Ana Cristina Monteiro

Plástica da valva mitral: resultados tardios de doze anos de experiência e evoluçäo das técnicas

Foram estudados 301 pacientes, sendo 151 (50,2%) do sexo masculino, com idade variando de 3 meses a 79 anos (media de 37,96 com desvio padrao de 21,4 anos). A etiologia das lesoes foi reumatica em 128 (42,52%), degenerativa em 78 (25,91%), congenita em 21 (6,97%), isquemica em 18 (5,98%), endomiocardiofibrose em 9 (2,99%), endocardite infecciosa em 8 (2,65%), valvulite cronica inespecifica em 5 (1,66%), e nao definida em 34 (11,29%) pacientes. Duzentos e quatro (67,8%) pacientes apresentavam insuficiencia mitral e 97 (32,2%) dupla lesao mitral. Cirurgia associada foi realizada em 45% dos pacientes sendo a mais frequente a substituicao da valva aortica em 41 (13%) pacientes. As principais tecnicas utilizadas foram: resseccao quadrangular da cuspide posterior em 97 (30,99%) pacientes, associada a deslizamento em 3, anel de Carpentier em 93 (29,71%), e tira posterior em 76 (24,28%) pacientes. Encurtamento de cordas tendineas foi realizado em 56 pacientes e encurtamento de papilar em 6. A mortalidade imediata foi de 12 (3,9%) pacientes. Foram reoperados no pos-operatorio imediato 3 (0,9%) pacientes por disfuncao da plastica. As taxas linearizadas para tromboembolismo, morte, replastia e troca valvar mitral no pos-operatorio tardio foram respectivamente 0,2%, 0,5%, 1,0% e 1,1 % pacientes/ano. A curva actuarial de sobrevida e de 83,6% em doze anos e a curva actuarial livre do evento reoperacao e de 83%. Setenta e nove por cento dos pacientes encontram-se em classe funcional I (NYHA) no pos-operatorio tardio (evolucao de 10077 meses/pacientes). Podemos concluir que os pacientes submetidos a plastica da valva mitral apresentaram evolucao satisfatoria, e que o aprimoramento das tecnicas com o passar dos anos tem contribuido para melhoria dos resultados.

Plástica da valva mitral em pacientes consecutivos: como é a evolução tardia?: avaliação clínica e ecocardiográfica

Thirty-nine patientes with mitral insufficiency or mitral stenosis and incompetence submitted to valvular repair were evaluated in the late postoperative period. Mean age of the patients was 30.5 years, with standard deviation of 17.2 years. Twenty-four patients were females (61.5%) and 15 (38.5%) males. Twenty-one Carpentier ring annuloplasties, 12 repair with a posterior sling, five Merendino type annuloplasties and one Kay type annuloplasty were performed. Twenty-three (58.97%) patients presented symptons related to rheumatic fever disease, 12 (30.76%) had no definite etiology and four (10.25%) presented mucoid degeneration occurred in this series. Evolution time was 1497 months/standard (meam 38.39 months and Standard deviation of 16.08 months). In the late postoperative period 34 (87.74%) patients were in NYHA functional class I. Two late deaths (5.12%) occurred, and two (5.12%) patients were reoperated on. Linearilized rates of the reoperation and thromboembolism events were 1.6% and 0.8% per patient/year, respectively. Estimated survival rate was 94.87%. Echocardiographic evaluation of the pre and postoperative values demonstrated significant decrease of the left ventricular diastolic diameter (p = 0.0001), of the left ventricular systolic diameter (p = 0.0001) of the left venticular systolic diameter (p = 0.0001) and of the left atrial diameter (p = 0.0001). The postoperative Doppler echocardiograpfic studies demonstrated absence of valvular area changes at effort. It was possible to conclude that patients submitted to mitral valve repair benefited from higher survival rates and satisfactory clinical evolution.

Autotransfusäo de coleta pré-operatória em cirurgia cardíaca

Autotransfusion (AT) is an alternative to reduce the incidence of complications following homologous blood transfusion. The utilization of autogenous blood is feasible in elective surgical procedures (Pre-AT). A prospective comparative study was carried out in order to establish the ideal parameters for pre-AT, concerning volume, time interval prior to surgery and benefits to the patient, among others. Ninety-six consecutive patients candidates for myocardial revascularization, were analized in the present study. These patients did not present hypoproteinemia, anemia, infections or more than 70 years of age; cardiac reoperations were discarded. Four groups (G) were considered: GI - control group, without pre-AT (41 patients); GII - collection of 500 to 600 ml, comprizing the groups; GII-A - until 7 days before surgery (35 patients); GII-B - from 8 to 15 days before surgery (14 patients); GIII - collection of 1000 ml more than 30 days before operation, with reinfusion and a new collection after 15 days (6 patients). Mean age and hemotocrit were comparable in the different groups. In a few patients postoperative AT was utilized. The results indicated that homologous blood transfusion were necessary in 63% of GI, 26% of GII-A, 43% of GII-B and 67% of GIII patients. The mean amount of autogenous blood reinfused was 534 ml/patient in GII-A, 539 ml/patient in GII-B, and 908 ml/patient in GIII. The postoperative hematocrit at discharge from the hospital was comparable in the four groups. There were no deaths. A smaller number of patients in GII-A received homologous blood (p = 0,008) and there was no statistically significant difference in the groups II-A, II-B and III concerning the volume of homologous blood received. There was no higher incidence of complications, specially bleeding, in the different groups when compared with the control group.

Análise do estudo anatomopatológico de pacientes submetidos a cirurgia valvar no InCór - HC FMUSP

Of the 44 necropsies which were carried out in patients submitted to valvar surgery in 199 0 at InCor (Instituto do Coracao), 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.