Volume 17 - Número 2

Keywords:

OBJECTIVE: The aim of this work is to analyze the myocardial flow direction of patients submitted to transmyocardial laser revascularization (TMLR), using the first - pass magnetic resonance imaging (MRI). METHODS: Ten patients submitted to TMLR with CO2 laser (potency of 800 W) were studied with magnetic resonance imaging (MRI) of fast gradient ¾ eco- EPI hybrid sequence used in a 1.5 TGE CV/i scanner (Sigma CVMR - General Eletric ¾ Milwaukee-USA) to evaluate myocardial perfusion. Bolus of Gadolinium ¾ DTPA (0.1mmol/Kg) was injected by a peripherical intra-venous line at 5 ml/sec at rest and during peak stress of dypiridamole. The distribution of the contrast through the myocardial regions was analyzed. RESULTS: After a mean follow-up of 14.7 months, 6 (60%) patients showed significant myocardial ischemia at least in one of the left ventricular walls. The blood flow was inverted, from subendocardium to subepicardium, just in 1 (10%) patient. CONCLUSIONS: First-pass MRI is an efficient method to show the direction of the myocardial blood flow. In one of the studied patients, the inverted myocardial blood flow (from the endocardium to the epicardium), suggested the patency of the channels created by TMLR. Keywords: Myocardial revascularization, methods; Laser surgery, methods; Magnetic resonance spectroscopy

OBJECTIVE: In this study, the hospital morbidity and mortality, in patients older than 70 years of age, submitted to coronary artery bypass grafting (CABG), and in their quality of life. MATERIAL AND METHODS: Between July 1992 and February 2000, 507 CABG were performed at the Cardiovascular Surgery Department of the "Instituto de Moléstias Cardiovasculares de Cascavel", being 70 patients older than 70 years of age. Fifty seven percent of the patients were male, and the mean age was 72.9 years (70-85 years). Twenty six patients had, pre-operatively, systemic arterial hypertension, 25 severe chronic obstructive pulmonary disease, 17 diabetes mellitus and eight chronic renal insufficiency; thirty seven patients presented with pre-operative myocardial acute infarction, seven had been submitted to a percutaneous transluminal coronary angioplasty, seven had left main coronary disease and one had previous CABG. The mean number of grafts/ patient was 2.8, being in 53% arterial conduits. In seven patients an endarterectomy was performed, in another seven a left ventricular aneurismectomy and in one a partial left ventriculectomy. Nine cases were performed in an emergency way. Intraaortic balloon pump was used in four cases. RESULTS: The mean intensive care and hospital stay was 4 (1-24) and 12.2 (3-34) days, respectively. The global hospital mortality was 7.1%. When analysed by subgroups, the 70 to 74 years of age patients' mortality was 5.3%, and that of the last 35 patients was 2.8%. During the postoperative period the most important complications were respiratory failure (10), atrial arrhythmia (7), mental confusion (6), pulmonary infection (6), pulmonary emboli (5), low output syndrome (4), hospital acute myocardial infarction (3), stroke (3), acute renal insufficiency (4) and mediastinitis (1). In the late follow-up four (6.1%) patients died, being two cases by non-cardiac causes. CONCLUSION: In view of these results, the authors believe that CABG can be performed in patients older than 70 years of age, with a mortality almost as the same as the all group, but due to the high morbidity, we should have strict criteria and preparation, in order to lower the postoperative complications. Keywords: Coronary disease, surgery; Myocardial revascularization, mortality; Myocardial revascularization, aged

The authors report the experience with the methodological implantation of thermo-coronary-angiography in the Division of Cardiovascular Surgery of the Hospital de Clínicas, Federal University of Paraná, and the Hospital Universitário Evangélico de Curitiba. It is a totally noninvasive technique that allows the real time assessment of the coronary blood flow with no interruption on the surgical procedure. Using TCA, it was possible to analyze the heart before and after the bypass graft completion, which allowed the visualization and recording of the ischemic area in the myocardial wall, the assessment of the graft patency, including stenoses, and the status of myocardial perfusion by preestablished collateral branches. Therefore, TCA is helpful in order to improve the results of the coronary artery bypass graft surgery, providing a higher treatment quality to the patient with coronary artery disease. Due to its great number of advantages, this infrared imaging method has an enormous likelihood to become a crucial tool to perform a safe myocardial revascularization. Further more, a permanent TCA system established in the operating room would extend all its benefits to other cardiac surgical procedures. Keywords: Myocardial revascularization, methods; Cardiac surgical procedures, methods

MATERIAL AND METHODS: We analyzed retrospectively the medium term mortality index in 113 patients with mitral regurgitation diagnosed clinically and echocardiographic who have undergone clinical or surgical treatment since January 1995 until December 1998. The age ranged from 29 to 67 years (mean 47 ± 4.3 years ) and 81 (71.7%) patients were female. In NYHA classification, 51 (45.1%) patients belonging to functional class I, 24 (21.3 %) class II 21 (18.6%) class III and 17 (15 %) class IV. RESULTS: After 4 years we observed that the mortality rate was 21.2%. All the 75 (66.4%) patients belonging to FC (NYHA) I and II, who received only clinical treatment presented mortality rate of 12%. From the 38 patients belonging to FC (NYHA) III and IV, 18 (47.4 %) were submitted to surgical treatment and showed mortality rate of 22.2%: (5.5% surgical mortality and 16.7% during 4 years). The 20 (52.6 %) patients that refused the surgery and presented similar clinical conditions to those operated, were treated clinically and demonstrated mortality rate of 55%. CONCLUSION: We conclude that the mitral regurgitation exhibit high mortality rate and that surgical treatment to the patients belonging to FC ( NYHA) III and IV reveals low mortality rate medium term when compared with clinical treatment. Keywords: Mitral valve insufficiency, surgery; Mitral valve insufficiency, therapy; Mitral valve insufficiency, mortality; Mitral valve, surgery

PURPOSE: To value the surgical treatment of adult patients with Ebstein's anomaly, using a Carpentier's modified repair technique. MATERIAL AND METHODS: Between January 1990 and March 2001 six adult patients with Ebstein's anomaly were treated using a modification of Carpentier's repair technique, four were males and two were females, ages ranging from 18 to 34 years (Mean 23.3 years), all were in Functional Class III or IV (NYHA), with increased cyanoses and frequent rhythm disturbance. Four patients had an associated atrioventricular septal defect; in four patients the tricuspid valve was Carpentier's type B and two type A and all were able to benefit from this conservative technique. RESULTS: There were not hospital deaths and one patient died 14º months after surgery in this series. Actuarial survival was 83.3% in 9 years. Four patients are in Functional Class I and one in Functional Class II (NYHA). Echocardiography and Doppler studies demonstrated a normal shape of right ventricle and good tricuspid valve function in four patients and one has moderate tricuspid regurgitation but still in Functional Class II (NYHA). CONCLUSION: Although the small number of patients in this series, the modification of Carpentier's repair technique in adult patients was efficient, reproducible and improved the preoperative status with regard to functional class, tricuspid regurgitation cyanoses and rhythm disturbance. Keywords: Ebstein´s Anomaly, surgery; Heart defects, congenital, surgery; Tricuspid valve, surgery

OBJECTIVE: To evaluate early and late results of aortic coarctation (CoAo) surgical repair in early months of life. MATERIAL AND METHODS: Between January 1994 and May 2001, 89 patients were submitted to CoAo repair by subclavian artery flap angioplasty (Group 1 - n=49) or resection with end-to-end anastomosis (Group 2 - n=40). We analyzed and compared the mean age at operation, associated cardiac malformations, pre and postoperative aortic pressure gradient, surgical complications and mortality, and actuarial freedom from events curve. RESULTS: Most of patients were male (n=60 - 68%) and underwent to aortic repair under than one month of age, with severe heart failure (n=62 - 70%). CoAo was associated with intracardiac defects in 66 cases (74%). The aortic pressure gradient before and after surgery was 42 mmHg and 4,5 mmHg, respectively. Postoperative complications were persistent arterial hypertension (n=27), residual stenosis (n=5) and bleeding (n=3), and operative mortality was 10,2% (n=9), markedly higher in patients with associated cardiac malformations (12% vs. 4% - p<0,05). There were no differences in complications and mortality in both groups. Late re-coarctation was 16% in group 1 and 15% in group 2 (NS) and actuarial freedom from events in 60 months was 76% and 81%, respectively (NS). CONCLUSIONS: Most of surgical repair in symptomatic CoAo during early months is a life-saving procedure, due to severe heart failure; operative mortality is significant in patients with others cardiac defects; there were no differences in morbidity, mortality and recurrent coarctation rate between two surgical techniques performed. Keywords: Aortic coarctation, surgery; Aorta, thoracic, abnormalities

We review all hospital recorders of the patients that was submitted to cardiac surgery with sternotomy at the Hospital de Base do Distrito Federal in period of six years. Fifteen patients (1.09%) developed mediastinitis in this period in a total of 1388 cardiac surgeries between January 1995 and March 2001. Sex, age, type of surgery, respirator time, ICU permanence, use of antibiotics and type of bacteria isolated were some variables analyzed. Keywords: Mediastinitis, surgery; Cardiac surgical procedures, adverse effects; Sternum, surgery; Osteomyelitis, sternum

INTRODUCTION: The glutataldehyde (GDA) treated pigs cusps are one of most employed tissues in bioprosthesis, but is late post-implant calcification is main cause of its failure. BACKGROUND: This study aims at comparing and analyzing two methods (ethanol 80% and l-glutamic acid 0.8%) to prevent calcification in pig cusps and aortic wall implanted subcutaneously in rats, the cusps and aortic wall segments of the control were in glutaraldehyde (GDA), during a 15, 30 and 60 days period after the implant. MATERIAL AND METHODS: We used 45 young rats, distributed in 3 groups of 15 rats each, which in turn were subdivided in 3 subgroups of 5 rats each, in which we implanted one cusp and one aortic wall segment in 2 subcutaneous pouches for each rat. We called each group as follows: GDA (control group), E80% (the group whose structures were previously prepared with ethanol 80%) and GA 0.8% (group previously prepared with L-glutamic acid 0.8%); in those groups we measured calcium and performed a microscopic analysis seeking for any calcification, its location and intensity; inflammatory infiltrate, location and type, during a 15, 30, and 60-day period after the implant. RESULTS: Calcium was found in the aortic cusp in the E80% group (1.30±0.21 mg calcium/mg tissue) at day 15, (1.05±0.22 mg calcium/mg tissue) at day 30, and (0.53±0.42 mg calcium/mg tissue) at day 60; in the GA 0.8% group (12.17±0.66 mg calcium/mg tissue) at day 15, (15.31±2.82 mg calcium/mg tissue) at day 30, and (34.24±16.28 mg calcium/mg tissue) at day 60; and in the control group, GDA at day 15 (12.44±2.26 mg calcium/mg tissue), at day 30 (13.44±3.34 mg calcium/mg tissue), and at day 60 (50.85±8.71 µg calcium/mg tissue). As for the calcium measured in the aortic wall, in the E80% group we found (4.62±0.68 µg calcium/mg tissue) at day 15, (9.47±2.59 µg calcium/mg tissue) at day 30, and (23.56±7.75 µg calcium/mg tissue) at day 60; in the GA 0.8% group at day 15 (4.31±0.85 µg calcium/mg tissue), at day 30 (7.69±1.48 µg calcium/mg tissue), and at day 60 (20.50±1.22 µg calcium/mg tissue); and in the control group (GDA) at day 15 (7.34±1.32 µg calcium/mg tissue), at day 30 (9.28±0.76 µg calcium/mg tissue), at day 60 (27.60±1.08 µg calcium/mg tissue). Microscopic evaluation of the aortic cusp, showed a progressive calcification in those fixed with GDA. Such process was found partially in the GA 0.8% group, and totally absent in the E80% group. As for the assessment of the aortic wall segments, we also observed progressive calcification, which was not inhibited by the treatment with either GA 0.8% or E80%. CONCLUSIONS: We concluded that a pre-treatment with ethanol at 80% inhibited calcification in pig aortic cusps, however it was not as effective on the aortic wall. However, L-glutamic acid at 0.8% did show that it minimizes calcification in the aortic wall. Further studies are required, to evidence if the anti-calcifying action of ethanol 80% is kept if the pig aortic bioprostheses are implanted in the circulatory system. Keywords: Bioprosthesis, conservation; Ethanol, pharmacology; Glutamic acid, pharmacology; Calcification, physiologic

It was tested in 30 dogs a circuit capable to allow extracorporeal circulation (ECC) with autogenous oxygenation (AO) of the blood employing an only centrifugal pump. With this assembly is unnecessary a pump to the right side: the gradient of transpulmonary pressure was obtained by increasing the pulmonary artery pressure by volemic expansion and decreasing the left atrial pressure by draining this camera by means of a siphon. The heart was electrically fibrillated in the beginning of the bypass and defibrillated in the end. This circuit allowed the maintenance of normal hemodynamic parameters and normal blood gases level during ECC. The operative field and the mobility of the heart were similar to those provided by conventional CEC. We concluded that the use of an only centrifugal pump simplifies ECC with AO, turning it a practical choice for the procedures of myocardial revascularization. Keywords: Extracorporeal circulation, methods; Cardiac surgical procedures, methods

Thrombocytopenia is a major problem in patients undergoing cardiac surgery. We will report two surgical cases with acquired decrease of platelets: one due uremia and other of a valvar dysfunction. These patients had an uneventful recovery in the transoperatory and immediately post-operatory phases. Blood loss was not higher than the expectected. Transfusion of platelets helded in the surgery could prevent future complications in the early recovery of the patient. Keywords: Thrombocytopenia, surgery; Blood platelets, pathology; Blood coagulation; Hemostasis

A case of a 44 years old man with chronic chest pain since one year and two episodes of stroke, secondary to a giant ruptured syphilitic aortic arch aneurysm and left carotid and left subclavian arteries occlusion, is reported. The patient has been successfully operated through a median sternotomy and antegrade selective cerebral and distal corporeal continuous perfusion. Technical details of the total surgical correction performed and bibliographic review, concerning different aspects of tertiary syphilitic cardiovascular compromise are discussed. Keywords: Aortic aneurysm; Aorta, surgery; Syphilis, cardiovascular; Aortitis, syphilitic, surgery; Aortic rupture, surgery