Cardiac surgery in infective endocarditis and predictors of in-hospital mortality. / Cirurgia cardíaca na endocardite infeciosa e preditores da mortalidade intra­hospitalar.

INTRODUCTION: Infective endocarditis (IE) is a serious disease with significant in-hospital mortality (15-30%) despite advances in medical and surgical therapy. AIMS: To perform a clinical characterization of patients undergoing cardiac surgery for IE and to identify factors that predict in-hospital mortality. METHODS: We retrospectively analyzed 145 patients with IE admitted between January 2006 and October 2017. RESULTS: The median age was 72 years. IE was acquired mainly in the community (69%), and involved the native aortic valve in 54% of patients, biological prosthetic valves in 22.1% and mechanical valves in 10.3%. Staphylococcus spp. (31.0%) were the most frequent etiological agents. Cardiac surgery was emergent in 29 patients, urgent in 108, and elective in eight. The main indications were heart failure (57.9%), large vegetations (20%), systemic embolism (17.2%) and valve dysfunction (15.2%). Overall, biological valves were implanted in 62.1% of patients and mechanical valves in 37.2%. A total of 19 patients (13.1%) died. Predictors of mortality were preoperative atrial fibrillation and lower left ventricular ejection fraction, postoperative severe valve regurgitation associated with cardiogenic shock, sepsis, septic shock associated with cardiogenic shock, cardiac tamponade, need for renal replacement therapy and, although without statistical significance, emergent surgery. CONCLUSIONS: There is a need for better indicators to enable early identification of surgical candidates for IE, implementation of a heart team, and better surgical strategies, including more rapid intervention, more specific postoperative care, and optimal antibiotic therapy.

Frailty Syndrome: Visceral Adipose Tissue and Frailty in Patients with Symptomatic Severe Aortic Stenosis.

BACKGROUND/OBJECTIVES: In patients with severe aortic stenosis (AS), frailty is a clinically relevant measure of increased vulnerability that should be included in the preoperative risk assessment. Bioelectrical impedance analysis (BIA) derived phase angle (PA) reflects cell membrane integrity and function. Few studies are available on the relative contribution of adiposity distribution on frailty, and about the influences of frailty and visceral obesity in PA value. Therefore, we aimed to evaluate associations among frailty, visceral fat depots and PA in patients with symptomatic severe AS. METHODS: In a cohort of patients with symptomatic severe AS and preserved ejection fraction, we examined the associations between frailty, visceral fat depots and bioelectrical impedance analysis (BIA) derived phase angle (PA); and between visceral fat and PA. Frailty was defined according the Fried et al. scale criteria and the body fat distribution was determined by multidetector computed tomography and by BIA. RESULTS: Of the fifty-five included patients, 26 were frail (47%). Adjusting for age and gender, frailty was associated with indexed epicardial adipose tissue volume (EATVi) (the odds of frailty increased 4.1-fold per additional 100 cm3/m2 of EAT [95% confidence interval (CI) of 1.03 to 16.40, p=0.04] and with PA (OR of 0.50, 95% CI, 0.26 to 0.97, p=0.04), but not with body mass index (BMI), waist circumference (WC), indexed total, visceral and subcutaneous abdominal fat areas (TAFAi, VAFAi and SAFAi) nor with indexed mediastinal adipose tissue volume (MATVi). In an age and gender adjusted linear model, PA was inversely correlated with EATVi (ß=-0.008, 95% CI, -0.016 to -0.001, p=0.03), but not with BMI, WC, nor with MATVi, VAFAi, SAFAi and TAFAi. CONCLUSIONS: In patients with symptomatic severe AS, EATVi is associated with frailty, independently of age and gender, but not with MAFVi or VAFAi. Moreover, frailty and EATVi are associated with impaired cell membrane integrity and function assessed by PA.

Surgical treatment of bronchiectasis: A review of 20 years of experience.

BACKGROUND: Bronchiectasis is defined as an abnormal and irreversible dilation and distortion of the bronchi, which has numerous causes. Surgical treatment of this disease is usually reserved for focal disease and when the medical treatment is no longer effective. We report our center experience and outcomes in bronchiectasis surgery during the last 20 years. METHODS: Between 1994 and 2014, sixty-nine patients underwent surgical resection for bronchiectasis. Patient demographics, presenting symptoms, indications for surgical treatment, type of lung resection, morbidity and mortality, as well as clinical follow-up and outcomes were analyzed. RESULTS: From the 69 patients included, 31 (44.9%) were male and 38 (55.1%) were female. Surgery was indicated because of unsuccessful medical therapy in 33 patients (47.8%), haemoptysis in 22 patients (31.9%), nondiagnostic lung mass in 9 patients (13.0%) and lung abscess in 5 patients (7.3%). The surgical procedures were lobectomy in 45 (65.2%) patients, pneumonectomy in 10 (14.5%) patients, bilobectomy in 8 (11.6%) patients, lobectomy plus segmentectomy in 3 (4.3%) patients and only segmentectomy in 3 (4.3%) patients. Morbidity rate was 14.5% and there was no perioperative mortality. The follow-up was possible in 60 patients, with an outcome reported as excellent in 44 (73.3%) patients, as improved in 11 (18.3%) and as unchanged in 5 (8.3%). CONCLUSION: Although the number of patients with bronchiectasis referred for surgical treatment has decreased, pulmonary resection still plays a significant role. Surgical resection of localized bronchiectasis is a safe procedure with proven improvement of quality of life for the majority of patients.

[Therapeutic implication of the azygos vein lobe in patients with pulmonary adenocarcinoma]. / Implicações terapêuticas do lobo da veia ázigos em doente com adenocarcinoma do pulmão.

The azygos vein lobe is an anatomic variant reported in 0.1 to 8% of the population and results from an anomalous development of the right lung upper lobe. In the majority of the cases, clinical implications are lacking. Since the original description of a tumor of the azygos vein lobe, in 1969, only two more cases have been reported in the literature. Behind its rarity, a tumor with such location may pose some management implications. The authors report the clinical case of a 56 years old smoker man, in whom a chest x-rays revealed a poorly defined image in the upper lobe of the right lung. Complementary studies and evaluation allowed the diagnosis of pulmonary adenocarcinoma, adherent to the azygos vein, in a patient with azygos vein lobe. The authors emphasize the fact that despite the origin of the tumor being the lung, the presence of this anatomic variant of the azygos vein played a determinant role in the surgical approach.

[Two-years experience with the use of radial artery in coronary revascularization surgery]. / Dois anos de experiência uso da artéria radial em cirurgia coronária.

INTRODUCTION: Among several other factors, in coronary surgery the results depend on the quality and durability of the grafts. Revascularization employing arterial conduits, namely the radial artery, has been playing a growing role, with the aim of replacing the autologous saphenous vein. The benefits and risks of this strategy is still a matter of controversy. The goal of the present study was the evaluation of the incidence of early complications related to the use of radial artery in the revascularization surgery of the myocardium. METHODS: A series of consecutive patients who underwent coronary revascularization surgery in the CHVNGaia using radial artery, from January 2000 to December 2001, was retrospectively analyzed. Data were obtained through the revision of the clinical charts and hospital database. The major end-point assessed was the 30-day or intra hospital postoperative death; furthermore, acute myocardial infarction, stroke, renal failure, prolonged ventilation and reoperations for acute graft occlusion, bleeding and mediastistinitis were also evaluated. RESULTS: During that period of time, 656 patients underwent coronary revascularization surgery, but the radial artery was used in only 230 (35%). Mean age was 60.2+/- 9.1 years and 42 (18.3%) were female. Two hundred and four patients (88.6%) were operated on under extracorporeal circulation. The average number of grafts was 2.6+/- 0.6 per patient. Mean duration of orotraqueal intubation was 2.4 +/- 6 hours. Thirty patients (14,3 %) developed atrial fibrillation and ten (4.3%) had postoperative bleeding. Perioperative myocardial infarction occurred in five cases (2.2%). Two patients (0.8%) underwent reoperation for mediastinitis and one patient (0.4%) was reoperated on for acute occlusion of the graft. The overall postoperative mortality was 1.3% (3 patients). CONCLUSION: The use of radial artery in coronary revascularization did not caused morbidity and mortality, out of the usual context of coronary surgery. The results of our experience suggest that radial artery can be successfully used in myocardial revascularization surgery, enlarging the possibilities of utilization of arterial autografts.

Intrapericardial paraganglioma.

We describe the case of an intrapericardial pheochromocytoma located in the anterior surface of the heart and spreading over the pulmonary trunk. Under cardiopulmonary bypass (CPB) the tumor was removed. "En bloc" resection of the anterior wall of the right ventricular infundibulum and the pulmonary trunk was performed, with implantation of a fresh aortic homograft in the pulmonary position to avoid free pulmonary regurgitation.

[Valve replacement with Macchi prosthesis]. / Substituição valvular com proótese de Macchi.

OBJECTIVE: to evaluate the performance of a new ball valve prosthesis. DESIGN: set up of two groups of patients who underwent mitral valve replacement with two different prosthesis: the Macchi prosthesis under evaluation and the well known Starr-Edwards model prosthesis. The chi-square test was used to compare the results. PATIENTS: Patients referred for valvular surgery. INTERVENTIONS: One group of 98 consecutive patients who underwent isolated mitral valve replacement with a Macchi prosthesis from January 1984 to June 30 1986 was compared to a matched group of 49 patients who received a Starr-Edwards prosthesis in the same period of time. Follow-up data were available from 99% patients in the Macchi group 96% in the Starr-Edwards group, with a mean follow-up time of 35.2 (2-57) and 42.9 (4-62) months, respectively. RESULTS: There was no statistical difference in the incidence per 100 patients--month of prosthetic complications--thromboembolism, hemorrhagic events, prosthetic endocarditis, reoperation and mechanical failure. CONCLUSIONS: In our experience and with the available follow-up data the Macchi prosthesis is a good cost effective option when there is indication for a ball valve prosthesis.

Liposarcoma of the heart. A case report.

The authors report a tumor of the heart in a 33-year-old man. Preoperative diagnosis was of a cardiac myxoma. Upon operation, the tumor was revealed to arise from the right atrial free wall, occupying most of the atrial and ventricular cavities and causing a noticeable enlargement and obstruction of the tricuspid valve as well as the mentioned cardiac chambers. A smaller part of the tumor was placed on the outside of the right atrial wall, and implants of the tumor in the distal part of the aorta, extending backward to the bifurcation of the pulmonary artery and its branches, were also observed. Histological examination showed a myxoid-type tumor with light and ultrastructural features of liposarcoma. The patient died 13 months after surgery with regional extension of the tumor.