Volume 13 - Número 1

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Keywords: Cardiac surgical procedures, history; Heart surgery, history, Brazil; Brazilian Society of Cardiovascular Surgery, history

This is a case report of a patient with two saccular aneurysms in the thoracic descending aorta. Treatment consisted of the positioning, through an opening in the aortic arch under deep hipothermia and total circulatory arrest, of two auto expandable stents, guided an Olympus endoscope. The bloodless field made possible the identification of the main thoracic and abdominal aortic branches facilitating the positioning and expansion of both stents. Immediate postoperative recovery was excellent. This is a previously unreported way of placing stents and could open a new perspective in the treatment of thoraco, abdominal and thoracic abdominal aortic aneurysms. Keywords: Aortic aneurysm, surgery; Aorta, thoracic, surgery; Stents; Endoscopia

After 1989, modifications were made for treatment of Aortic Aneurysm and Dissection, they included: Cardiocirculatory arrest, deep hypothermia, hemodynamic monitoring and others. Between January 1980 and July 1994, 520 patients were submitted to surgical treatment of Aortic Aneurysms and Dissection. The patients was divided into three groups according todiagnoses:  Ascending Aortic Aneurysms (AAAS)  Aortic Arch Aneurysm (AAAO)  Aortic Dissections type I and II (DAAO I and II) In the three groups the mortality was inferior to patients operated before 1989, predictive variables of death for AAAS were: pulmonary complications (p = 0.0210), renal (p = 0.0310), neurological (p < 0.0001); for DAAO I and II: arterial hypertension (p < 0.0001), cardiac complications (p < 0.0001), neurological (p < 0.0001), renal (p < 0.0001) and rupture (p < 0.0001) and for AAAO, age (p = 0,001) and renal complications (p = 0.0015). The authors conclude that the modifications utilized in the method of Surgical treatment for Aortic Aneurysm and Dissections achieved better results. Keywords: Aortic aneurysm surgery, treatment outcome; Aortic diseases, surgery, treatment outcome

Introduction: Clinical analysis after three years of observation of the Magalhães-HP pivoting disc valve. Material and Methods: Since 01/94, 34 patients were discharged from the hospital. All the survivors were contacted during the last three months and the average time of observation was 24.5 months (ranging from 2 to 35 months), with a total of 834 months-patient (69.5 years patient). Results: The survival actuarial curve was 85.3%. There was a fatal complication unrelated to the valve (kidney insufficiency) (0.98 PCPY) (percent patient per year) and three fatal complications related to the prosthesis (thrombosis - 2.94 PCPY) (one case in another hospital, one case reoperated, and one case treated with streptokinase with initial good results and fatal pulmonary complications). There were three significant hemorrhagic episodes (2.94 PCPY), one of them fatal (0.98 PCPY), one moderate complications (0.98 PCPY), and eight cases of lesser importance (7.8 PCPY). There were nine non-fatal complications related to the valve (8.8 PCPY), heart murmurs - six cases (5.8 PCPY), small thromboembolism without sequelae - two cases (1.96 PCPY), and thrombosis - one case (0.98 PCPY) (reoperated with success, maintaining the same prosthesis with excellent evolution). Conclusion: The covering of the pivoting disc valve with heterologous biological material with a minor dose of anticoagulant seems to reduce, after one year, the incidence of thrombosis (zero cases), thromboembolism (two cases with low repercussion, transitory, and without sequelae) and hemorrhagic events (two small epistaxe cases). In the first three months after the operation, occured the major incidence of thrombosis and hemorrhagic events due to deflections in the anticoagulant protocol. In this period there must be a full and effective anticoagulation to allow the least of fibrin deposit, and a thin slow cicatrization. The secure weekly average dose of phenprocoumon was 4.5 tablets (minimum of 2.5 and maximum of 7 tablets). The excellent results in the last two years of clinical observation completely justify the use of the valve, but double attention must be taken in the first three months to have an effective anticoagulant protection. Keywords: Heart valve prosthesis; Bioprosthesis; Anticoagulants, therapeutic use

From January 1996, to November 1997, 15 consecutive infants ranging in age from 3 to 11 months (mean: 6 months) and weigh ing from 5 to 9 kilograms (mean: 7.2 kilograms) underwent elective total repair of tetralogy of Fallot. Thirteen had symptoms of hypoxemia and two were acyanotic. Definitive diagnosis was established in all cases by two-dimensional echocardiography. Intracardiac correction was accomplished with conventional cardiopulmonary bypass and moderate hypothermia. Myocardial protection was obtained by cold cristaloide cardioplegia infused into the aorta and topical hypothermia of the heart. Bypass time ranged from 50 to 125 minutes (mean: 84 minutes) and aorta cross clamp time ranged from 32 to 86 minutes (mean: 56 minutes). Intracardiac repair was accomplished through right ventriculotomy in 14 cases and by a transatrial approach in one. A right ventricular outflow patch was used in 11 cases but was extended across the pulmonary valve ring only in four. Transannular pulmonary gradient after correction ranged from 2 to 25 mmHg (mean: 12 mmHg). There were no deaths or major complications in this series. It is concluded that intracardiac correction of the tetralogy of Fallot in the first year of life may be accomplished with low mortality and may have advantages over the two-stage approach. Keywords: Tetralogy of Fallot, surgery; Tetralogy of Fallot, diagnosis

The author reviews the surgical techniques utilized for reconstruction of continuity of the right ventricle and pulmonary artery trunk, giving emphasis to the different techniques and their associations, depending on the anatomy of each cardiac malformation. He illustrates two cases operated with the use of a new concept of biologic prosthesis manufactured with pig pulmonary valve and artery trunk, preserved in glutaraldheyde. There are two models: bivalvar graft and tubular valvar graft, in the present experiment. From May 91 to June 95, forty eight cases were operated. In 43 cases the bivalvar graft was used and in 5 cases the tubular valvar graft was used. There were 5 deaths (10.4%) in the early postoperative period and 2 cases (4.6%) in the late period. This new concept of reconstruction of pulmonary valve and outlet of the right ventricle using integral biological graft, avoided pulmonary obstruction, insufficiency, and low incidence of calcification. This technique is easily reproduced. Keywords: Reconstructive surgical procedures, methods; Heart valve prosthesis, methods; Heart ventricle, surgery; Pulmonary artery, surgery

Deep hypothermic circulatory arrest (DHCA) increased the number of pediatric patients operated on our Service and it is an important aid for the correction of complex cardiovascular procedures. We studied 130 patients from January, 1995 to June, 1996. Patient ages ranged from 2 days to 16 years. The most frequent pathology was VSD (26%), tetralogy of Fallot (13%), TGA (10%) and AVSD (10%). All patients used membrane oxygenators, rectal temperature was maintained at a mean of 15,4°C. Mean perfusion time was 45 minutes. In the early postoperatory stage, low output was the most frequent complication (49 - 38%). Neurological changes occured in 27 patients (20%): 13 seizures (10%), 8 neuropsychologic disfunction (6.1%), 5 extrapyramidal signs (3,8%), 4 neuro-ophthalmic deficits (3%), 4 comas. 5 of these symptoms appeared early in the postoperative period and could be attributed to DHCA (3.8%). There were 20 (15%) deaths. 3 had a permanent neurologic deficit on discharge (2 dysartrias and 1 muscular hypertonya). We concluded that DHCA is useful for the correction of complex cardiac anomalies with a low risk of neurologic complications permanent. Our late follow up is too short for precise analysis of psycomotor development in these patients. Keywords: Heart defects, congenital, surgery; Hypothermia, induced, methods; Heart arrest, induced, methods; Postoperative complications; Neurologic manifestations

The aim of this research was to develop an experimental model, with dogs, to study homologous aortic valve grafts. A group of twenty randomly selected dogs was divided into two subgroups of tem, being Group I the donor group and Group II the recipient group. The surgical approach to the animals of Group I was through a median thoracotomy through which the heart was explanted. The homograft aortic valve was trimmed and prepared. The technical procedures are described step by step. All the dogs from Group II had a median laparotomy performed and the homograft was immediately implanted in the abdominal aorta below the emergence of both renal arteries. The median weight of Group I dogs was 5.5 ± 1.7 kg and 11.9 ± 2.3 kg for Group II. The abdominal aorta's diameter was 8.8 ± 1.2 mm and the one of the homograft valve was 11.8 ± 1.4 mm. The only problem during surgery was the injury of the lymphatic ducts in four cases, with no consequences after its ligation. The mean period of occlusion was 37.6 ± 13.3 minutes. One animal died ten days after surgery due to inferior mesenteric infarction; a second one was sacrificed 14 days after surgery due to a serious infection of the surgical wound; a third animal escaped from the bioterium 25 days after surgery. All the remaining dogs were submitted to a new laparotomy after 30 days. The abdominal cavity was analyzed for adhesions and grafts' haematoma and the aortic pressures proximal and distally to the graft registered (mean gradient was 2.5 mm/Hg). The cusps and the graft were satisfactory, except in two cases, due to partial fixation of one of the cusps; thrombi appeared on all the other two sinuses of Valsalva. Concluding it was felt that this experimental model is compatible, for future studies, of aortic valve homologous grafts. Keywords: Heart valve prosthesis implantation, methods; Aortic valve, surgery; Transplantation, homologous

From the early days of surgical treatment of coronary artery disease by Vineberg until the present time using several types of grafts, we are hoping to improve outcome. Case 1 - A 60 year old man with angina and syncope. An angiographic study has shown a 90% obstruction in A. D., 99% in the right coronary (Fig. 1). An anastomosis between the left Internal thoracic artery and the right coronary artery. A resection of the narrow segment with an end to end anastomosis (Fig. 2). Case 2 - A 40 year old man, with 80% obstruction in the right coronary artery (Fig. 4) and 99% in the descending aorta. A 4 cm segment of ATIE was replaced with a bypass from the right coronary artery (Fig. 3). And a free graft of ATIE from descending anterior artery. The one year follow up of both patients has been good with normal stress test and symptoms. Keywords: Coronary vessels, surgery; Myocardial revascularization; Thoracic arteries, surgery; Anastomosis, surgical

The authors report a case of intrapericardial transdiaphragmatic hernia due to blunt trauma and review about 37 similar cases. They conclude that traffic accidents with motor vehicles are responsible for 71.05% of these injuries. Patients presented delayed symptons predominantly involving the heart and gastrointestinal tract. However, heart failure was confirmed only twice. In most cases GI symptoms were confirmed by signs of rigidity, distensions or visceral occlusions. The diagnosis in 28.94% of cases was made using barium contrast radiology. A diaphragmatic hernia was suspected in 57.89%. All cases were managed surgically with few postoperative complications and only three deaths (7.89%). The transition between the central tendinous diaphragmatic center and the basal pericardium was the common site of rupture in all cases. The transverse colon was the most herniate viscera of the abdominal cavity. In some cases the ruptures affected the diaphragmatic hemicupulas allowing hernias into the pleural spaces. Theories about the existence of embryonic weak points in the hemicupulas, of slimmer central phrenocardial anatomic regions and the possibility of latent periods occurring for hernia formation are discussed with the proper arguments. Selective details of the supplementary tests are included to facilitate the diagnosis. Critical analyses are realized concerning the surgical approach and suggestions are presented regarding the abdominal or thoracic approach. Keywords: Hernia diaphragmatic, traumatic, diagnosis; Pericardium, lesion; Hernia diaphragmatic, traumatic, surgery

Annular subaortic aneurysms are not common, and are usually situated in the mitro-aortic intervalvular fibrosa (MAIVF) region. We present a ruptured annular subaortic aneurysm with left ventricular outflow tract to left atrial communication submitted to a successful surgical repair. An 18-year-old man developed a septic shock in april-1996 with meningitis and intra-venous disseminated coagulation, but without evidence of infective endocarditis. Blood cultures grew Staphylococcus aureus. In march 1997, a mitral systolic ejection murmur was noted. Transthoracic and transesophageal echocardiography showed a bicuspid aortic valve, a prolapsed anterior mitral leaflet, and an annular subaortic aneurysm at MAIVF with left ventricular tract to left atrial communication. Cardiac catheterization confirmed left ventricular to left atrial shunt, but no aneurysmatic structure was seen. Cardiac operation with cardiopulmonary bypass was performed on May 1997. The left atrium was opened. An annular subaortic aneurysm was present in the area of MAIVF and measured 1.8 cm in extension. Its neck measured 1.0 cm. A fibrous-thin-walled aneurysm (fibrous sac) extended into the left atrium and its extremity was perforated . The aneurysm was resected and its neck was plicated using pledgeted sutures. Valve replacement was not necessary. The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. Echocardiogram at discharge showed normal function of aortic and mitral valves and no residual shunt. Concluding, a successful surgical repair of annular subaortic aneurysm is possible, with out valve replacement, and with no residual shunt. Keywords: Aortic aneurysm, surgery; Aortic aneurysm, diagnosis

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