetivo Evaluar la efectividad de un protocolo de reiki en los niveles de ansiedad en el período preoperatorio de cirugías cardíacas. Métodos Ensayo clínico controlado y aleatorizado, realizado en un hospital universitario de referencia en cardiología entre junio y diciembre de 2021. La aleatorización se realizó por bloques y la asignación por sorteo con sobres cerrados opacos en dos grupos: Control (n=44, sin intervención) y Experimental (n=44, sometidos a dos sesiones de reiki, una tres días antes y otra en la víspera de la cirugía). Los criterios de valoración principales (ansiedad, bienestar y tensión muscular) fueron evaluados a lo largo de las sesiones, mediante un modelo de efectos mixtos. Para evaluar el tamaño del efecto se calcularon los valores parciales de eta cuadrado (η2p). Resultados Se observaron diferencias en la puntuación de ansiedad (+2,7 puntos más en el grupo de control), bienestar (-0,78) y tensión muscular (1,27), consideradas estadísticamente significativas (p<0,001). En el análisis del tamaño del efecto, el estudio percibió mejor la variación en la variable ansiedad (η2p=0,74) que en las otras dos variables (η2p=0,14; η2p=0,23). Cirugía El estudio ofrece evidencias favorables para la efectividad del reiki en el control de la ansiedad preoperatoria de cirugías cardíacas. Registro Brasileiro de Ensaios Clínicos: RBR-2nhgvn6

Abstract Objective To assess the effectiveness of a Reiki protocol on anxiety levels in the preoperative period of cardiac surgery. Methods This is a controlled and randomized clinical trial carried out in a university reference hospital in cardiology between June and December 2021. Chunk randomization and allocation by draw with opaque sealed envelopes were carried out in two groups: Control (n=44; not subjected to intervention); and Intervention (n=44; submitted to two Reiki sessions three days before and the day before surgery). The main outcomes (anxiety, well-being and muscle tension) were assessed across sessions using a mixed effects model. To assess the effect size, partial eta squared (η2p) values were calculated. Results Differences in anxiety scores (+2.7 points more than the control), well-being (-0.78) and muscle tension (1.27) were determined, being considered statistically significant (p<0.001). In analyzing the effect size, the experiment better distinguished the variation in the anxiety variable (η2p=0.74) than in the other two variables (η2p=0.14; η2p=0.23). Conclusion The study offers favorable evidence for the effectiveness of Reiki in controlling preoperative anxiety after cardiac surgery. Brazilian Clinical Trials Registry: RBR-2nhgvn6

Relação entre a Complacência Pulmonar Estática e a Falha de Extubação em Pacientes Pós-Operatório de Cirurgia Cardíaca / Relationship between Static Lung Compliance and Extubation Failure in Postoperative Cardiac Surgery Patients

Resumo Fundamento: Pouco explorada na decisão de extubação no pós-operatório de cirurgia cardíaca, a complacência pulmonar estática seriamente afetada no procedimento cirúrgico pode levar à insuficiência respiratória e à falha na extubação. Objetivo: Avaliar a complacência pulmonar estática no pós-operatório de cirurgia cardíaca e relacionar sua possível redução aos casos de falha na extubação dos pacientes submetidos ao método fast-track de extubação. Métodos: Foram incluídos pacientes que realizaram cirurgia cardíaca com uso de circulação extracorpórea (CEC) em um hospital universitário estadual admitidos na UTI sob sedação e bloqueio residual. Tiveram sua complacência pulmonar estática avaliada no ventilador mecânico por meio do software que utiliza o least squares fitting (LSF) para a medição. No período de 48 horas após a extubação os pacientes foram observados respeito à necessidade de reintubação por insuficiência respiratória. O nível de significância adotado para os testes estatísticos foi de 5%, ou seja, p<0,05. Resultados: Obtiveram sucesso na extubação 77 pacientes (75,49%) e falharam 25 (24,51%). Os pacientes que falharam na extubação tiveram a complacência pulmonar estática mais baixa quando comparados aos que tiveram sucesso (p<0,001). Identificamos o ponto de corte para complacência por meio da análise da curva Receiver Operating Characteristic Curve (ROC) sendo o ponto de corte o valor da complacência <41ml/cmH2O associado com maior probabilidade de falha na extubação (p<0,001). Na análise de regressão múltipla, verificou-se a influência da complacência pulmonar (dividida pelo ponto de corte da curva ROC) com risco de falha 9,1 vezes maior para pacientes com complacência <41ml/cmH2O (p< 0,003). Conclusões: A complacência pulmonar estática <41ml/cmH2O é um fator que compromete o sucesso da extubação no pós-operatório de cirurgia cardíaca.

Abstract Background: Static lung compliance, which is seriously affected during surgery, can lead to respiratory failure and extubation failure, which is little explored in the decision to extubate after cardiac surgery. Objective: To evaluate static lung compliance in the postoperative period of cardiac surgery and relate its possible reduction to cases of extubation failure in patients submitted to the fast-track method of extubation. Methods: Patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) at a state university hospital admitted to the ICU under sedation and residual block were included. Their static lung compliance was assessed on the mechanical ventilator using software that uses least squares fitting (LSF) for measurement. Within 48 hours of extubation, the patients were observed for the need for reintubation due to respiratory failure. The level of significance adopted for the statistical tests was 5%, i.e., p<0.05. Results: 77 patients (75.49%) achieved successful extubation and 25 (24.51%) failed extubation. Patients who failed extubation had lower static lung compliance compared to those who succeeded (p<0.001). We identified the cut-off point for compliance through analysis of the Receiver Operating Characteristic Curve (ROC), with the cut-off point being compliance <41ml/cmH2O associated with a higher probability of extubation failure (p<0.001). In the multiple regression analysis, the influence of lung compliance (divided by the ROC curve cut-off point) was found to be 9.1 times greater for patients with compliance <41ml/cmH2O (p< 0.003). Conclusions: Static lung compliance <41ml/cmH2O is a factor that compromises the success of extubation in the postoperative period of cardiac surgery.

Prolonged survival after thoracic metastasectomy in patients with nonseminomatous testicular cancer

Abstract Introduction Almost 20 % of patients with Non-Seminomatous Germinative Cell Tumors (NSGCT) will require intrathoracic metastasectomy after chemotherapy. The authors aim to determine their long-term survival rates. Methods Retrospective study including patients with NSGCT and intrathoracic metastasis after systemic therapy from January 2011 to June 2022. Treatment outcomes and overall survival were analyzed with the Kaplan-Meier method. Results Thirty-seven male patients were included with a median age of 31.8 years. Six presented with synchronous mediastinum and lung metastasis, nine had only lung, and 22 had mediastinal metastasis. Over half had retroperitoneal lymph node metastasis. Twenty-two had dissimilar pathologies, with a discordance rate of 62 %. Teratoma and embryonal carcinoma were the prevalent primary tumor types, 40.5 % each, while teratoma was predominant (70.3 %) in the metastasis group. Thoracotomy was the main surgical approach (39.2 %) followed by VATS (37.2 %), cervico-sternotomy (9.8 %), sternotomy (5.8 %), and clamshell (3.9 %). Lung resection was performed in 40.5 % of cases. Overall, 10-year survival rates were 94.3 % with no surgical-related mortality. Conclusion Multimodality treatment with systemic therapy followed by radical surgery offers a high cure rate to patients with intrathoracic metastatic testicular germ cell tumors.

Utilización del ultrasonido como herramienta para el diagnóstico y tratamiento en cirugía de tórax

Objetivo: presentar la utilización de la guía ecográfica en el tórax para realizar biopsias y colocación de drenajes, ya sean pleurales o pericárdicos. Material y método: se realizaron 124 procedimientos ecoguiados en el Instituto del Tórax del Hospital Maciel, desde enero de 2014 hasta agosto de 2022. Resultados: se evaluaron franja etaria, tipo de procedimiento y rentabilidad diagnóstica en los procedimientos ecoguiados. Se realizaron 69 punciones con fines diagnósticos, 48 colocaciones de drenajes pleurales bajo apoyo ecográfico y 7 drenajes pericárdicos. Conclusión: la realización de procedimientos ecoguiados en el tórax es una herramienta diagnóstica y terapéutica segura, con buen rendimiento y mínimas complicaciones.

Objective: To present the use of ultrasound guidance to perform thorax biopsies and place drainages, whether pleural or pericardial. Method: A total of 124 ultrasound-guided procedures were performed at the Thoracic Institute, Maciel Hospital, from January 2014 to August 2022. Results: The results were assessed based on age group, type of procedure, and diagnostic yield in the ultrasound-guided procedures. There were 69 diagnostic punctures, 48 ultrasound-guided pleural drainage placements, and 7 pericardial drainages. Conclusions: The performance of ultrasound-guided thoracic procedures are a safe diagnostic and therapeutic tool with excellent efficacy and minimal complications.

Objetivo: fica no tórax para realização de biópsias e colocação de drenos pleurais ou pericárdicos. Materiais e métodos: foram realizados 124 procedimentos guiados por ultrassom no Instituto del Tórax do Hospital Maciel no período de janeiro de 2014 a agosto de 2022. Resultados: foram avaliadas faixa etária, tipo de procedimento e rentabilidade diagnóstica em procedimentos guiados por ultrassom. Foram realizadas 69 punções para fins diagnósticos, 48 colocações de drenos pleurais sob suporte ultrassonográfico e 7 drenos pericárdicos. Conclusão: a realização de procedimentos guiados por ultrassom no tórax é uma ferramenta diagnóstica e terapêutica segura, com bom desempenho e complicações mínimas.

Disección de aorta secundario a trauma, manejo clínico en Hospital General / Aortic dissection secondary to trauma, clinical management in General Hospital

INTRODUCCIÓN. La disección de aorta es una patología poco frecuente, cuando se presenta, lo hace de una manera catastrófica manifestada por dolor torácico o lumbar intenso acompañado de compromiso hemodinámico agudo, un diagnóstico y tratamiento temprano suelen ser cruciales para evitar la muerte del paciente, así mismo, una disección de aorta puede ser secundario a un trauma torácico por desaceleración y se presenta en 1,5% a 2%, lo que induce sobre todo a un desgarro localizado en la región del istmo aórtico. CASO CLÍNICO. Paciente masculino de 35 años, con antecedente de accidente en vehículo motorizado que provocó un traumatismo cráneo encefálico moderado, hematoma epidural parietal derecho, con resolución quirúrgica hace 18 meses, se descartó lesiones a nivel de tórax con radiografía de tórax normal, además se realizó ecografía FAST en ventana perihepática, suprapúbica, periesplénica y subxi-foidea sin encontrar alteración. Acudió al servicio de emergencia por un cuadro de hemiparesia derecha más disartria de 4 horas de evolución, se realiza tomografía de cráneo sin encontrarse lesión, catalogándose como evento cerebrovascular isquémico con recuperación neurológica. Durante su estancia hospitalaria presenta un cuadro de disnea de grandes esfuerzos y tras realizar exámenes complementarios de control se llega a una conclusión de una cardiomegalia, por lo que es referido a consulta de cardiología donde se realiza ecocardiograma, en la cual se observa disección de aorta ascendente más aneurisma por lo que se decide su ingreso y se instaura tratamiento mediante medidas de soporte, con derivación a hospital de especialidades para cirugía cardiotorácica. CONCLUSIONES. La disección de aorta secundario a un traumatis-mo es poco frecuente, sin embargo, el diagnostico siempre debe estar presente en caso de trauma por desaceleración, ya que es vital para la supervivencia del paciente y su manejo oportuno.

INTRODUCTION. Aortic dissection is an infrequent pathology; when it occurs, it does so in a catastrophic manner manifested by intense thoracic or lumbar pain accompanied by acute he-modynamic compromise. Early diagnosis and treatment are usually crucial to avoid the patient's death; likewise, aortic dissection can be secondary to thoracic trauma due to deceleration and occurs in 1.5% to 2%, which mainly induces a localized tear in the region of the aortic isthmus. CLINICAL CASE. 35-year-old male patient, with a history of motor vehicle accident that caused a moderate head injury, right parietal epidural hematoma, with surgical resolution 18 months ago, chest injuries were ruled out with normal chest X-ray, and FAST ultrasound was performed in perihepatic, suprapubic, perisplenic and subxiphoid window without finding any alteration. She went to the emergency department for a picture of right hemiparesis and dysarthria of 4 hours of evolution, a cranial tomography was performed without finding any lesion, being clas-sified as an ischemic cerebrovascular event with neurological recovery. During his hospital stay he presented with dyspnea of great effort and after performing complementary control tests, a cardiomegaly was found, so he is referred to a cardiology clinic where an echocardiogram is per-formed, which showed dissection of the ascending aorta plus aneurysm, admission is decided and treatment is instituted through supportive measures, with referral to a specialty hospital for cardiothoracic surgery. CONCLUSIONS. Aortic dissection secondary to trauma is rare, however, the diagnosis should always be present in case of trauma due to deceleration, as it is vital for the survival of the patient and its timely treatment.

Efeito da manobra de recrutamento alveolar no pós-operatório imediato de cirurgia cardíaca: uma revisão sistemática / Effect of the alveolar recruitment maneuver in the immediate postoperative period of cardiac surgery: a systematic review

Introdução: as cirurgias cardíacas são as intervenções de escolha em níveis mais avançados das doenças cardiovasculares, e complicações pulmonares podem ocorrer como consequência das alterações fisiológicas causadas pela circulação extracorpórea, pela anestesia e pela incisão esterno torácica. A fisioterapia atua com o intuito de prevenir e tratar essas complicações, através da utilização de uma das técnicas de expansão pulmonar mais utilizadas na reversão de hipoxemia e atelectasias, a manobra de recrutamento alveolar, com o objetivo de abrir alvéolos colapsados e aumentar as trocas gasosas. Objetivo: revisar sistematicamente os efeitos da manobra, na relação PaO2/FiO2, SatO2, o tempo de ventilação mecânica, o tempo de internamento, a incidência de atelectasia, a pressão arterial média e a frequência cardíaca. Metodologia: revisão de ensaios clínicos controlados e randomizados nas bases de dados PubMed, Cochrane Library, LILACS e PEDro. Foram incluídos estudos que utilizaram a manobra como prevenção de complicações pulmonares, publicados em inglês e português. Resultados: foram incluídos 4 estudos, publicados entre os anos 2005 e 2017. O nível de pressão da manobra variou entre 30 cmH2O a 40 cmH2O. Os estudos mostraram que a manobra foi estatisticamente relevante na relação PaO2/FiO2, SatO2 e na redução da incidência de atelectasias, sem impacto no tempo de ventilação mecânica, no tempo de internamento, na pressão arterial média e na frequência cardíaca. Conclusão: a manobra de recrutamento pode ser considerada como uma técnica a ser utilizada na prevenção de alterações pulmonares, porém não é possível afirmar se os benefícios da manobra perduraram em longo prazo.

Introduction: Cardiac surgeries are the interventions of choice in more advanced levels of cardiovascular disease, and pulmonary complications can occur as a result of physiological changes caused by cardiopulmonary bypass, anaesthesia and the sternum thoracic incision. Physiotherapy acts with the aim of preventing and treating these complications, through the use of one of the most used lung expansion techniques in the reversal of hypoxemia and atelectasis, the alveolar recruitment maneuver, with the objective of opening collapsed alveoli and increasing gas exchanges. Objective: To systematically review the effects of the maneuver on the PaO2/FiO2 ratio, SatO2, duration of mechanical ventilation, length of hospitalization, incidence of atelectasis, mean arterial pressure and heart rate. Methodology: Review of controlled and randomized clinical trials in PubMed, Cochrane Library, LILACS and PEDro databases. Studies that used the maneuver to prevent pulmonary complications, published in English and Portuguese, were included. Results: 4 studies, published between 2005 and 2017, were included. The maneuver pressure level ranged from 30 cmH2O to 40 cmH2O. The studies showed that the maneuver was statistically relevant in relation to PaO2/FiO2, SatO2 and in reducing the incidence of atelectasis, with no impact on the duration of mechanical ventilation, length of hospitalization, mean arterial pressure and heart rate. Conclusion: The recruitment maneuver can be considered as a technique to be used in the prevention of pulmonary alterations; however, it is not possible to state whether the benefits of the maneuver lasted in the long term.

Resección completa en dos tiempos de teratoma quístico gigante del mediastino que debuta con compromiso vital

Objetivo: Describir resolución quirúrgica de teratoma de mediastino en dos tiempos que debuta en paciente con urgencia vital. Materiales y Métodos: Revisión de caso clínico y descripción retrospectiva del manejo quirúrgico realizado. Resultados: Estudio imagenológico evidenció tumor con contenido quístico que comprometía ambos hemitórax. Dado compromiso vital del paciente, se realiza quistocentesis descompresiva en pabellón, seguido de videotoracoscopía que demuestra origen mediastínico y quistectomía parcial por toracotomía. En un segundo tiempo quirúrgico, se reseca remanente vía esternotomía media. Discusión: Los teratomas mediastínicos son extremadamente infrecuentes, reportándose 44 casos en literatura mundial, sin registros a nivel nacional. Afecta a jóvenes sanos, la mayoría asintomáticos, siendo su hallazgo tardío e incidental. El compromiso de estructuras mediastínicas y de vía aérea pueden ocasionar riesgo vital. Conclusión: La descompresión perioperatoria del contenido quístico del teratoma fue fundamental para mantener fuera de riesgo vital al paciente durante el acto quirúrgico.

Objective: To describe the successful surgical resolution of a giant teratoma of the mediastinum that presents with a vital emergency. Clinical Case: Male patient, 30 years old, with no known history, consulted for a 1-year history of dyspnea on minimal exertion, associated with weight loss without dietary restriction. Imaging study showed tumor with cystic content that compromised both hemithorax. Given the patient's vital commitment, decompressive cystocentesis was performed, followed by video-assisted thoracoscopy that showed mediastinal origin and partial cystectomy by thoracotomy. In a second surgical time, resection of the remnant was performed via median sternotomy. Discussion: Mediastinal teratomas are extremely rare, reporting 44 cases in the world literature, with no national registry. They usually affect healthy young people, most of them asymptomatic and therefore, their discovery is late and incidental. In this case, due to the compression of noble structures, perioperative cystic decompression was essential. Conclusion: Perioperative decompression of the cystic content of the teratoma was essential to maintain stable hemodynamics and subsequent surgical resection.

Catorce años después de abierto el debate sobre formación de un cirujano torácico general certificado / Fourteen Years following the Discussion about Training a Certified General Thoracic Surgeon

Introducción: En Cuba existen numerosos cirujanos que han dedicado una gran parte de su vida profesional a la cirugía del tórax no cardiovascular, pero solo ostentan el título de especialista de primer o segundo grado en cirugía general. Objetivo: Exponer los argumentos que demuestren la necesidad de crear e implementar la especialización de primer grado en cirugía torácica general o la maestría en cirugía del tórax. Métodos: Se realizó una búsqueda documental a partir de los motores de búsqueda de información científica Google Académico y Highwire Press. De la Web of Science, PubMed, Lilacs y Scopus se seleccionaron 23 artículos relacionados directamente con el objetivo propuesto. Desarrollo: En 2008 el profesor Benito Saínz Menéndez publicó un artículo en el cual expuso la necesidad de crear un programa de posgrado sobre cirugía torácica general; sin embargo, después de 14 años, aún se mantiene el debate sobre este tema. En tal sentido, los reclamos de la comunidad quirúrgica cubana en la propuesta de un programa de maestría y en una tesis doctoral se han hecho sentir en varias reuniones académicas y en diversas publicaciones. La nueva solicitud se justifica desde distintas aristas. Conclusión: El desarrollo de la educación de posgrado y la necesidad de formar recursos humanos capacitados en cirugía general ha acumulado los suficientes preceptos para solicitar la cirugía torácica como una subespecialidad o la inserción de una maestría sobre este tema. Se recomienda que se evalúe la posibilidad de la creación e implementación de la especialización o maestría en cirugía de tórax no cardiovascular(AU)

Introduction: In Cuba, there are numerous surgeons who have dedicated a large part of their professional life to noncardiovascular thoracic surgery, but they only hold the title of first- or second-degree specialist in General Surgery. Objective: To present the fundamentals demonstrating the need to create and implement the first-degree residence for general thoracic surgery or a master's degree in thoracic surgery. Methods: A document search was carried out using the scientific information search engines Google Scholar and Highwire Press. From the Web of Science, PubMed, Lilacs and Scopus, 23 articles directly related to the proposed objective were selected. Development: In 2008, Professor Benito Saínz Menéndez published an article in which he presented the need to create a postgraduate curriculum for general thoracic surgery; however, after 14 years, the debate on this subject is still ongoing. In this respect, the claims of the Cuban surgical community concerning the proposal of a master's program and a doctoral dissertation have been felt in several academic meetings, as well as in several publications. The new request is justified from different points of view. Conclusion: Through the development of postgraduate education and the need to train skilled human resources in general surgery, enough principles have been accumulated for requesting that thoracic surgery be taught as a subspecialty, or the insertion of a master's degree on this subject. The assessment is recommended for the possibility of creating and implementing a specialization or a master's degree in noncardiovascular thoracic surgery(AU)

Predictores clínicos y ecocardiográficos del síndrome de bajo gasto cardiaco en la cirugía valvular cardiaca

Objetivo: Determinar los posibles elementos predictores clínicos y ecocardiográficos asociados a la aparición del síndrome de bajo gasto cardiaco. Materiales y métodos: Se realizó un estudio analítico de casos y controles en pacientes con síndrome de bajo gasto cardiaco posoperatorio atendidos en el Centro de Cardiología y Cirugía Cardiovascular del Hospital Provincial Docente Saturnino Lora de Santiago de Cuba, desde enero 2019 a diciembre 2021. Ambos grupos de estudio formaron parte de la misma población de pacientes operados de cirugía cardiovascular, diferenciados por presentar o no síndrome de bajo gasto cardiaco postoperatorio al ingreso. La variable dependiente fue la presencia de bajo gasto cardiaco; las variables independientes, factores clínicos, hemodinámicos y ecocardiográficos. Resultados: En la serie predominaron los pacientes menores de 65 años tanto en el grupo de casos como de controles (51,2 % y 73,5 %, respectivamente). La fibrilación auricular, la función sistólica del ventrículo derecho y la hemorragia periprocedimiento (p = 0,008) presentaron alta significación estadística p 50 % (102 [91,10 %; p = 0,047]), así como amplio dominio de pacientes (76 [45,24 %; p ≤ 0,05; OR: 2,14]) con cirugías de emergencia. Se realizó una regresión logística, y se determinó que las variables clínicas y ecocardiográficas tales como la edad superior a 65 años, la función de ventrículo derecho deprimida, la circulación extracorpórea ≥90 minutos y la presión sistólica de arteria pulmonar elevada tuvieron una asociación estadísticamente significativa. El AUC mostró que variables como la edad, el tiempo de circulación extracorpórea y la hemorragia perioperatoria tuvieron capacidad predictiva. Conclusiones: Se observó que algunos elementos clínicos y ecocardiográficos, como la edad, la presencia de fibrilación auricular, la función sistólica del ventrículo derecho deprimida y la cirugía de emergencia, se asociaron como predictores de síndrome de bajo gasto cardíaco.

Objective: To determine the possible clinical and echocardiographic predictors associated with the onset of low cardiac output syndrome. Materials and methods: An analytical case-control study was conducted in patients with postoperative low cardiac output syndrome treated at Centro de Cardiología y Cirugía Cardiovascular of Hospital Provincial Docente Saturnino Lora in Santiago de Cuba from January 2019 to December 2021. Both study groups were part of the same population of patients who underwent a cardiovascular surgery but differed in the fact that, at admission, some suffered from postoperative low cardiac output syndrome and others did not. The dependent variable was the presence of low cardiac output and the independent variables were clinical, hemodynamic and echocardiographic factors. Results: In the series, patients under 65 years of age prevailed in both case and control groups (51.2 % and 73.5 %, respectively). Atrial fibrillation, right ventricular systolic function and perioperative bleeding (p = 0.008) were statistically significant (p 50 % and a large number of patients (76 [45.24 %; p ≤ 0.05; OR: 2.14]) had undergone emergency surgeries. A logistic regression analysis determined that the clinical and echocardiographic variables, such as age over 65 years, depressed right ventricular function, extracorporeal circulation ≥ 90 minutes and elevated pulmonary artery systolic pressure, had a statistically significant association. The area under the curve (AUC) showed that variables including age, extracorporeal circulation time and perioperative bleeding had predictive capability. Conclusions: It was observed that some clinical and echocardiographic elements, such as age, atrial fibrillation, depressed right ventricular systolic function and emergency surgery, were associated as predictors of low cardiac output syndrome.

Lobectomías pulmonares en Colombia: una caracterización demográfica y clínico-patológica / Pulmonary lobectomies in Colombia: a demographic and clinicopathological characterization

Introducción. La lobectomía pulmonar es uno de los procedimientos más frecuentes en la cirugía torácica en Colombia y a nivel mundial. El objetivo de este estudio fue proporcionar información sobre el comportamiento clínico de los individuos sometidos a este tipo de cirugías. Métodos. Estudio observacional retrospectivo en un Hospital Universitario de Cali, Colombia, que incluyó todos los pacientes sometidos a lobectomía pulmonar, por causas benignas o malignas, entre los años 2010 y 2020. La información se extrajo del registro institucional de cirugía de tórax, obteniendo datos demográficos, clínicos y patológicos. Resultados. Se evaluaron los registros clínicos de 207 individuos. El 55,5 % eran mujeres, la edad promedio fue 58 años y el 41 % tuvieron antecedente de tabaquismo. En el 51,6 % de los casos se diagnosticaron neoplasias, de las cuales el 47,8 % eran primarias de pulmón, siendo el adenocarcinoma el subtipo más común. Las enfermedades benignas no tumorales representaron el 48,3 % de los casos y la causa más frecuente fueron las infecciones, dentro de las que se incluyeron 17 casos de tuberculosis pulmonar. La técnica más frecuente fue la cirugía toracoscópica video asistida (82,6 %). Presentaron un porcentaje de reintervención del 5,8 %, 10,6 % de complicaciones severas y una mortalidad hospitalaria del 4,3 %. Conclusión. La población evaluada muestra una carga alta de comorbilidades y riesgo operatorio elevado; de forma consecuente, al compararla con otras series internacionales, se encontró un porcentaje mayor de complicaciones perioperatorias y mortalidad.

Introduction. The pulmonary lobectomies is one of the most common procedures in thoracic surgery in Colombia and worldwide. The objective of this study is to provide information on the clinical behavior of individuals who underwent this type of surgeries. Methods. Retrospective observational study at a University Hospital in Cali, Colombia, including all individuals who had pulmonary lobectomies, between the years 2010 to 2020 for benign and malignant causes. The information was extracted from the institutional registry of thoracic surgery, obtaining demographic, clinical and pathological data. Results. The clinical records of 207 individuals were evaluated, 55.5% were women, the average age was 58 years, and 41% had a history of smoking. Of these cases, 51.6% were diagnosed with neoplasms, of which 47.8% were primary lung neoplasms, with adenocarcinoma being the most common subtype. As for benign diseases, they represented 48.3% of the cases and the most frequent cause was infections, including 17 cases of pulmonary tuberculosis. The most frequent technique was video-assisted thoracoscopic surgery in 82.6%, with a reoperation rate of 5.8%, up to 10.6% of severe complications, a median hospital stay of 6 days, and a hospital mortality of 4.3%.Conclusion. The population evaluated shows a high burden of comorbidities and high operative risk; consequently, when compared with other international series, it shows a higher percentage of perioperative complications, hospital stay, and mortality.

Biocompatibility of the Oxygenator on Pulsatile Flow by Electron Microscope

ABSTRACT Introduction: Extracorporeal perfusion flow type requires further investigation. The aim of this study is to compare the effects of pulsatile and nonpulsatile flow on oxygenator fibers that were analyzed by scanning electron microscope (SEM) and to extensively study patients' coagulation profiles, inflammatory markers, and functional blood tests. Methods: Twelve patients who had open heart surgery were randomly divided into two groups; the nonpulsatile flow (group NP, six patients) and pulsatile flow (group P, six patients) groups. Both superficial view and axial sections of the oxygenator fiber samples were examined under SEM to compare the thickness of absorbed blood proteins and amount of blood cells on the surface of oxygenators. Platelet count, coagulation profile, and inflammatory predictors were also studied from the blood samples. Results: Fibrinogen levels after cardiopulmonary bypass were significantly lower in group NP (group P, 2.57±2.78 g/L; group NP; 2.39±0.70 g/L, P=0.03). Inflammatory biomarkers such as C-reactive protein, interleukin (IL)-6, IL-12, apelin, S100β, and tumor necrosis factor alpha were comparable in both groups. Axial sections of the oxygenator fiber samples had a mean thickness of 45.2 µm and 46.5 µm in groups P and NP, respectively, and this difference is statistically significant (P=0.006). Superficial view of the fiber samples showed obviously lower platelet, leukocyte, and erythrocyte levels in group P. Conclusion: Our study demonstrated that both cellular elements and protein adsorption on oxygenator fibers are lower in the group P than in the group NP. Pulsatile perfusion has better biocompatibility on extracorporeal circulation when analyzed by SEM technique.

Ministernotomy in Aortic Root and Arch Surgery: Early Outcomes

ABSTRACT Introduction: Minimally invasive methods have become more preferred in cardiac surgery today. In this study, the comparative results of patients who underwent an aortic root, arch or hemiarch replacement by ministernotomy and full sternotomy in our clinic are presented. Methods: Between January 2017 and October 2019, a series of operations including aortic root, ascending aorta, and aortic arch replacements were performed on 278 patients. The ministernotomy technique was used in 25 of them. Twenty patients who underwent full sternotomy were selected and matched to this group for comparison. Results: The ministernotomy group had a longer cross-clamping time (128.3±30.8 vs. 104.7±23.4 min, P=0.007) but the total operating time was similar in the two groups (249.76±28.56 vs. 248.25±37.53 min, P=0.879). The number of red blood cell (RBC) transfusions per patient was higher in the full sternotomy group (4.65±3.74 vs. 2.44±1.85 unit, P=0.020). The ministernotomy group had shorter ventilation times (7.60±4.88 vs. 32.30±32.25 h, P<0.001) and shorter ICU stay (1.56±0.58 vs. 3.35±1.46 d, P<0.001). The 30-day mortality was 0% in the ministernotomy group. Conclusion: Early results of our study show that, in combined or isolated aortic root, ascending aorta, and aortic arch surgeries, ministernotomy can be applied with relatively safety and low mortality and morbidity rates.

Cirugía de revascularización miocárdica: comparación de supervivencia a 10 años de la cirugía coronaria con y sin circulación extracorpórea mediante Propensity Score Matching / Ten-year survival after off-pump coronary artery bypass grafting compared with traditional bypass grafting

BACKGROUND: Long-term outcomes of Off-Pump Coronary Artery Bypass Grafting (OPCAB) as an alternative to the traditional Coronary Artery Bypass Grafting (CABG) technique with cardiopulmonary bypass (CPB) are not well defined. AIM: To compare 10-year survival of isolated OPCAB versus CABG with CPB. MATERIAL AND METHODS: Analysis of information obtained from databases, clinical records and surgical protocols of patients treated with isolated CABG between January 2006 and November 2008 at a Regional Hospital. Of 658 isolated CABG, 192 (29.2%) were OPCAB and 466 (79.9%) CPB. Propensity Score Matching (PSM) was performed to compare both groups. After PSM, two groups of 192 cases were obtained. Mortality data was obtained from the Chilean public identification service. Ten-year survival was calculated and compared with Kaplan-Meier and log-rank methods. RESULTS: Follow-up data was obtained in all cases. No statistically significant differences were found when comparing 10-year survival between OPCAB versus CPB (78.6% and 80.2% respectively, p 0.720). There was also no statistical difference in cardiovascular death free survival (90.1% with CPB versus 89.1% OPCAB, p 0.737). Survival was comparable when analyzing subgroups with diabetes mellitus, left ventricular dysfunction or chronic kidney disease, among others. CONCLUSIONS: In our series, OPBAB has a comparable 10-year survival with CABG with CPB.

Spontaneous pneumothorax in a young male athlete: A case report with review of literature

Spontaneous pneumothorax (SP) is a serious and life-threatening condition often caused by ruptured apical lung bulla in young male individuals. It is commonly associated with different syndromes but also occurs in healthy individuals. In this case report, we aim to discuss the etiology, clinical course, and surgical treatment of a 21-year-old male kickboxer with a right-sided pneumothorax that occurred during a sparring session. A chest tube with negative suction was inserted to resolve the pneumothorax. Because there was no visible resolution, video-assisted thoracoscopic surgery (VATS) was performed. During VATS, a large, apically placed, ruptured lung bulla, was revealed and removed. One month after surgery, the patient is in great clinical condition. There are no signs of a recurrence of SP.

Brazilian Adults' Hope and Spirituality in Preoperative Heart Surgery: A Cross-Sectional Study

ABSTRACT Introduction: Given the incipience of domestic studies on hope and spirituality in cardiology, this study evaluated adult cardiac patients' hope in the preoperative period of cardiac surgery and its potential association with spirituality. Methods: This is a cross-sectional study carried out at a university hospital in the State of São Paulo (Brazil). A total of 70 patients answered the Herth Hope Scale and a sociodemographic questionnaire before undergoing surgical procedure between January and October 2018. Descriptive and inferential analyses were performed using the Spearman's rank correlation coefficient and the Mann-Whitney U test. The R-3.4.1 software and SAS System for Windows 9.2 were also used. P-value < 0.05 was considered statistically significant. Results: Patients had a high prevalence of modifiable risk factors. Having a religion (37.53±4.57) and practicing it (38.79±4.25), regardless of its denomination and time dedicated to that religion, was associated with hope (P<0.01) in the immediate preoperative period of cardiac surgery. However, hope did not exhibit a significant correlation with factors such as age (P=0.09) and time dedicated to religious practice (P=0.07). Conclusion: Regardless of the religious strand and time dedicated to religious practices as an expression of spirituality, hope was associated with the participants' religion and religiosity. Considering the importance of this construct on the processes of health and disease, the whole health team should consider in their praxis a setting of conditions to make the patient's spirituality process feasible during hospitalization.

Risk Factors Associated with Ischemic Stroke in the Immediate Postoperative Period of Cardiac Surgery

ABSTRACT Introduction: Stroke remains a major complication of cardiac surgery. Despite all efforts, the incidence of postoperative stroke remains as high as 6%. We aimed to investigate risk factors for ischemic stroke in a contemporary cohort of patients undergoing cardiac surgery. Methods: This is a retrospective cohort study of 678 consecutive adult patients who underwent cardiac surgery requiring cardiopulmonary bypass in a tertiary hospital in Brazil between July 1, 2011, and December 31, 2018. The primary outcome was the rate of early (perioperative and seven-day postoperative) stroke, defined as the occurrence of the outcome during the index admission. We developed a predictive model of stroke using the Poisson regression analysis with robust variance. Results: Postoperative stroke occurred in 24 patients (3.5%), 23 (3.3%) were ischemic, and 21 (3.0%) were diagnosed in the first 72 hours after surgical procedure. After multivariate analysis, the following factors were significantly associated with stroke: previous stroke/transient ischemic attack (relative risk [RR]=2.75; 95% confidence interval [CI], 1.11-6.82), carotid artery disease (RR=4.0; 95% CI, 1.43-11.0), previous atrial fibrillation (RR=3.26, 95% CI, 1.31-8.1), and postoperative platelets > 200,000/mm3 (RR=2.26; 95% CI, 1.01-5.1). Conclusion: We developed a contemporary model to determine risk predictors for stroke after cardiac surgery. This model may help clinicians to identify patients at risk and could be useful in clinical practice.

Pioneer of Cardiothoracic Surgery - Joaquim Cavalcanti

ABSTRACT Joaquim de Souza Cavalcanti was a pioneer among us - the Brazilian State of Pernambuco and North-Northeast region - in cardiac surgery in its initial phase (Blalock-Taussig surgery and mitral valvulotomy), in thoracic surgery (pneumectomy, lung lobectomy and segmentectomy, lung decortication, and mediastinal tumor resection), and in numerous techniques and operative tactics in general surgery.

Validation of Blood Transfusion Risk Scores (TRACK and TRUST) in a Cardiac Surgery Service in Brazil

ABSTRACT Introduction: Transfusion of red blood cells is recurrent in cardiac surgery despite the well-established deleterious effects. Identifying patients with higher chances of requiring blood transfusion is essential to apply strategic preventive measures to reduce such chances, considering the restricted availability of this product. The most used risk scores to predict blood transfusion are the Transfusion Risk and Clinical Knowledge (TRACK) and Transfusion Risk Understanding Scoring Tool (TRUST). However, these scores were not validated for the Brazilian population. The objective of this study was to assess the accuracy of TRACK and TRUST scores in estimating the need for postoperative transfusion of red blood cell concentrates (TRBCC) after cardiac surgery. Methods: A clinical retrospective study was conducted using the database of a Brazilian reference service composed of patients operated between November 2019 and September 2021. Scores were compared using Mann-Whitney U test. Hosmer-Lemeshow goodness of fit test assessed calibration of the scores. Accuracy was assessed using the area under the receiver operating characteristic curve (AUC). All analyses considered a level of significance of 5%. The study was approved by the research ethics committee (CAAE 55577421.4.0000.5201). Results: This study assessed 498 patients. Only the TRACK score presented good calibration (P=0.238; TRUST P=0.034). AUC of TRACK was 0.678 (95% confidence interval 0.63 to 0.73; P<0.001), showing a significant accuracy. Conclusion: Between the scores analyzed, only the TRACK score showed a good calibration, but low accuracy, to predict postoperative TRBCC after cardiac surgery.