A Transposição Valvular nos Doentes com Úlceras dos Membros Inferiores Consequentes a Síndromes Pós-Trombóticos

Venous ulcers in patients with post thrombotic syndromes are complex situations with multiple therapeutic options. They are responsible for high morbidity rates, conservative treatment is very slow and recurrences are very common. Deep venous reconstructive surgery is an alternative, but it should be based on the morphologic and functional aspects of the venous system and only adopted after a very careful study, including venography. The authors describe a morphological "pattern", found in some of these patients and related to the competence of the saphenous femoral junction, rendering possible to perform a valvular transposition. Seven patients with post thrombotic ulcers who have been treated during the last 6 years in which the pattern already described was detect, underwent a transposition of the superficial femoral vein, to the great saphenous vein and when necessary complemented with skyn grafts. Before the operation all patients had ulcers with more than 3 cm in size (3.2-5.4 cm) and with more than 4 months duration (4-16 months). All ulcers healed in the postoperative period (mean time 28 days). All patients have been reevaluated in 2003 and it was diagnosed the thrombosis of two procedures, one of them with the recurrence of the ulcer who healed with conservative treatment. The authors consider this method as a very easy technique to perform, although rarely used, and a valid alternative in a highly selected group of patients.

Operação de Ross - Como Minimizar os Efeitos da Curva de Aprendizagem

The introduction of new procedures in surgery usually implies the costs of the so called learning curve. However patients should not suffer the negative effects of surgeon's learning curves. We report our results with the first 15 Ross procedures, a single surgeon and institution experience, and how it was possible to build a safe learning curve without major consequences for the patients. We emphasize the need for a continuous program of surgical performance assessment throughout the learning curve period, as was demonstrated in our series.

Cirurgia Cardíaca em Doentes de Muito Alto Risco

Purpose: To assess the results obtained in very high-risk patients, which are those patients with an EUROSCORE greater than 13 points. Material and methods: From September 2001 to September 2003, thirty-three very high-risk patients were operated on in our department, which represents 1.6% of all the surgical activity during that period of time, being 17 male and 16 female, with an average of 69 years old (maximum 86 and minimum 32). Diagnosis includes: post infarction CIV 5, coronary insufficiency 11, aortic dissection 3, mitral prosthesis 3, valvular disease 9, aortic prosthesis disfunction 2. Fifteen patients underwent an emergency procedure, 12 were urgent and the remaining 6 were electively operated on. Results: Overall post-operative mortality was 12 patients (36%), being 6 emergent, 5 urgent and 1 elective patient. Patients who survived the operation had longer intensive care and hospital admission periods, which will be analyzed in detail. Conclusion: Surgery can be justified in very high risk patients. Despite the high perioperative mortality and longer periods of hospital stay, they will be otherwise condamned to death, if surgery would not be performed.

Síndrome de Churg-Strauss, Aneurismas Femorais Venosos e Tromboembolismo Pulmonar

OBJECTIVE: Venous aneurysms of the lower limbs are rare. When they involve the deep venous system, they can be associated with deep venous thrombosis and pulmonary embolism. The authors report the case of a 63-year-old women evaluated by duplex imaging and venography, in the context of a pulmonary embolism, and detected bilateral large aneurysms of the femoral veins (5 cm in the right femoral vein and 4 cm in the left femoral vein). The aneurysms were located at the bifurcation of the common femoral vein with the superficial and profound veins. METHOD: The right aneurysm was partially thrombosed. The patient was asymptomatic in the lower-limb extremities. After a period of anticoagulation, the authors proceeded to surgically excise the right aneurysm and replaced the venous system using a polytetrafluoroethylene (PTFE) graft with the construction of an a-v fistula. RESULT: The patient had no complications in the postoperative period and her 8-month follow-up examination revealed no symptoms, not even leg edema. The duplex scan showed patency of the graft. She continued with oral anticoagulation. The histologic examination revealed an eosinophilic inflammatory reaction of the vein wall, compatible with the diagnosis of Churg-Strauss syndrome. CONCLUSION: The authors conclude that they have probably described the first case in the international literature of a venous aneurysm with a Churg-Strauss syndrome and pulmonary embolism.

Protecção Cerebral na Cirurgia do Arco Aórtico

In this paper the authors proceed to a revision of the three main methods employed for cerebral protection in aortic arch surgery, namely the deep hypothermia and total circulatory arrest, the retrograde cerebral perfusion and the selective anterograde cerebral perfusion. After a deep analysis on their advantages and disadvantages, they proposed the utilization of an association of methods (integrated approach) that has proved to be extremely well succeed in their clinical practice, specially in high-risks patients.

Lesões Traumáticas Iatrogénicas das Veias Femorais no Decurso da Cirurgia de Varizes

Traumatic lesions of the femoral veins during varicose veins surgery are very uncommon and they raise several therapeutic difficulties. They occur in 1/1000 cases of varicose veins operated. The authors describe four cases of lesions of this type that were seen and treated for the last six years, probably because there was an increase in the number of varicose veins operated on in the Lisbon area. The authors discuss the surgical options and they concluded that these complications can be minimized with good anatomical and surgical skills, specially of the saphenous-femoral and saphenous-popliteal junctions.

Úlceras de Perna em Portugal: um Problema de Saúde Subestimado

To determine the prevalence and aetiology of leg ulceration in a population of patients registered with five health centres within Lisbon, a study was undertaken to identify patients receiving care from community and hospital. Identification of patients was through health professionals, with a simple questionnaire completed for all patients identified who were registered with the five health centres. In 263 patients were identified in a population of 186,000 (total prevalence 1.41/1,000 population). The prevalence was similar between men and women (1.3 and 1.46/1,000, respectively). As expected this was highly age dependent, being most common in patients aged over 80 years (6.5 and 4.9/1,000, respectively). The ulceration was highly chronic in nature, with median ulceration of 18 months. Of the 240 with ulcer duration recorded, 158 (66%) had the present ulcer for longer than one year, and 40 (17%) for longer than five years. The cause of ulceration was unknown to the health professional treating the patient in 86 (33%) of the cases. Of those with a cause, most commonly this was venous (80%) with 10% mixed arterial/venous ulceration and 3% frank arterial disease. Most care was provided by community services, with 145 (55%) treated in health centres and 77 (29%) treated in the patient's home. The mean number of treatments per week was 3.0, with 21 (9%) of patients being seen on a daily basis. Most patients (80%) had seen a specialist doctor for their ulceration, most often a dermatologist (48%) and a vascular surgeon (33%). The prevalence of chronic leg ulceration is similar to other reported studies in western Europe, and indicates that approximately 14,000 patients suffer from leg ulceration at any one time in Portugal. This produces a high burden on both hospital and community services.

Cirurgia de Reparação Mitral em Crianças com Valvulopatia Adquirida

BACKGROUND: Valve surgery in children is aimed at restoring correct hemodynamics with few reoperations and limited resort to prostheses, which would imply early deterioration or definitive hypocoagulation. OBJECTIVES: Report a series of paediatric pts with acquired mitral valve disease, mostly due to rheumatic disease, in whom it was possible, for the great majority, to repair the damaged valve. DEMOGRAPHICS: Fifty children with predominant mitral valve disease, 47 rheumatic (94%) and 3 after endocarditis were consequently operated by the same surgical team over the last five years. Ages were 12.5+/-3.1 yrs and weights 33.2+/-8.4 Kg, 30 pts presented with predominant mitral regurgitation and 20 pts had significant stenosis. In 8 pts there also moderate to severe aortic regurgitation and in 2 pts severe tricuspid regurgitation was present. Patients were not operated during the acute phase of the disease. Five pts were reoperations and from those, all but one received mechanical prosthesis. RESULTS: In all operations the intention was to repair the mitral valve. In 46 pts complex mitral valvuloplasties were performed extended comissurotomies, shortening of chordae, chordal replacement with PTFE, and reconstruction of valve leaflefts by direct patching or pericardial extension of the retracted posterior leaflet (78.2% cases), plus reshaping of the annulus by using a fixed prosthetic CE ring (sizes 26 to 32) in every case. Ring sizes correlated poorly with body weights, but correlation was close and positive for the use of pericardial advancement of the posterior leaflet (p<0.01). There was no operative mortality, but one pt died early from sepsis and there was no late mortality. Maximum follow up extends now to 50 months (median 28 months) and functional evaluation, at latest follow up, as assessed by Doppler Echocardiography, showed residual mitral regurgitation, mild-moderate in 4 pts and LA-LV gradients mild in 5 and moderate in 2 pts. NYHA functional class, at present follow-up is class I for 43 pts (88%) and class II in the remaining 6 pts. Along the follow-up period 2 pts had to be reoperated for early repair failures and other three for late failures, presently freedom for reoperation is 91.8% at 5 years. CONCLUSIONS: Mitral valve repair in children with rheumatic lesions can be achieved for the great majority of cases by using different techniques. Pericardial extension of the retracted posterior leaflet allowed the use of a bigger size prosthetic ring. Intermediate functional results are good with fair functional classes and few reoperations but follow-up is short and does not allow us to draw conclusions about the long-term results of the repair in these rheumatic patients.

Dissecção da Aorta Ascendente Associada a Sarcoma Primário da Aorta. Caso Clínico

Os tumores primários da aorta são raros e já têm sido associados a dissecção aórtica, sendo como tal reconhecido o sarcoma da íntima, muito agressivo, com potencial metastático precoce. Uma vez confirmado o diagnóstico, a ressecção cirúrgica pode ser curativa, não deixando o prognóstico de ser reservado, resultando na mortalidade na maioria dos casos. Descrevemos um caso de uma dissecção aórtica do tipo A, com hematoma intramural, associado a sarcoma da íntima, numa doente jovem, apresentando-se com hematoma cerebral e culminando na morte da doente.

Tamponamento Cardíaco por Migração Intratorácica de Fio de Kirschner

Apresentamos um caso raro de migração de fio de Kirschner usado para osteossíntese de fractura multifragmentar de colo do úmero causando tamponamento cardíaco por lesão do tronco da artéria pulmonar e lesão do lobo superior esquerdo do pulmão. Reportamos o caso de uma doente do sexo feminino de 65 anos de idade, admitida no Serviço de Urgência após queda acidental, que resultou em fractura multifragmentar do colo do úmero tratada cirurgicamente com implantação percutânea de três fios de Kirschner. Seis dias após a intervenção, a doente iniciou um quadro de dor torácica lancinante com irradiação ao braço e região dorsal esquerda, dispneia e ortopneia, tendo sido readmitida dois dias mais tarde no Serviço de Urgência onde a telerradiografia do tórax revelou a migração de um fio de Kirschner para a cavidade intratorácica e alargamento do mediastino. O ecocardiograma confirmou o diagnóstico de tamponamento pericárdico e a TAC do tórax complementar demonstrou a migração do fio de Kirschner para a cavidade pleural esquerda.

Quisto Broncogénico: Elemento Radiológico Sugestivo

O quisto broncogénico constitui a lesão quística mais comum do mediastino. Descreve-se o caso de uma criança do sexo feminino, de quatro anos de idade, com tosse estridulosa recorrente desde os dois anos e febre de início recente. A radiografia de tórax revelou desvio da linha ázigo-esofágica, o que levantou a suspeita de lesão mediastínica.A tomografia computorizada torácica mostrou lesão mediastínica que foi posteriormente identificada por ressonância magnética como correspondendo a um quisto broncogénico. Três meses depois foi submetida a cirurgia com exérese do quisto e desde então, decorrido um ano, tem estado assintomática. Destaca-se a importância da identificação de referências radiológicas que podem ser relevantes para o diagnóstico de lesões ocupando espaço no mediastino.

Pancreatite Aguda como Manifestação de Linfoma de Burkitt: em Idade Pediátrica

A pancreatite é uma patologia pouco frequente em Pediatria, com etiologia mais variada que no adulto, sendo as causas tumorais particularmente raras. Os autores apresentam o caso de um adolescente de 13 anos, previamente saudável, internado na Unidade de Cuidados Intensivos com os diagnósticos de pancreatite aguda, derrame pleural bilateral e ascite. Na avaliação imagiológica apareceram imagens sugestivas de processo infiltrativo da parede gástrica. A endoscopia digestiva alta mostrou tumor infiltrativo da mucosa gástrica e bulbo duodenal com úlcera gigante, com biópsias compatíveis com Linfoma de Burkitt, confirmado por citologia e citometria do líquido ascítico. Durante a evolução houve ainda necessidade de colocação de endoprótese biliar por colestase obstrutiva de agravamento progressivo. Após estadiamento (estádio III), iniciou o protocolo FAB LMB 96 obtendo remissão completa. A pancreatite aguda e a colestase são formas de apresentação raras de linfoma neste grupo etário.

Tuberculose Costal. A Propósito de Dois Casos Clínicos

Os autores apresentam dois casos clínicos de tuberculose costal. Em ambos, os doentes eram do sexo masculino, sendo que, no decorrer da investigação, o primeiro dos doentes revelou elevado grau de imunodepressão. Apesar da clínica característica, com um quadro insidioso de febre associada a abcessos frios da parede costal, flutuantes, com tendência a fistulização e tendo ambos os doentes recebido ciclos de antibioterapia sem aparente resposta à mesma, o diagnóstico revelou-se difícil. No primeiro caso, só o elevado grau de suspeição e a decisão de iniciar terapêutica quádrupla antibacilar, com resolução total das queixas, conduziu ao diagnóstico. No segundo caso, apenas o exame realizado em meio de Löwenstein, com material obtido por punção, confirmou o diagnóstico. A tuberculose costal é uma patologia infecciosa rara e de difícil diagnóstico. O mesmo baseia-se no elevado grau de suspeição, na endemicidade da tuberculose e na existência de possíveis comorbilidades imunodepressoras.

Fluido Torácico Total. Um Possível Determinante da Eficácia Ventilatória em Doentes com Insuficiência Cardíaca

A eficácia ventilatória, avaliada por prova de esforço cardiorrespiratória (PECR), tem um importante valor prognóstico em doentes (dts) com insuficiência cardíaca crónica (ICC) por disfunção sistólica ventricular esquerda (DSVE). Os seus determinantes mantêm-se, contudo, controversos. Objectivo: Investigar a eventual correlação entre parâmetros de eficácia ventilatória, obtidos por PECR, e o valor do fluido torácico total (FTT), avaliado por bioimpedância eléctrica torácica (BET), em dts com ICC por DSVE. Métodos: Estudámos 120 dts com ICC por DSVE, referenciados ao nosso laboratório para PECR — 76% do sexo masculino, idade 52,1 ± 12,1 anos, 37% de etiologia isquémica, fracção de ejecção ventricular esquerda 27,6 ± 7,9%, 83% em ritmo sinusal, 96% sob iECA e/ou ARAII, 79% sob beta-bloqueante e 20% tratados com dispositivo de ressincronização cardíaca. Os dts efectuaram PECR, em tapete rolante, protocolo de Bruce modificado,sendo considerados para análise, como parâmetro de capacidade funcional, o consumo de oxigénio de pico (VO2p) e, como parâmetros de eficácia ventilatória, o declive (d) da relação entre ventilação minuto(VE) e produção de CO2 (VCO2) e o valor do VE/VCO2 no limiar anaeróbico (LANA). Os estudos por BET, média de 20 minutos de aquisição, foram efectuados após 15 minutos de repouso, em posição supina, imediatamente antes das PECR, sendo analisado o valor do FTT. Resultados: O valor do FTT variou entre 20,6 e 45,8 kOhm−1, média = 32,2, DP = 5,7, mediana = 32,7, o de VO2p entre 8,9 e 40,6 ml/kg/min, média = 21,0, DP = 6,2, mediana = 20,2, o do dVE/VCO2 entre 19,8 e 60,7, média = 30,7, DP = 7,9, mediana = 29,1 e o do VE/VCO2 no LANA entre 21 e 62,média = 33,1, DP = 7,5, mediana = 31,5. Por regressão linear, o FTT não se correlacionou com o VO2p — r = 0,05, p = 0,58 — mas apresentou correlação com os parâmetros de eficácia ventilatória analisados: r = 0,20, p = 0,032, r² = 0,04 com dVE/VCO2 e r = 0,25, p = 0,009, r² = 0.06 com VE/VCO2 no LANA. Conclusão: O FTT correlaciona-se com os parâmetros de eficácia ventilatória, avaliados por PECR, em dts com ICC por DSVE, o que indica que poderá ser um dos seus determinantes.