Volume 14 - Número 3

Keywords: Cardiac surgical procedures, history, Heart surgery, history; Thoracic surgery, history

From March 1980 to December 1997, 545 patients underwent 560 mitral valve repairs at the Heart Institute of HCFMUSP. Ages ranged from 3 months to 86 years with mean age of 42.2 and standard deviation of 21.4 years. Two hundred and seventy four (50.3%) were male. Ethiology was rheumatic disease in 234 (42.9%) patients. The techniques used were: quadrangular resection of posterior leaflet in 204 (36.5%) patients, annuloplasty with posterior sling in 139 (24.5%), Carpentier ring annuloplasty in 102 (18.2%), segmentary posterior annuloplasty in 37 (6.6%) and others. Associated procedures were performed in 267 (35.6%) patients with the most frequent tricuspid valve repair in 95 (17%) patients. Immediate mortality was 3.7% (21 patients). The linearizated rates of reoperation, thromboembolism, endocarditis and hemolysis, were respectively 2.9%, 0.6%, 0.3% and 0.1% patient/ year. The actuarial survival rate at 17 years was 76.8 ± 10.8% and the actuarial freedom from endocarditis, thromboembolism, reoperation and hemolisis at 17 years was 98.9 ± 0.6%, 93.9 ± 3.7%, 61.0 ± 7.9% and 99.7 ± 0.2%, respectively. We conclude that patients submitted to mitral valve repair presented satisfactory evolution. Keywords: Mitral valve, surgery; Heart valve disease, surgery

The results of maze procedure in rheumatic mitral valve disease are subject to debate. This paper reports medium term results in rheumatic and degenerative mitral valve surgery associated with maze procedure. From 1994 to 1997, 57 patients were operated on. They were divided into two Groups; R (rheumatic) 40 patients and D (degenerative) 17. Group R included 8 (20%) males and 32 (80%) females. Group D: 8 (47%) males and 9 (53%) females (NS). Age in R = 47 ± 11 and D 54 ± 17 years (p < 0.05). Left atrial size was 6.1 ± 1.1 cm in R and 5.9 ± 1.2 in D (NS). There were 3 hospital deaths, 1 (2.5%) in R and 2 (12%) in D. One D patient (7%) died late. Pacemakers were implanted in 4 (10%) R and 2 (17%) in D (NS). There were no significant differences regarding surgical duration of perfusion or myocardial ischemia, antiarrhythmic medications, immediate or late cardiac rythms and occurrence of arrythmias. Ergometric evaluation for measuring chronotropic response revealed a normal response in 6 (25%) R and 1 (10%) in D at a mean of 16.6 months PO. In the lower response group, 3 (12.5%) R and 6 (60%) D had intermediate values (p = 0.009) and 15 (62.5%) R versus 3 (30%) D had values below 75% of expected heart rate (p = 0.09). Rheumatic or degenerative ethiology of mitral valve disease does not influence the results of maze procedure in this patient population. Mean chronotropic response to exercise tends to be lower in degenerative patients. Keywords: Mitral valve, surgery; Atrial fibrillation, surgery; Arrhythmia, sinus, surgery; Rheumatic heart disease

The surgical management of diseases of the aorta is usually followed by high rates of morbidity/mortality. The patient who is usually elderly and debilitated presents in serious condition, and often with changes in various organs and systems caused by the acute disease itself. Conventional surgery requires complex coadjuvant techniques such as prolonged extracorporeal circulation (ECC), deep hypothermia, complete circulatory arrest besides prolonged time of aortic clamping. In 1988, in an attempt to reduce the surgical aggression on this already feeble patient, we developed an intraluminal ring (1, 2). It was projected and measurements were experimented to simplify its handing and anastomosis resulting in a marked decrease in operative time, ECC time and aortic clamping. It often eliminated the need of ECC and hypothermia resulting in easy, rapid, safe and hemostatic anastomosis. Between March 1988 and Jannuary 1999, 432 patients underwent surgical treatment of dissections or aneurysms of the aorta on our Service. The intraluminal ring with anastomosis was employed in 328 patients. Four hundred and eighty-nine rings were utilized. Diseases included acute dissection of the aorta type A (25), acute dissection of the aorta type B (29), aneurysms of the ascending aorta (81), aneurysms of the aortic arch (08), aneurysms of the descending thoracic aorta (28), thoraco-abdominal aneurysms (17) and aneurysms of the infra-renal abdominal aorta (40). Over-all mortality was 13.41%. Out-patient followup ranged from 11 years to 25 days. The actuarial survival curve in 11 years was 67.3%. In no case did we observe the complications described in the literature such as emboli, formation of pseudo-aneurysms, ruptures or stenosis. On our Service, use of the intraluminal ring simplifies surgery, shortens the time necessary for anastomosis and reduces bleeding, simplifying techniques, reducing mortality and providing a good perspective of survival over the long term. Keywords: Aorta, surgery; Blood vessel prosthesis; Stents; Vascular diseases, surgery

The clinical treatment of acute type B aortic dissection has a mortality of about 25%, therefore, less than surgical mortality. The surgical treatment of chronic dissections also produces a high morbidity and mortality. The use of self-expanding endovascular stents offers a new alternative for the treatment of this disease. From April to December 1998, 15 endovascular stent grafts were implanted, 10 in acute dissections and 5 in chronic aneurysms. Ages ranged from 48 to 75 years (mean = 60.53±9.73 years), with 66.6% males. The patients were submitted to medium sternotomy, extracorporeal circulation (ECC), with deep hipothermia (18°-20°C), total circulatory arrest (TCA), and retrograde cerebral perfusion (RCP). The transverse aorta was incised and the stent was implanted in the descending proximal aorta with the aid of aortoscopy. The times of ECC, aortic clamping, TCA, RCP, rewarming, mechanic ventilation, hospitalization, trans and post-operative bleeding, blood replacement, arterial samples, event curve and survival curve were analysed. The hospital mortality (30 days) was 6.6%; two patients were reoperated 3 and 6 months after surgery with aortic ascending dissection and new distal aneurysm to the stent, 14 have been followed up from 1 to 8 months post-operative, 85.7% are free of events with a survival curve of 93.1% (240 days). We conclude that the self-expanding intraluminal stents implant presented a lower mortality during the acute stage of the disease (6.6%) compared to our previous experience with clinical treatment (30%). In spite of the small sample the procedure seems to be promising and needs more follow up. Keywords: Aortic aneurysm, surgery; Dissecting aneurysm, surgery; Stents

From January to December 1998, ten patients with dissecting aneurysms of the Aorta (ADA Ao) were operated on, 4 type A and 6 type B. Males predominated and ages ranged from 34 to 78 years. In all of them aortoscopy was performed with deep hypothermia and circulatory arrest. A gastroscope was used with visualization of the aortic lumen and all patients had less than 15 days of disease. In type A group, there was re-entrance below the left subclavian artery in 2 patients and on the iliac bifurcation in the other 2. In the type B group, there was re-entrance at the renal arteries level in 2 patients and at the aorta bifurcation level of the iliac in 4 patients. The aortoscopy guided us in implanting an elephant trunk supplement in two patients in group type A. In the other 2, it guided us in the inversion of arterial line direction. It directed us in the correct elephant trunk placement in the type B group. In 4 patients we used the aortoscopy as a diagnostic complement. The time spent with the aortoscopy did not alter morbidity concluding that aortoscopy is a rapid diagnostic method with good definition of anatomic changes of the aorta, leading to an efficient treatment. In acute unstable cases we can dispense with some diagnostic scans that could delay surgery, once the re-entrance is on the end of the aortoscopy helps avoid retrograde dissection. We belive that aortoscopy can, in the future, be of great value in the diagnosis and treatment of A D A Ao, as well as in other aortic diseases. Keywords: Surgical procedures, endoscopy, methods; Acute aneurysm, radiography, surgical; Aneurysm, dissecting, radiography, surgical

Surgical correction of complex cardiac malformations that require extended extracorporeal circulation (ECC) increase morbidity/mortality due to water retention and systemic inflammatory reaction. The purpose of this study is to compare the immediate postoperative evolution of patients submitted to conventional ultrafiltration (CUF) during ECC and modified ultrafiltration (MUF) after ECC. Forty-one patients submitted to surgical correction of congenital cardiac disease were divided into 2 groups: G1 - 21 patients with ages from 15 days to 36 months (median 11 months) and weighing from 3.6 kg (M: 7.27 ± 3.07), operated on between 1996 and 1997 were submitted to CUF; G2 - 20 patients with ages ranging from 9 days to 36 months (median 5.5) and weighing from 2.2 to 12 kg (M: 5.7±2.5) operated on between 1997 and 1998 were submitted to CUF + MUF. Among the most frequent surgeries were: ventriculoseptoplasty, 15 (36.58) cases; Jatene's surgery, 10 (24.38) cases; correction of septal A-V defect, 7 (17.08) cases, etc. Statistical analysis regarding age, weight and surgical complexity showed similarity between the groups. There were 6 (28.58) deaths in G1 and 4 (20.08) in G2, p= 0.71. The mean ultrafiltered volume in G1 (CUF) was 143.3 ml and 227.0 ml in G2 (CUF+MUF) p<0.001, showing a statistically significant difference. However, the mean time of mechanical ventilation (G1: 94.8 h and G2: 95.6 h, p= 0.97), mean time of inotropic drug use (G1: 145.2 h and G2: 137.6 h, p=0.85), mean time stay in Intensive Care Unit (G1: 169.6 h and G2: 157.8 h, p= 0.79) and mean time of hospital stay (G1: 14.8 d and G2: 14.6 d, p= 0.95) did not show significant differences between the groups. The CUF technique used for more than 8 years on our Service showed similar results when compared with the CUF + MUF association. MUF was efficient regarding removal of body water after ECC without intercurrent episodes due to the method. Possibly a randomized study on a greater number of patients would allow to detect differences between the two methods. Keywords: Heart defects, congenital, surgical; Hemofiltration, methods; Extracorporeal

Background: The mechanical circulatory assistance is a therapeutic option in cases of cardiogenic shock refractory to the pharmacological treatment, and is frequently used as a bridge for heart transplantation. Objective: To evaluate the action of the Ventricular Assist Device (VAD) developed by the Bioengineering Division of the Instituto do Coração, implanted as a substitute of the left heart. Patients and Methods: Ten Girolando calves with medium weight of 73 kg were studied. The VAD-InCor implant was accomplished with the drainage cannula positioned in the left atrium (LA) or in the apex of the left ventricle and the replacement cannula implanted in the descending thoracic aorta. The pressures of the right and left heart, cardiac output and the flow of VAD were determined before and after the pharmacological induction of myocardial failure, at different levels of vacuum of the drainage system. Results: Values of the flow of VAD with the drainage in LA were of 2.2 ± 0.5 l/min without vacuum, of 3.7 ± 0.4 with vacuum of 10 mmHg, of 4.3 ± 0.4 with vacuum of 20 mmHg and of 4.8 ± 0.6 with vacuum of 30 mmHg. The values of the pressure of LA were: 11.7 ± 6; 9.8 ± 5.3; 8.5 ± 4.4 and 5.6 ± 3.3 mmHg under the same conditions, respectively. With the ventricular cannula, the VAD flow was 4.2 ± 0.6 without vacuum and of 4.4 ± 0.7 with vacuum of 10 mmHg, with of LA pressure of 11.1 ± 2 and 10.3 ± 3.5 mmHg in the two conditions. Those results were observed in similar hemodynamic conditions, with the VAD flow responsible for a greater percentile of the total cardiac output according to the level of vacuum. That percentile was of 86 ± 13% with the atrial cannula and vacuum of 30 mmHg and of 97 ± 3% with the ventricular drainage and vacuum of 10 mmHg. Conclusions: The VAD-InCor demonstrated its effectiveness as a substitute of the left heart. The performance of this device was proportional to the level of vacuum of the drainage system and was better with the ventricular cannula. Keywords: Heart ventricle, surgery; Heart-assist devices

The present study was developed to determine the early and late prognosis of patients submitted to myocardial revascularization (with or without extracorporeal circulation) and the relationship with troponin-I serum levels at the postoperative period. One hundred and eight patients were studied between December 1996 and December 1997. The serum troponin-I levels were determined by chemoluminescence (Acess - Sanofi-Pasteur) during four periods: preoperative, admission to Intensive Care Unit, first postoperative day and second postoperative day. Values below 0.1 ng/ml were considered normal. Cut-off levels for prognostic evaluation (0.5, 1.0, 2.5 and 5.0 ng/ml) were chosen. Follow-up was measured in months with the aim of construction survival curves. The only event considered was cardiac death. Serum troponin-I had a characteristic early behaviour with higher levels on the first postoperative day. When extracorporeal circulation was utilized (Group I), the levels were significantly higher but there was no correlation with ischemic or perfusion times. Perhaps the troponin-I high serum levels could be due to specific myocardial injury, i. e. coronary artery obstruction, saphenous bypass graft acute failure and so on and not due to extracorporeal circulation per se. It was also possible to determine the cut-off levels as markers of poor prognosis. Serum troponin-I higher than 2.5 ng/ml on the first postoperative day were followed by mortality rates between 33% and 50% up to 6 months of follow-up. Serum troponin-I levels were higher than normal in patients submitted to myocardial revascularization with or without extracorporeal circulation, signifying myocardial cell injury. Values close to 2.5 ng/ml on the first postoperative day alert to the necessity of more aggressive diagnostic and therapeutic measures. Keywords: Myocardial revascularization, mortality; Troponin I, blood

Cardiopulmonary bypass (CPB) induces the development of a systemic inflammatory response syndrome, with the release of cytokines that are responsible for many clinical manifestations. Purpose: The purpose of the study was to observe the release of the cytokines - tumor necrosis factor alpha (TNFa) and Interleukine-6 (IL-6), and to verify the clinical alterations produced in patients undergoing myocardial revascularization with CPB, with or without corticoids. Material and Methods: Thirty patients were studied - 15 used corticoid (methylprednisolone, 30 mg/kg -Group I) and 15 did not (Group II). Serial blood samples were collected and the TNFa and IL-6 release were analyzed, as well as the leukocyte count, erythrocyte sedimentation rate and glycemia. The blood pressure, cardiac rate, temperature, postoperative bleeding, orotracheal tubing time and inotropic drug requirement were also compared. Statistical significance was assumed when p £ 0.05. Results: In Group I TNFa was not detected and IL-6 was detected in 13 patients, with levels ranging from 8.6 to 101.8 pg/ml. In Group II TNFa was detected in 13 patients, with levels between 5.4 and 231.0 pg/ml. The IL-6 in this group was detected in 15 patients, with higher levels than those in Group I, varying between 5.5 and 2569.0 pg/ml. The Group I patients had higher medium blood pressure (7.9 ± 0.5 vs 7.3 ± 0.4 mmHg) and lower inotropic drug requirement (5 vs 11). They evolved with less tachycardia (105.6 ± 5.9 vs 109.3 ± 7.2 bpm), lower temperature (36.5 ± 0.2 vs 37.3 ± 0.2°C), lower postoperative bleeding, (576.6 ± 119.5 vs 810.0 ± 176.2 ml), shorter orotracheal tubing time (11.0 ± 2.0 vs 14.6 ± 2.9 hs) and lower leukocytosis. The glycemia level was just significant (Group I > Grupo II) in the immediate postoperative and in the first postoperative samples. The erythrocyte sedimentation rate did not present significant statistical difference between the two groups. Conclusion: The methylprednisolone significantly inhibited the release of inflammatory cytokines mainly the TNFa. The systemic adverse effects caused by the inflammatory response after CPB were minimized by corticoid use. Keywords: Myocardial revascularization; Extracorporeal circulation,adverse effect; Corticoids, farmacology; Sepsis syndrome, etiology; IL6, antagonists & inhibitors; TNF-alpha, antagonists & inhibitors