Volume 9 - Número 1

Utilizing equipment and conditions similar to the operating room we have reproduced all that it is necessary for simulating cardiac surgery with extracorporeal circulation. Surgeries are performed in a dummy who has a freshly fixed human anatomic piece firmly attached to a device specially developed and which is placed inside the thorax of the dummy. The procedures performed are videotaped and are also displayed simultaneously in a large screen situated in an auditorium with free communication with the surgical team. The system was utilized in July 1993 - XI Unicor International Symposium, and in November 1993 - 3rd SCICVESP Congress and in March 1994 - 21th Brazilian Congress of Cardiac Surgery with the following procedures being perfomed: Senning, Jatene, cavo-pulmonary anastomosis, Konno, Monaghian, mitral valve replacement, labyrinth surgery, retrograde cardioplegy, implantable defibrillator and orthotopic heart transplantation.The method was received enthusiastically by our colleagues and proved to be an efficient teaching technique as well as an excellent rehearsal tool due to its: 1) perfect reproducibility of the surgical conditions; 2) excellent image of the procedures as viewed in the large screen at the auditorium; 3) improvement in the way surgery is learned and taught due to the fact that the surgical field is clear cut and the surgical team is relaxed; 4) interruption of the surgical act without the complications that could develop during a "real" surgery; "surgery" can be interrupted at any time; 5) obtaining a video library with high quality definition images of different procedures; 6) we can foresee a frozen archive of hearts with congenital or acquired heart defects prepared to undergo surgical correction and 7) the future utilization of this technique in other surgical specialties. Keywords: heart surgery, methods; surgery, operative methods; cardiac surgery, teaching

From January 1980 to december 1992, 301 patients underwent mitral valve repair in Heart Institute of HCFMUSP. Mean age of the patients was 37.96 years, with standard deviation of 21.4 years and 151 (50.2%) were males. One hundred and twenty eight (42.52) patients presented symptons of rheumatic fever disease, 78 (25.91%) had degenerative valve disease, 21 (6.97%) were congenital, 18 (5.98%) were ischemic, 9 (2,99) had endomyocardial fibrosis, 8 (2.65%) had bacterial endocardis, 5 (1.66%) had chronic valvulitis, and 34 (11.29%) had no defined ethiology. Two hundred and four (67.8%) patients had mitral insufficiency and 97 (32.2%) double mitral lesion. Associated procedures were performed in 45% of the patients, the most frequent was aortic valve replacement in 41 (13%) patients. Merendino type annuloplasty was performed in 97 (30.99%) patients. Carpentier ring annuloplasty in 93 (29.71 %), and posterior sling in 76 (24.28%) patients. There were 12 operative deaths (3.9%). Three (0.9%) patients were reoperated upon in the immediate postoperative period due to valve disfunction. Linearilized rates of thromboembolism, late death, re-repair, and valve replacement were 0.2%; 0.5%; 1.0%; and 1.1% per patient/years, respectively. The actuarial survival rate at 12 years was 83.6% and the actuarial freedom from reoperation was 83%. Seventy nine percent of the patients were in NYHA class I at the last follow-up (evolution time was 10077 months/patients). We concluded that patients submitted to mitral valve repair presented satisfactory clinical evoluation. Keywords: heart valves, mitral, surgery; heart valves, mitral, plastic repair

From September 1984 to December 1992, 145 selected patients underwent mitral valve replacement using cadaver aortic valves obtained during rotine autopsy, processed in glutaraldehyde and mounted into flexible stents made of Celcon and covered with Dacron fabric. Mean age was 22.5 years, ranging from 5 to 77 years and 54.5% (79 patients) were 15 years old or younger. Twenty patients (13.8%) had undergone previous mitral valve replacement using porcine, bovine pericardial and dura mater valves, which were calcified. Six patients had undergone a previous mitral valvuloplasty. Hospital mortality (30 days) was 2.1% (3 patients). It was collected 709 patient-years of total follow-up, corresponding to a mean follow-up of 5 years per patient. The longest follow-up was 9 years and 5 months. Late complications related to the allograft were present in 48 patients, including fibrocalcification, thromboembolism, endocarditis and peri-valvular leak, corresponding to an incidence of 6.8% ± 0.9% per patient-year. Fibrocalcification was the most important late complication, and it was observed in 37 patients, representing an incidence of 5.2% ± 0.8% per patient-year. All patients who developed calcification in the implanted valves were 15 years old or younger. Calcification developed from 14 to 100 months after implantation and the mean interval between valve insertion and calcification was 46 months. Reoperations were performed on 44 patients, and the allobioprosthesis was replaced in 30 of them. The incidence of reoperation was 6.3% ± 0.9% per patient-year. There were 15 late deaths with a mortality rate of 2.1 % ± 0.5% per patient-year. Only 3 deaths were valve related. The 10-year acturial survival was 82.9% ± 4.8%. The overall 10-year freedom from valve dysfuntion due to calcification was replaced in 30 of them. The incidence of reoperation was 6.3% ± 0.9% per patient-year. There were 15 late deaths with a mortality rate of 2.1 % ± 0.5% per patient-year. Only 3 deaths were valve related. The 10-year 62.1 % ± 11.2%; for patients 15 years old or younger was 24.2% ± 11.2%, and it was 100% for patients older than 15 years. Although fibrocalcification has remained the most important late complication observed in the pediatric age group and the main cause for reoperation, its incidence was much lower than the calcification rate reported in the literature for xenobioprostheses in young patients. Keywords: heart valves prostheses, biological; valvar substitutes

In the cardiomyoplasty, the contraction of the skeleton muscle, undergone electric stimulation on the dilated ventricle wall, increases the ventricle function, which is dependent of the heart and the base disease previous conditions. One of the main problems which interferes with the sucess of the cardiac muscle replacement is the myocardial synchronic stimulation and the skeleton muscle. The stimulation of this muscle in long-term has been possible because of the special electrodes associated with the sequential progressive stimulation, adjusting it to the cardiac function, through the gradual transformation of glicolitic fibers exposed to fatigue in highly resistant slow oxidizers. The pulse generator Myos (Biotronik) has been used in our center for electrical stimulation of the latissimus dorsalis in synchronization with the myocardium. This electronic circuit and lithium battery type of cardiomyostimulator stores a stimulation program responsible for different operational modes, adapted by acomputer program. In order to program the cardiomyostimulator, the moment of the pulse synchronization with the aortic valve opening is extremely important. The high velocity M mode is utilized to evaluate the synchronism. The cardiomyoplasty clinical evaluation is based on the results obtained from 32 patients at 22 ti 72 years old (average=46.2 years) most of patients (72%) presented dilated myocardiopathy due to undetermined cause, 24% of chagasic origin, 3% virus and 3% due to peripartum. Hospital and late mortality rate were both 12.5% and 3.1% and 3.7% respectively, excluding the chagasic patients. The actuarial survival was 81.3 + - 0.22% after 6 years and 94.4 + - 0.1 % after 5 years, withdrawing the chagasic patients. The average indexes of systolic diameters (55,1 mm), diastolic (70,7 mm), segmental shortening (22.8%) and ejection fraction (51.0%), related to an average follow-up of 14.2 months, reflect that the cardiomyoplasty can be effective to assist the left ventricle. Choosing the right patient seems to be key to the goog operative result in short and long terms. Keywords: cardiomyoplasty; cardiomyostimulator; latissimus dorsalis

The authors propose the treatment of aortic aneurysms by using an intraluminal graft. A new device which transforms any kind of graft of different sizes and diameters into an intraluminal one is described. This new device just needs an extra-vascular circunferential ligature and does not require any fixation suture. The use of the rigid, sulcated DELRIN (R) ring simplifies the technique shortening the duration of the surgery, reducing surgical bleeding and dispensing the use of profound hypothermia and platelet transfusion. Between May 1989 and January 1993, 22 patients were submited to aneurysmectomy of the aorta using this technique. Twelve patients exhibited acute aortic dissection (type I and II DeBakey), one DeBakey type III acute aortic dissection, two presented descending aortic aneurysm, two cases were of thoraco-abdominal aortic aneurysm and five aneurysms of abdominal aorta. Three patients died in the imediate post-operative period from cerebrovascular accident, mesenteric thrombosis and pulmonary infection. The survivors have been followed up as outpatients. Keywords: aneurysms, aortic, intraluminal graft, surgery

From May 1990 to January 1994, one hundred and twenty (120) patients underwent aortic valve replacement with the use of the porcine aortic stentless valve. This group comprised of eighty-three (83) male and thirty-seven (37) female patients. The age ranged from eleven (11) to seventy-six (76) years with a mean of 36. There were 85 patients under 40 years of age. Sixty-four patients (64) underwent their first aortic valve replacement due to rheumatic heart disease, thirty (30) because of prosthetic valve failure and of those: twenty (20) due primary tissue failure and in ten (10) due to prosthetic endocarditis, native aortic bicuspid valve in eleven (11) and senile calcificant aortic valve disease in four (4). Thirty-three (33) patients had aortic annular related pathology. The functional class revealed sixty-one (61) patients in class III and fifty-nine (59) in class IV. The longest follow-up was 42 months with a mean of 26. The surgical technique used in the aortic valve surgery rendered consistent and reproducible results. The hospital mortality was 5% (6 patients). This mortality was not valve related. The hospital morbidity revealed full recovery of all patients. There were four (4) late reoperations, in two (2) due to recurrent endocarditis and in two (2) because of paravalvar leak. All patients had full recovery after the reoperation. There was a late mortality of six (6) patients (non valve related). The follow-up of these patients revealed full competent valve in ninety-seven (97) patients and only minor jet in nine (9). Most patients are in functional class I and II. The stentless concept has proven to be outstanding in the aortic position throughout the current follow-up. Although the test of time is required, we have gained confidence in the procedure due to the good clinical results. Keywords: heart valves prostheses, aortic