[A retrospective study on the quality of life of patients with primary focal hyperhidrosis that underwent a video-assisted thoracoscopic sympathectomy]. / Avaliação do Impacto na Qualidade de Vida de Pacientes Diagnosticados com Hiperdrose Primária Submetidos a Simpaticectomia Torácica por Vídeo-Toracoscopia.

Backgroud: Primary focal hyperhidrosis affects between 1 to 4% of the general population, with a higher prevalence in teenagers and young adults. The condition is characterized by excessive sweating in 1 or more body part, most often the palms, face, armpits and soles. This condition causes a significant negative impact on patient's quality of life. The pathophysiology of focal hyperhidrosis is believed to be due to excessive sympathetic stimulation, and videothoracoscopic sympathectomy is a recognized form of treatment. The aim of this study is to evaluate the post-operative quality of life of patients who underwent thoracoscopic sympathectomy. MATERIALS AND METHODS: This is a retrospective study of fifty-four patients with primary focal hyperhidrosis submitted to bilateral thoracoscopic thoracic sympathectomy at the Center of Cardiothoracic Surgery of Casa de Saúde da Boavista, between January 2011 and December 2014. The Quality of Life questionnaire and the Hyperhidrosis Severity Scale questionnaire were used to evaluate the quality of life in the pre-operative period and 3 months after surgery. Further to this, data was collected regarding medium-term follow-up by telephone. All patients underwent general anesthesia and had bilateral video-assisted thoracoscopic resection of the sympathetic chain. RESULTS: The majority of patients are females 59.3% (32). The mean age is 30.8 ± 7.70 (between 16 and 49 years). Prior to surgery, 85% of the patients had severe hyperhidrosis. 79.6% of respondents stated that general discomfort was promoted by the condition, with the Funcional-Social domain being the most affected aspect of their life (61.1%). The rates of peri-operative complications and major post-operative complications were null, and minor complications were 5.5%. After 3 months, improvement in patient's quality of life and satisfaction level were of 100% and 96.3% respectively, however compensatory hyperhidrosis was observed in 53.7% of patients. 57.3% of the patients reported significant improvements in the Funcional-Social domain. Medium-term follow-up (mean=6 years) allowed for the evaluation of 31 patients (57.4% of the population), of whom 77.4% maintained compensatory hyperhidrosis. 93.5% reported to be highly satisfied with the surgical results and claimed to have improved their quality of life by 93.5%. 94% and 94.4% respectively of the patients evaluated in the medium term follow-up and after 3 months and in the medium term follow-up, recommend the surgery. CONCLUSION: Sympathectomy by video-assisted thoracoscopic surgery (VATS) is an effective and viable therapeutic option for primary focal hyperhidrosis patients. Despite compensatory hyperhidrosis being observed at time, this procedure produces very satisfactory results particularly in regard to the patient's post-operative quality of life.

Introdução: A Hiperidose Focal Primária afeta entre 1 a 4% da população, principalmente adolescentes e jovens- -adultos. É um distúrbio secundário a um excesso de estimulação simpática caracterizado por sudorese excessiva que pode envolver as mãos, a face, as axilas e os pés, representando um importante impacto negativo na qualidade de vida dos pacientes. A simpaticectomia vídeotoracoscópica é uma forma reconhecida de tratamento desta patologia. Este estudo tem como principal objetivo avaliar a qualidade de vida pós-cirúrgica dos pacientes submetidos a simpaticectomia por cirurgia toracoscópica videoassistida. Material e Métodos: Estudo retrospetivo de cinquenta e quatro pacientes com hiperidrose focal primária submetidos a simpaticectomia torácica por videotoracoscopia bilateral, na Clínica de Cirurgia Cardiotorácica da Casa de Saúde da Boavista, entre Janeiro de 2011 e Dezembro de 2014. Foram utilizados o questionário Quality of Life e a Hiperhidrosis Severity Scale na avaliação da qualidade de vida no pré-operatório e nos 3 meses após a cirurgia, bem como, a recolha de dados via telefónica num follow up a médio prazo. Todos os pacientes foram submetidos a anestesia geral e a técnica cirúrgica usada foi a secção da cadeia simpática bilateralmente por cirurgia vídeo-toracoscópica. Resultados: A maioria dos pacientes é do sexo feminino 59,2% (32). A idade média de idades é de 30,8 ± 7,70 (entre 16 e 49 anos). Antes da cirurgia, 85% dos pacientes apresentavam hiperidrose severa. O grau de desconforto geral promovido pela hiperidrose é de 79,6% sendo o domínio mais afetado o Funcional-Social (61,1%). Não houve complicações perioperatórias e pós-operatórias major. A taxa de complicações minor foi de 5,5%. Após 3 meses, obteve- -se um índice geral de 100% de melhoria na qualidade de vida dos pacientes e um grau de satisfação positivo de 96,3% apesar do aparecimento de hiperhidrose compensatória em 57,3% dos pacientes. O Domínio que apresentou melhorias significativas foi o Funcional-Social, em 55,5% dos pacientes. O follow up a médio prazo (média de 6 anos) permitiu avaliar 31 pacientes (57,4% da população) dos quais 77,4% mantém hiperhidrose compensatória. 93,5% Refere satisfação elevada com o resultado cirúrgico tendo melhorado a sua qualidade de vida em 93,5%. Dos pacientes avaliados no follow up a 3 meses e a médio prazo, 94,4% e 94,0% recomendam a cirurgia, respetivamente. Conclusão: A simpaticectomia por cirurgia toracoscópica videoassistida é uma opção terapêutica eficaz e viável da hiperidrose focal primária. Apesar da incidência de hiperidrose compensatória, é um procedimento bastante satisfatório no que respeita à qualidade de vida da grande maioria dos pacientes submetidos a este tipo de cirurgia.

A rare cause of hoarseness in a young patient.

Syphilis is nowadays a rare cause of aortic aneurysms in developed countries. Commonly saccular, syphilitic aneurysms are frequently single, involving the ascending aorta and arch and are frequently asymptomatic unless large enough to cause symptoms due to compression of surrounding structures or death from rupture. In this paper, the authors present the case of a 32-years old patient presenting with progressive weakness, anorexia, weight loss and hoarseness, who was diagnosed with a multiple saccular aortic aneurysms, which were syphilitic in nature. The patient underwent surgery for a hemiarch replacement after receiving a cycle of antibiotics and had an uneventful recovery. This case illustrates that, although rare, syphilis must be recognized as a potential source of aneurismal disease as it warrants antibiotic therapy and screening of involvement of other organs.

A sífilis é atualmente uma causa rara de aneurisma da aorta em países desenvolvidos. Normalmente saculares, os aneurismas sifilíticos são frequentemente simples, envolvendo a aorta ascendente e arco. São frequentemente assintomáticos a menos que grandes o suficiente para causar sintomas devido à compressão das estruturas vizinhas, ou morte por ruptura. Neste artigo, os autores apresentam o caso de um paciente de 32 anos de idade com queixas de fraqueza progressiva, anorexia, perda de peso e rouquidão, a quem lhe foi diagnosticado múltiplos aneurismas saculares da aorta, de natureza sifilítica. O paciente foi submetido a uma cirurgia de substituição do hemiarco aórtico depois de receber um ciclo de antibióticos e teve uma recuperação sem intercorrências. Este caso ilustra que, embora rara, a sífilis deve ser reconhecida como uma fonte potencial de doença aneurismática, tanto aórtica como também de outros órgãos.

Interrupted aortic arch: A misdiagnosed cause of hypertension.

We present the case of a 47-year-old man with hypertension for over 20 years, referred to our hospital due to mild aortic dilatation detected on a transthoracic echocardiogram. On physical examination weak lower limb pulses and a blood pressure differential of >50 mmHg between arms and legs were detected. Complete interruption of the aortic arch below the left subclavian artery was diagnosed by computed tomography angiography. With this case we aim to draw attention to aortic coarctation and interrupted aortic arch as potential causes of hypertension and to highlight the importance of the physical examination in the diagnosis of secondary causes of hypertension.

Mid-term outcomes of mitral valve repair in a low-volume hospital.

INTRODUCTION: Mitral valve repair is feasible for all patients with mitral regurgitation and its advantages are well documented; however, there is general agreement that it is technically demanding and that success rates are related to volume/ experience centers. The aim of this study was to evaluate the clinical and echocardiographic mid-term outcomes of patients who underwent a mitral repair in a low-volume hospital. METHODS AND RESULTS: Between 2009 and 2014, 55 patients (23 female) with mitral regurgitation underwent mitral repair. The mean age was 60.7±11.4 years (range, 21-81 yr). The most prevalent cardiovascular risk factors were: hypertension 61.8%, dyslipidemia 47.3% and diabetes 21.8%. Nine patients (16.4%) were in class III-IV of NYHA and ten (18.2%) had atrial fibrillation. Repair procedures included mitral ring annuloplasty (n=55), quadrangular resection (n=20), chordal replacement (n=13) and commissuroplasty (n=5). Postoperative complications included atrial fibrillation 16.4%, check bleeding 3.6%, wound infection 1.8% and renal failure 1.8%. The hospital mortality rate was 1.8%. Follow-up echocardiography (median 19±5 months) revealed trivial or no mitral regurgitation in 38.2%, mild (1+) in 34.5% and severe (3+) only in 3 patients. CONCLUSION: In the current era, patients undergoing successful mitral valve repair have low mortality and morbidity even in low-volume hospitals.

Transcatheter aortic valve implantation in a very young patient.

Transcatheter aortic valve implantation (TAVI) is the standard treatment for patients with severe aortic stenosis and unacceptable surgical risk. These are usually elderly patients with multiple comorbidities. We report the case of a 20-year-old man with mandibuloacral dysplasia, an extremely rare premature ageing syndrome, and severe symptomatic aortic stenosis, referred to our center for TAVI after being considered unsuitable for surgical aortic valve replacement. TAVI by a transfemoral approach was performed successfully. Severe acute respiratory failure that did not respond to optimal conventional treatment led us to employ venovenous extracorporeal membrane oxygenation. The device was removed after 10 days, and the patient was discharged home 27 days later. At one-year follow-up he is in NYHA class I with full functional autonomy. To the best of our knowledge, this is the youngest patient to undergo TAVI reported in the literature.

[Cardiac papillary fibroelastoma of the mitral valve. Case report]. / Fibroelastoma papilar cardíaco da válvula mitral. Caso clínico.

Cardiac papillary fibroelastomas (CPF) are rare primary cardiac tumors with predilection for heart valves, being increasingly incidentally discovered due to the widespread use of echocardiography. Most of them are asymptomatic, but they are a potential source of systemic emboli, stroke, myocardial infarction and sudden death. This report describes the case of a 70-year-old female with previous transient ischaemic attacks and an echocardiographic finding of a mass in the mitral valve. Surgery was performed with complete resection of the tumor and preservation of the mitral valve. Pathological evaluation confirmed the diagnosis of cardiac papillary fibroelastoma.

Impact of incomplete surgical revascularization on survival.

Complete revascularization is considered superior to incomplete revascularization (IR), with better long-term survival and a lower rate of reintervention. However, it has yet to be established whether this difference is due directly to IR as a surgical strategy or whether this approach is merely a marker of more severe coronary disease and more rapid progression. We believe that IR is a prognostic marker for a more complex coronary pathology, and adverse effects are probably due to the preoperative condition of the patient. In fact, although IR may negatively affect long-term outcomes, it may be, when wisely chosen, the ideal treatment strategy in selected high-risk patients. IR can derive from a surgical strategy of target vessel revascularization, where the impact of surgery is minimized to reduce perioperative mortality and morbidity, aiming to achieve the best feasible safe revascularization.

[Repair of iatrogenic aortic dissection during Bentall operation in a patient with annulo-aortic ectasia and mitral regurgitation]. / Correção de disseção iatrogénica da aorta ascendente durante uma operação de Bentall num doente com com ectasia anulo-aórtica e insuficiência mitral.

Intraoperative aortic dissection is a rare but potentially fatal complication of cardiac surgery. In this report, we present a case of intraoperative aortic dissection during a Bentall operation for annulo-aortic ectasia repair combined with mitral valve replacement. The aorta was successfully repaired using another dacron tube graft after profound hypothermic circulatory arrest.

[Cardiac surgery in Portuguese octogenarians]. / Cirurgia cardíaca em octogenários portugueses.

The purpose of this study was to investigate the operative results and the clinical outcomes of Portuguese octogenarians who underwent cardiac surgery. Records of 339 consecutive octogenarians who had had cardiac operations between 2003 and 2005 were reviewed. The effect of cardiac and operative risk factors on mortality was evaluated. Selected variables included risk factors, cardiac status, preoperative hemodynamics and surgical procedures were collected on all patients. The mean age was 82.4+/-2.4 years-old (range 80-94) and 51.9% were male. Octogenarians had often diabetes (23.6%), renal failure (5.9%), cerebrovascular disease (8.3%), peripheral vascular disease (16.5%) and chronic lung disease (10.0%). The surgical priority was elective for 206 patients, urgent for 120 patients and it was emergent for 8 patients. Coronary artery bypass grafting was performed in 46.9%of patients, valve surgery was performed in 31.6% and combination of these in 19.5% of patients. Overall hospital mortality was 10.0%. Operative mortality for coronary artery bypass and valve surgery were 9.4% and 8.0%, respectively. Combined surgery (16.7%), diabetes (15.7% vs 9.3%, p<0.05), and urgent/emergent (14.3% vs 7.3%, p<0,05) increased significantly operative mortality. In conclusion, cardiac surgery can be performed within acceptable limits of risk and an acceptable mortality. Several factors might help both in case selection and in perioperative decisions.

Combined carotid stenting and urgent coronary artery surgery in unstable angina patients with severe carotid stenosis.

Staged or combined carotid endarterectomy (CEA) offers the potential benefit of decreased neurological morbidity during and after cardiac surgery; however, the strategy for treating unstable high-risk patients, who need urgent coronary artery surgery, remains unresolved. We report in-hospital and 30-day outcomes of 23 consecutive patients admitted with unstable angina, who underwent carotid angioplasty and stenting (CAS) immediately prior to urgent coronary artery surgery, from October 2007 to October 2008. Aspirin and unfractioned heparin were administrated during carotid stenting and clopidogrel was only started after cardiac surgery. All patients remained event-free during and immediately after the carotid stenting procedure. One patient died due to sepsis 22 days after cardiac surgery. There was neither stroke nor myocardial infarction at follow-up. No patient needed a cardiac or carotid re-intervention. This new approach (combined carotid stenting and coronary artery surgery) provides a less radical intervention, can be performed with a low periprocedural complication rate and may become a valuable alternative in the treatment of high-risk patients with combined carotid and cardiac disease.

[Indications and results of lung resection in bronchiectasis]. / O papel da ressecção pulmonary no tratamento das bronquiectasias.

The prevalence of bronchiectasis has decreased significantly over recent decades in developed countries. However, resection for bronchiectasis still plays an important role in thoracic surgery practice in some countries such as Portugal. Between 1994 and 2004, 51 patients (29 female and 22 male) with a mean age of 38.6 years (range, 4-65 years) underwent pulmonary resection for bronchiectasis. Mean duration of symptoms was 4.8 years. Surgery was indicated because of unsuccessful medical therapy in 25 patients (49.1%), hemoptysis in 12 (23.5%), lung mass in 9 (17.6%) and lung abscess in 5 (9.8%). The surgical treatment was as follows: pneumectomy in 7 patients, bilobectomy in 3, lobectomy in 36 segmentectomy in 5. There was no operative mortality. Complications occurred in 8 patients and the morbidity rate was 15.7%. Follow-up was complete in 45 (88.2%) patients with a mean of 3.4 years. Overall, 35 (77.7%) patients were asymptomatic after surgery symptoms were improved in 7 (15.6%). Unsuccessful medical therapy was still our main indication for surgery of bronchiectasis, despite aggressive antibiotic therapy. Surgical resection was performed with acceptable morbidity and morbility rates and markedly improved symptoms in the majority of patients.

Impact of isolated bypass grafting of the left internal thoracic artery to the left anterior descending coronary artery in high-risk patients with three-vessel coronary artery disease.

INTRODUCTION: Multiple strategies to achieve some degree of myocardial revascularization are available. In some, less complete revascularization is accepted to limit invasiveness, mostly in older, high-risk patients and patients with unsuitable coronary anatomy. METHODS: Patient and operative data were collected retrospectively for all patients with three-vessel coronary artery disease who had off-pump coronary artery bypass surgery from January 2003 through December 2005. In-hospital outcomes, preoperative risk, survival and postoperative complications were compared between patients with complete (n = 89) and incomplete (n = 61) revascularization. RESULTS: The mean follow-up was 20.2 +/- 4.6 months. Patients with incomplete revascularization tended to be older (76.8 +/- 1.4 years) than those with complete revascularization (66.3 +/- 1.0 years) and were more likely to have diabetes (43% versus 30%), cerebrovascular disease (18% versus 11%) and peripheral arterial disease (20% versus 9%), poorer ejection fraction (34.7 +/- 1.7% versus 50.8 +/- 1.5%) and greater EuroSCORE risk (9.7 +/- 2.1 vs. 5.1 +/- 1.3). In-hospital (3.3% versus 3.4%) and 6-month (4.9% versus 5.6%) mortality were not statistically different in the two groups, nor was recurrence of angina (3.3% versus 1.1%) or need for repeat revascularization (percutaneous or surgical) (4.9% versus 3.3%). CONCLUSION: In high-risk patients with three-vessel coronary artery disease, the potential benefits of less invasive surgery should be considered. Surgical outcomes depend on preoperative condition rather than incomplete revascularization. Medium-term mortality and cardiac-related events associated with this surgical strategy are not increased.