Carlos R. Moraes

Surgery for endomyocardial fibrosis revisited

OBJECTIVE To identify life expectancy after surgery for endomyocardial fibrosis (EMF) and the events that influence it. METHODS Eighty-three patients with EMF underwent endocardial decortication and atrioventricular valve replacement or repair, between December 1977 and December 1997. There were 66 (79.6%) female and 17 (20.4%) male patients, ranging in age from 4 to 59 years (mean, 31). Thirty-seven (44.5%) had biventricular disease, 34 (41.0%) had disease of the right ventricle alone and 12 (14.5%) had EMF confined to the left ventricle. All were in functional class III or IV (New York Heart Association classification). RESULTS Sixty-eight (81.9%) patients survived the operation and were followed up for periods ranging from 2 months to 17 years. The total follow-up time was 6290 patient/months (mean, 92 months). There were 15 late deaths, but in six, the cause was not related to the underlying disease. Four (5.8%) patients presented recurrence of the fibrosis and were reoperated on and in six (8.8%), EMF appeared in the other ventricle. Five (7.3%) patients were reoperated on to replace either a valve prosthesis or a native valve which had been preserved during the first procedure. Only 24 (45%) of the 53 surviving patients are in functional class I or II. The actuarial probability of survival at 17 years, including operative mortality, was 55%. CONCLUSION Surgical treatment of EMF should be considered a palliative procedure because surgery does not alter the progressive nature of the disease. However, surgical therapy is recommended for patients with EMF and heart failure as it is their only hope of survival.

Avaliação do EuroSCORE como preditor de mortalidade em cirurgia de revascularização miocárdica no Instituto do Coração de Pernambuco

OBJECTIVE: To assess the applicability of the European Risk System in Cardiac Operations (EuroSCORE) in patients undergoing myocardial revascularization at the Heart Institute of Pernambuco. METHOD: During 2003 and 2004, 759 patients underwent myocardial revascularization. Of these, seven were excluded owing to the lack of information on one aspect or another involved in obtaining a EuroSCORE. In order to assess the applicability of the EuroSCORE, an adjustment was made using a logistic regression model of operative mortality (response variable) on the EuroSCORE (explanatory variable). The calibration of the model was measured by comparing the morbidity observed with that expected, using the Hosmer-Lemeshow Test of Goodness of Fit. The accuracy of the model was evaluated by means of Statistic-c. RESULTS: The accuracy of the model, estimated at 69.9%, and the calibration (Hosmer-Lemeshow test, p=0.663) were satisfactory. The total predicted mortality was practically identical to that observed - 1.7%. The low-risk group (EuroSCORE: 0-2) comprised 231 patients and two (0.87%) deaths occurred. The medium-risk group (EuroSCORE: 3-5) comprised 268 patients and one (0.37%) death occurred. The high-risk group (EuroSCORE: > 6) comprised 253 patients and ten (3.95%) deaths occurred. The discrepancies between the percentages of deaths observed in these groups and those predicted by the model were not statistically significant on the basis of the result of the chi-square test (p=0.624). CONCLUSION: The EuroSCORE, a simple and objective index, proved to be a satisfactory predictor of operative mortality in patients submitted to myocardial revascularization in the Heart Institute of Pernambuco.

Assesment of the EuroSCORE as a predictor for mortality in valve cardiac surgery at the Heart Institute of Pernambuco

OBJECTIVE To assess the applicability of the European Risk System in Cardiac Operations (EuroSCORE) in patients undergoing cardiac valve surgery at the Heart Institute of Pernambuco. METHOD 840 patients operated on between 2001 and 2009, who medical records contained all the informations to calculate the EuroSCORE were included in the study. Hospital death was the end-point of the study. In order to assess the applicability of the EuroSCORE it was used the non parametric test of Mann-Whitney. The calibration of the model was measured by comparing the morbidity observed with that expected, using the Hosmer-Lemeshow Test of Goodness of Fit. The accuracy of the model was evaluated by the ROC curve (receiver operating characteristic curve). RESULTS The comparison of expected and observed mortality, by Hosmer-Lemershow test, showed good predictive capacity (P = 0.767) as well as when compared to each value of addictive EuroSCORE (P = 0,455). The area of ROC curve was 0.731 (IC 95%, 0.660 - 0.793) with P < 0.001. The global predicted mortality was practically identical to that observed (7.9%). The low-risk group (EuroSCORE 0-2) comprised 345 patients with a mortality of 3.19%. The medium-risk group (EuroSCORE 3-5) comprised 364 patients, with a mortality of 7.69% and the high-risk group (EuroSCORE > 6) included 131 patients, with a mortality of 20.6%. The regression logistic analyses allowed to identify the following risk-factors for death: age > 60 years, gender female, previous operation, active endocarditis, associated surgery of the thoracic aorta and extra-cardiac arteriopathy. CONCLUSION The EuroSCORE, a simple and objective method, proved to be a satisfactory predictor of operative mortality and risk factors for death in patients submitted to valve cardiac operations in the Heart Institute of Pernambuco.

Diabéticos devem ter a artéria torácica interna esqueletizada? Avaliação da perfusão esternal por cintilografia

OBJECTIVE: To assess, by scintillography, the effect of using bilateral internal thoracic arteries (BITAs) - prepared by two different techniques - on the sternal perfusion. METHODS: 35 patients undergone coronary artery bypass grafting (CABG) were divided into two groups: Group A (18) had both ITAs dissected using skeletonization technique and group B (17) as pedicle preparation. There was no difference in the two groups relating gender, age and demographic characteristics. On the 7th postoperative day the patients underwent bone scintillography. The statistical analysis was performed using the Students t test with 95% significance. RESULTS: Group A (skeletonized ITA) showed higher perfusion (11.5%) of the sternum as a mean, than Group B (pedicled ITA) patients; however this was not statistically significant (P = 0.127). On the other hand, comparing the diabetic population, seven in each group, there was a marked 47.4% higher perfusion of the sternum in Group A patients (skeletonized ITA) comparing to Group B (pedicled ITA) and this difference reached statistical significance (P = 0.004). CONCLUSION: 1- Sternal perfusion is not affected significantly apart from the dissection technique used for both internal thoracic arteries in the general population when assessed by bone scintillography. 2 - In the diabetic subgroup, a significant preservation of the sternal perfusion was observed in patients undergone skeletonized dissection of the internal thoracic arteries. Although these findings should be confirmed in a greater number of cases, diabetic patients should have the internal thoracic arteries dissected using skeletonization techinque.

Endomyocardial Fibrosis: Report of 6 Patients and Review of the Surgical Literature

Six patients with endomyocardial fibrosis were treated by endocardium decortication and atrioventricular valve replacement. There were 5 female patients and 1 male patient ranging from 14 to 48 years old (mean, 30 years). Four patients had involvement of the right ventricle, 1 patient had involvement of the left ventricle, and 1 patient had biventricular disease. There was 1 operative death due to low cardiac output state (the patient with biventricular endomyocardial fibrosis), and there was 1 late noncardiac death. The surgical literature, which describes 19 previously reported cases, was reviewed. On the basis of the results of this series and those of the reported cases, it is concluded that surgical treatment of endomyocardial fibrosis is feasible and provides good clinical improvement.

Ventricular septal defect following nonpenetrating trauma. Case report and review of the surgical literature

From the Institute of Diseases of the Chest of Recife. Real Hospital Português de Beneficência em Pernambuco. Av. Portugal, 163, Recife Brazil. Rupture of the interventricular septum may result from blunt trauma of the chest or from a penetrating wound of the heart. Patients with traumatic ventricular septal defect from a penetrating wound usually have symptoms and signs of cardiac tamponade or hemothorax and do not develop the typical clinical picture of an acute ventricular septal defect, due to blunt trauma, which is quite similar to those of interventricular septal ruptures following myocardial infarction. Traumatic ventricular septal defect was first described by Hewett’ in 1847. EaSt2 made the first diagnosis in life and Guilfoil and Doyle3 reported the first case proven by cardiac catheterization. The first successful repair of traumatic ventricular septal defect was performed by Lillehei in 1955. This case was reported upon by Campbell .4 Since then, at least twenty-one4-23 patients have received surgical treatment for ventricular septal defect due to indirect trauma. In the present paper a case of traumatic ventricular septal defect repaired surgically is described and the surgical literature reviewed.

Transplante cardíaco: a experiência do Instituto do Coraçäo de Pernambuco com 35 casos

Material and Methods: From August/ 1991 to February/ 2000, 35 orthotopic heart transplants were performed at the Heart Institute of Pernambuco. There were 29 male and 6 female patients ranging in age from 15 to 69 years (mean: 46.9 yr.). Recipient diagnoses included ischemic cardiomyopathy in 18, idiopatic dilated cardiomyopathy in 13, mixomatous disease in 2, rheumatic valvar disease in 1 and Chagas` disease in 1. All were in the final stage of heart failure (functional class III or IV of the New York Heart Association) and the ejection fraction ranged from 16 to 27% (mean: 20.9 ± 2.9). Seventeen (48.5%) patients had had previous cardiac operations. The classical surgical technique described by Lower and Shumway, in 1960, was used in all cases. Mean graft ischemic time was 91 ± 21 minutes (ranged from 60 to 180 minutes). Results: There were 7 (20%) deaths in the early postoperative period. Non-fatal postoperative complications occurred in other 13 patients including 5 episodes of rejection. Mean follow-up period of the 28 survivors was 31.2 months (ranged from 1 to 68 mo.) There were 14 late deaths owing to rejection (4), infection (4), graft coronary artery disease (2), chronic renal failure (2) and sudden death (2). The actuarial survival estimated is 70% at 1 year and 30% at 5 years. Conclusion: It is concluded that cardiac transplantation program is feasible in our community but poorer results in comparison to international experience should be expected owing to social problems of the recipient population.

Supravalvular congenital mitral stenosis.

Congenital supravalvular mitral stenosis is a rare malformation characterized by the presence of a shelf-like fibrous membrane, with 1 or 2 small orifices, covering and obstructing the mitral valve. The membrane is positioned closely to the mitral valve (and sometimes it is attached to it); therefore, a preoperative diagnosis is inevitably difficult, even with the use of biplane echocardiography. Two patients with supravalvular mitral stenosis aged 3 years and 3 months are described. In 1 patient, a preoperative diagnosis was made, and both successfully underwent correction.

Aortic-right atrial tunnel.

We describe an asymptomatic 1-year-old boy who presented a continuous murmur, and was found to have a tunnel between the right atrium and the aorta. The definitive diagnosis was established by both echocardiography and aortography, and surgical interruption of the tunnel was successful. We emphasise the rarity of this condition, and discuss its major features.

Endomyocardial fibrosis in children.

We describe 10 children with endomyocardial fibrosis who underwent surgical treatment between 1978 and 1999. Seven were male and 3 female, with an age range from 4 to 15 years, having a mean age of 11 years. All were in the final stage of heart failure. Three had biventricular disease, 6 had involvement of the right ventricle alone, and one had endomyocardial fibrosis confined to the left ventricle. There were 3 deaths (30%) in the postoperative period due to low cardiac output. The 7 survivors were followed up for a period ranging from 12 to 168 months, with a mean of 72 months. Two late deaths have occurred resulting from heart failure and infectious endocarditis. Five (50%) children are still alive. Two required 3 reoperations for dysfunction of the inserted valvar prosthesis. One patient is in functional Class IV, and 4 are in Class II to III, despite intensive medical treatment. It is concluded that surgery for endomyocardial fibrosis is an essentially palliative procedure and, especially in children, the results of surgical treatment leave much to be desired.