Volume 7 - Número 4
ORIGINAL ARTICLE
The usefulness of intraoperative transesofageal echocardiography for mitral valve surgery
Braz J Cardiovasc Surg 7;
Publish in: 8/2/2025
The usefulness of routine intraoperative transesophageal echocardiography (TEE) for mitral valve (MV) surgery was studied in 65 patients (pts) with MV disease (mean age = 31 ± 14.8 to 62 yrs): 1 - Mitral regurgitation (MR): 19 pts-MV prolapse in 12 pts; Ischemic in 6 pts and post repair of ASD: 1 pt; 2 - Mitral stenosis (MS): 23 pts (4 of them with previous surgery); 3 - MS+MR and/or tricuspid valve (TV) lesions: 16 pts; 4 - Bioprosthetic valve (BV) dysfunction: 6 pts and 5 - Left atrial myxoma: 1 pt. Initial precardiopulmonary bypass TEE was used to confirm MV dysfunction, TV involvement and to assess LV function. On the 1 st run bypass (RBP), the MV commissurotomy was performed in 27 pts (23 with MS and 4 with MS+MR); the MV was replaced with BV (pericardial #21 to #29) in 18 pts (6 with BV dysfunction and 12 with MS+MR) and the MV repair was performed in all of 19 pts with MR). The 2nd RBP was required in 7 pts (11%): 1 pt with MR; 4 pts with MS+MR and 2 pts with MS. TEE caused changes in pre pump plans in 9 pts with TV lesions and in 10 pts with MS or MS+MR - preservation of native in 6 pts in which replacement was planned. Thus intraoperative TEE provides helpful information in MV surgery and can help avoid a mitral replacement in pts with MS or MS+MR.
Keywords: transesofageal echocardiography in surgery; mitral valve, surgery
Anatomopathological study of patients submitted to valvar surgery at InCór-HC FMUSP
Braz J Cardiovasc Surg 7;
Publish in: 8/2/2025
Of the 44 necropsies which were carried out in patients submitted to valvar surgery in 199 0 at InCór (Instituto do Coração), the following clinical causes of death were found in Mitral patients: coagulopathy and bleeding in 11 cases; low cardiac output in 7; cardiogenic shock in 5; septic shock in 3; failure of multiple organs in 3; acute respiratory distress syndrom (ARDS) in 2; severe ventricular arrythmia in 2, and pulmonary thromboembolism in 1. In aortic patients: coagulopathy and bleeding in 5 cases; cardiogenic shock in 2; septicaemia in 3; ruptured micotic aneurism in 1; stroke in 1, and ventricular arrhythmia in 1. In mitroaortic patients: coagulopathy and bleeding in 2 cases; pulmonary thromboembolism in 2; septicaemia in 1; severe ventricular arrythmia in 1, and ARDS in 1. The following anatomopathological causes of death were observed. In mitral patients: hemorrhagic shock in 13 cases; failure of multiple organs in 4; septic shock in 3; broncopneumonia in 4; acute myocardial infarction (AMI) in 3; cardiogenic shock in 3; cerebral hemorrahage in 1, and ARDS in 1. In aortic patients: endocarditis in 3 cases: hemorrhagic shock in 2; cerebral hemorrhage in 2; AMI in 1; cardiogenic shock in 1; septicaemia in 1; acute respiratory distress syndrom (ARDS) in 1, and acute dissection of the aorta, with coagulopathy in 1. In mitroaortic patients: failure of multiple organs in 2 cases; pulmonary thromboembolism in 2; ARDS in 1; hemorrhagic shock in 1, and endocarditis in 1. We concluded that there was correlation between the clinical and anatomopathological diagnoses in 36 patients, corresponding to 82 % of the cases, the principal cause of death being due to hemorrhagic shock. An important observation which was made in this study, was that 11 (25%) patients had some form of chronic hepatopathy which had not previously diagnosed from the clinical laboratory study. Some of the patients which developed clinically unexplained low cardiac output presented subendocardial infarct as an anatomopathological finding.
Keywords: heart valves, anatomopathological study; heart valves, surgery
Allotransplantation of chordae tendineae
Braz J Cardiovasc Surg 7;
Publish in: 8/2/2025
One of the most frequent causes of mitral valve prolapse is rupture of the chordae tendineae. Several techniques have been used to correct severe mitral regurgitation. However, mitral valve replacement is the principal surgical approach to it. We describe a technique used in four patients with marked mitral regurgitation due to ruptured chordae tendineae of the anterior leaflet. We have grafted chordae tendineae from the tricuspid valve onto the mitral valve. In the first and fourth case we removed part of the anterior leaflet of the tricuspid valve, together with chordae tendineae and part of the papillary muscle. In the other two cases we removed the posterior leaflet, together with its chordae tendinease and papillarly muscle. In the first and fourth cases the tricuspid valve was repaired. In the other two cases it was turned into bicuspid valve by means of an annular plication. The first extremity of the graft to be sutured was the papillary muscle, followed by the leaflet. Studies carried out 15, 11, 2 and 1 month, postoperatively, showed that both valves, i. e., mitral and tricuspid, were competent and the patients were asymptomatic. In spite of our limited experience, we believe, this technique is a sensible alternative to mitral valve replacement.
Keywords: cordae tendineae, autotransplantation; cordae tendineae, rupture; mitral valve, surgery; mitral insufficiency
The role of lung biopsy in the decision-making process for congenital heart disease
Braz J Cardiovasc Surg 7;
Publish in: 8/2/2025
Open lung biopsy has been performed in patients with congenital heart disease and severe pulmonary hypertension in order to complement the decision-making process for surgical correction. All patients had clinical, hemodynamic and angiographic evaluation previously and would not be surgical candidates by conventional criteria. The 49 patients were studied from 198 0 to 1991 at the Instituto de Cardiologia do Rio Grande do Sul, Brazil. Age range was 5m to 28y6m (mean=7y7m). The diagnoses were: VSD (16); PDA (3); VSD and SubAortic Stenosis (1); PDA and VSD (2); PDA and ASD (1); AVSD (7); Incomplete AVSV and PDA (1); PDA and ACo (1); AAI with PDA and VSD (2); DORV with VSD and or PDA (6); DOLV with PS (1); TA (1), TGA (1); Corrected TGA with VSD (1) and Truncus Arteriosus (5). There were 3 hospitalar deaths after the biopsy procedure (6.1%). When the pulmonary vascular lesions were classified as Heath-Edwards class III or less, surgical correction was performed. There were 21 patients, 11 simple defects (PDA; VSD; AVSD) with 4 deaths (36.4%) and 10 complex heart defects with 3 deaths (30%) . One patient with VSD had persistent evolutive pulmonary hypertension. The remaining 13 had benefited from the correction. In conclusion, lung biopsy may be useful for the surgical decision in congenital heart disease with severe pulmonary hypertension. As a surgical procedure with the involved risks, it must be selectively indicated. Most patients with vascular lesions below class III (H-E), despite other methods of evaluation would benefit from the corrective procedure.
Keywords: hypertension, pulmonary; lung biopsy
Assisted circulation in cardiac surgery
Braz J Cardiovasc Surg 7;
Publish in: 8/2/2025
In patients with cardiogenic shock following cardiopulmonary bypass, not responsive to intraortic balloon pump and drugs, the centrifugal pumps are the first option in many centers. These centers that use modern vortex pumps cite their simplicity, availability, relatively low cost, and low amount of blood trauma. The aim of this study is to describe the experience of InCór with 8 patients submitted to assisted circulation with biopump from May 1990 to December 1991 . Intraortic balloon counterpulsation was used in these 8 patients with conventional medical therapy. Their ages ranged from 54 to 66 . Three patients were submitted to coronary bypass, 2 to mitral valve replacement, 2 to left ventricular aneurysm correction and 1 to heart transplantation. Left atrial to aortic bypass was done in 7 patients and in 1 , right atrial to pulmonary bypass. The patients were assisted from 18 to 12 6 hours. Three patients died during assisted circulation: 2 were in bridge to transplantation and didn't achieve donor organ, and 1 died due to bleeding and acute renal failure. Five (62.5%) patients were weaned from the device, but 2 died at hospital, 1 due to respiratory failure and 1 due to neurologic and renal failure. When we compared the clinical evaluation with CKMB, we noted that 3 patients with CKMB greater than 80 died, 2 during assisted circulation. In 5 patients with CKMB less than 80 , 4 were weaned from the device and 3 were discharged from the hospital. Two patients discharged from the hospital are in NYHA functional class II and 1 in class I. The early utilization of assisted circulation will lead to better results in this group of high risk patients.
Keywords: biopump, mechanic, in cardiac surgery; assisted circulation
Endomyocardial fibrosis surgical treatment
Braz J Cardiovasc Surg 7;
Publish in: 8/2/2025
Sixty-six (66 patients) with endomyocardial fibrosis underwent surgical treatment at the Heart Institute between January 1978 and June 1990. A study involving two subgroups was designed with the aim to compare the operative techniques; 1) patients submitted to endocardiectomy and valvar substitution; and 2) patients submitted to endocardiectomy and valvoplasty. Clinical, radiologic, hemodynamic, surgical and postoperative parameters were included in the protocol. It is a retrospective study, an statistical analysis was performed using Pearson's X2 test and Loog-Rank test. At this time, the comparative analysis does not reveal significant statistical differences between the two subgroups, both regarding nosocomial mortality and late survival, however comparison of the actuarial survival curves allows to identify a tendency towards improvement, with decrease in the nosocomial mortality and a great late survival, when the conservative technique for surgical treatment of endomocardial fibrosis is used. Therefore, endocardiectomy associated to atrioventricular valvoplasty for surgical treatment of the patients with endomyocardial fibrosis is recommended.
Keywords: endomyocardial fibrosis, surgery; heart valves, surgery
Tranexamic acid and hemostasis in myocardial revascularization with extracorporeal circulation
Braz J Cardiovasc Surg 7;
Publish in: 8/2/2025
The synthetic antif ibrinolytic drug tranexamic acid was evaluated in its hemostatic and blood saving effects, in patients submitted to myocardial revascularization with extracorporeal circulation. To 40 patients were administered placebo and to 55 tranexamic acid I.V. in a dosage of 10 g in the operative period (2 g in the anesthetic induction and the remaining 8 g in a continuous way during the operative procedure). Tranexamic acid, in this dosage, has proved to have a very impressive hemostatic effect, leadir g to a reduction in post operative bleeding of 47% in 12 h, 42,5% in 24 h and 40,5% when drains were taken off, related to the control group (p < 0.05). Tranexamic acid have led to less utilization for homologous paked red cells per patient, but statistical significance was found only in the 24 h of post operative period, with 1,025 units/patient in control group and 0,333 units/ patient in treated group. Concerning post operative complications, there have been more neurological alterations without sequelae (2.5% against 12.7%) and creatinin alterations (5% against 10.9%) in the tranexamic acid group. Such alterations were attributed to the high dosage used. As a conclusion, we do not recommend routine use of tranexamic acid to patients submitted to myocardial revascularization in the dosage of 10 g I.V., but, owing to the evident hemostatic effect of the drug, we recommend more investigations concerning the ideal dosage and way of administration.
Keywords: tranexamic acid; surgical hemostasis; myocardial revascularization, surgery; extracorporeal circulation
Selective arterialization of the anterior interventricular vein
Braz J Cardiovasc Surg 7;
Publish in: 8/2/2025
The purpose of this study is to report two surgical cases, whereby after the repair of the left ventricular aneurysm, the myocardial revascularization of the interventricular anterior artery (IAA) was not possible. Using the left internal thoracic artery it was decided to perform anastomosis with the interventricular anterior (IAA) and its cephalad ligation, in order to obtain a retrograde flow and to avoid an arteriovenous fistula formation. There was no mortality and the results are optimistic in a short follow-up of these two patients. Myocardial perfusion tests and pre and post-operative angiography of the coronary system and the left internal thoracic artery are assessed and discussed. The geometrical reconstruction of the left ventricle and the revascularization of the ischemic areas play major role in the repair of postinfarction ventricular aneurysm. When it is not possible to access diretly the revascularization of the IAV this technique is safely and easily perfomed and shows satisfactory results in a short period of time.
Keywords: myocardial revascularization, surgery
Intraoperative autotransfusion in heart surgery
Braz J Cardiovasc Surg 7;
Publish in: 8/2/2025
An intraoperative autotransfusion was planned in order to decrease or to avoid transfusion of blood in severe surgical cases. It was done a comparative study in 14 0 heart surgeries; 70 cases (Group A) were submitted to heart surgery making use of Cell-Saver and 70 without the use of it. The majority of the cases have had a previous surgery; 77.1 % of the cases in Group A and 74.2 % in Group B. Besides this similarity other likeness included age, sex, kind of surgery, clinical conditions and laboratory data concerning coagulation, erythrocyte count and blood biochemistry. The averaged homologous blood volume intraoperative transfused was 628 ml in Group A and 1271 ml in Group B, but it was 479 ml in Group A and 1095 ml in Group B after surgery. The intraoperative blood lost was 38 0 ml in Group B. During the hospitalization time the percentage of cases that did not receive blood was 5.7 % in Group A and 2,8 % in Group B. The average amount of units transfused was 2 in Group A and 3 ro 5 or higher in Group B. The study pointed out that intraoperative autologous transfusion using Cell Saver is a safety and efficient procedure. The transfusion of homologous blood decreased in 50 % as well as the risk of infection disease to be transmited.
Keywords: blood, autotransfusion in heart surgery
Evaluation of continuous normothermic blood cardioplegia using Phosphorus 31 nuclear magnetic ressonance
Braz J Cardiovasc Surg 7;
Publish in: 8/2/2025
An isolated, blood perfused pig heart model was adapted for metabolic studies using 31 P NMR spectroscopy during continuous normothermic blood cardioplegia (CNBC). The experiment comprised two groups: In Group I (n=5) the hearts were subjected to 1 hour of CNBC. In Group II (n=5) a 20 min period of ischemia was introduced in the middle of the period of CNBC. Left ventricular function was assessed, in the beating heart, prior to the period of CNBC and after 60 min of cardioplegia, using an intra-ventricular balloon. During the entire period of the experiment, spectra were obtained using a 4.7 T/30 cm bore BrukerTM Biospec 31P NMR spectrometer with 2 min of resolution. At the end of the experiments myocardial biopsies were taken for ATP and phosphocreatine (PCr) analyses using high performance liquid chromatography (HPLC). ATP and PCr were maintained after the period of cardioplegic arrest (Group I). However the Group II, complete loss of PCr was shown after 14 ± 2 min of normothermic ischemia, followed by an increase of inorganic phophate (Pi) and decrease of intracellular pH. Following reperfusion after CNBC, PCr, pH and Pi returned normal values in 3 min. Left ventricular function, assessed by end-systolic elastance, was maintained at 100±10% of control in Group I. In the Group II, left ventricular function was 88 ± 7% (p<0.05) of the control. HPLC analyses of the myocardial biopsies showed normal values for Group I, ATP (24 ± 3 µmol/g dry weight) and PCr (55 ± 14 µmol/g dry weight), but in Group II, despite normal levels of PCr after reperfusion, the ATP levels decreased to 21 ± 3 µmol/g dry weight at the end of the experiments. These results showed that cardiac metabolism was seriously compromised after 14 min of normothermic ischemia and left ventricular function had decreased (Group II). However in Group I, in which CNBC was used without interruptions, function and metabolism were preserved, suggesting this is the ideal technique to protect the heart during cardiac surgery.
Keywords: nuclear magnetic ressonance; cardioplegia