Djalma Luis Faraco

Coronary dominance patterns in the human heart investigated by corrosion casting

OBJECTIVES The aim of this work was to analyze the dominance patterns of the circulation of the human heart, the number of branches from the right coronary artery to the left ventricle, the number of branches from the left coronary artery to the right ventricle and the frequency and location of intercoronary anastomoses. METHODS Casts were made of 25 hearts by the injection of colored acrylic resin and subsequent corrosion using hydrochloric acid at the experimental surgery laboratory of Furb. Specimens with lesions or scars were discarded. RESULTS The hearts, from both men (17 - 68%) and women (8 - 32%), had a mean age of 40.2 (15 to 70) years-old. Right dominance occurred in 18 (72%) subjects, with 1, 2, 3 and 4 branches leading to the left ventricle in 2, 14, 2 and 2 casts, respectively. Left dominance occurred in 5 (20%) with 1 branch leading to the right ventricle in 4 molds and 2 in one. Balanced circulation was observed in two molds (8%). There were significant differences between right and left dominance (alpha > 5%) and between right dominance and balanced circulation (alpha > 5%), however the same was not true between left dominance and balanced circulation (alpha < 5%). CONCLUSION The most common form of coronary circulation is right dominance with an average of 2.16 branches leading to the left ventricle: when dominance is left, the average is 1.2 branches. No intercoronary anastomoses were observed.

Extubação precoce na sala de operação após cirurgia cardíaca infantil

INTRODUCAO: A extubacao precoce esta relacionada a diminuicao do tempo de internacao e de complicacoes. OBJETIVO: Analise das caracteristicas clinicas e evolucao imediata dos pacientes extubados em sala apos cirurgia cardiaca infantil com CEC. METODOS: Analise retrospectiva dos dados. RESULTADOS: Entre marco de 2006 e janeiro de 2008, 15 pacientes, com idade de 4 a 216 meses (media 76,1 meses) foram extubados em sala. A duracao da CEC variou de 30 a 95 minutos (media 51,4 min) e anoxia de 14 a 67 minutos (media 35,2 min). Um paciente apresentou acidose respiratoria. CONCLUSAO: Extubacao precoce e factivel em casos selecionados.

Anel vascular associado a divertículo de Kommerell: relato de caso

Report of a surgical treatment for vascular ring (right aortic arch and the anomalous origin of the left subclavian artery) related to Kommerell diverticulum with resection of the ligamentum arteriosum (ductus arteriosus), suture of the Kommerell diverticulum, and reimplantation of left subclavian artery in the ipsilateral carotid artery through left thoracotomy in a 13-year-old female.

Cinco anos de experiência com a operação de Ross: o que aprendemos?

OBJETIVO: Analisar a evolucao clinica e funcional de 96 pacientes submetidos a substituicao da valva aortica por auto-enxerto pulmonar. CASUISTICA E METODOS: De maio/95 a marco/2000, 96 pacientes com media de idades de 25,4±11,4 anos foram consecutivamente submetidos a substituicao da valva aortica por auto-enxerto pulmonar. O diagnostico pre-operatorio mais comum foi de insuficiencia aortica de origem reumatica e 89% encontravam-se em classe funcional II ou III. Todos realizaram ecocardiograma bidimensional com Doppler e 42 tambem foram submetidos a cateterismo cardiaco antes da operacao. O auto-enxerto foi implantado pela tecnica de substituicao total da raiz aortica em 85 casos, como cilindro intraluminal em seis e em posicao subcoronariana nos demais. A reconstrucao da via de saida do ventriculo direito foi feita com homoenxertos pulmonares (84) ou aorticos (12), conservados em solucao nutriente com antibioticos (34) ou criopreservados (62). Antes da alta hospitalar, todos repetiram o exame ecocardiografico e 30 foram submetidos a cateterismo cardiaco. Atraves deles, foi feita avaliacao do desempenho hemodinâmico dos auto e homoenxertos, assim como da funcao e massa ventricular esquerda. No periodo de acompanhamento, os pacientes foram examinados e repetiram o ecocardiograma a cada seis meses. Vinte pacientes, com tempo de evolucao superior a seis meses, submeteram-se a ecocardiografia de stress com dobutamina, para estudar o desempenho hemodinâmico dos auto e homoenxertos em condicao de exercicio. RESULTADOS: A mortalidade hospitalar foi de 6,2%. Apos um tempo medio de 32,1 meses (1 - 58), 98,9% dos pacientes estao vivos. A incidencia de pacientes livres de tromboembolismo, endocardite, disfuncao do auto-enxerto, disfuncao do homoenxerto, reoperacoes mitrais e de qualquer tipo de complicacao apos 41 meses e de 100%, 100%, 97,1%, 96,5%, 93,9% e 87,5%, respectivamente. O auto-enxerto pulmonar teve desempenho hemodinâmico fisiologico, com media de gradiente medio de 3,8±3,3 mmHg. O grau de insuficiencia valvar foi negligenciavel. Mesmo em condicao de exercicio, os gradientes nao se elevaram de forma significativa, com media de gradiente medio de 6,8±3,8 mmHg. A funcao hemodinâmica dos homoenxertos foi excelente na fase imediata, com gradiente medio de 4,1±4,6 mmHg. Houve, entretanto, discreto aumento desses gradientes na fase tardia, com media de 13,9±10 mmHg. Durante o exercicio, houve aumento significativo destes gradientes, que foram para 33,6±18,9 mmHg. Diâmetro do homoenxerto e idade do receptor tiveram correlacao inversa com o gradiente pulmonar tardio. O indice de massa ventricular diminui de 180±68 g/m2 no pre-operatorio para 117±32 g/m2 na fase tardia. A funcao ventricular no pos-operatorio tardio foi normal tanto em repouso como em exercicio na maioria dos pacientes. CONCLUSOES: O implante do auto-enxerto pulmonar em posicao aortica pode ser feito com baixa mortalidade imediata. A sobrevida tardia foi excelente, com baixa incidencia de complicacoes. O desempenho hemodinâmico dos auto-enxertos pulmonares foi proximo ao fisiologico tanto em repouso como em exercicio. Houve significativa regressao da massa ventricular esquerda, e, os indices de funcao ventricular tambem foram normais na fase tardia de pos-operatorio. Apesar dos homoenxertos da via de saida do ventriculo direito apresentarem desempenho hemodinâmico adequado na fase imediata, o aparecimento de discretos gradientes na fase tardia foi frequente.

Homoenxerto mitral: uma realidade

Background: the use of cryopreserved aortic valve homografts is associated with excellent quality of life, low morbidity and satisfactory durability. We expect to achieve similar results in the mitral position with the use of cryopreserved mitral homografts. Objectives: Evaluate the immediate and short-term results of mitral valve replacement with cryopreserved mitral homografts. Material and Methods: Between July/97 and February/98, 8 patients with a mean age of 40.3 ± 6.2 years were submitted to mitral valve replacement with cryopreserved mitral homografts. Operative technique consisted of latero-lateral papillary muscle fixation, a running continuous suture at annulus level and annuloplasty with a Carpentier ring. Before hospital discharge, all patients were submitted to Doppler echocardiographic control for assessment of valvar and ventricular function. Patients were requested to return at the first and subsequently every 3 months postoperatively for further clinical and echocardiographic control. Results: There was one early non valve-related death. Echocardiographic evaluation before hospital discharge revealed a mean mitral valve area of 3.1 ± 0.6 cm2 and a mean gradient of 3.5 ± 1.6 mmHg. Valvar insufficiency was graded as non-existent or trivial in four cases and mild in the remaining three patients. Ejection fraction which was 57 ± 7% pre-operatively was well preserved in the postoperative period (62 ± 6%). Pulmonary hipertension reduced significantly from 87 ± 15 mmHg pre-operatively to 48 ± 12 mmHg post-operatively. There was also a reduction in the left atrial cavity from 61 ± 10 mm to 53 ± 7 mm. No patient was lost to follow-up. After a mean follow-up time 4.1 ± 2.5 months, all patients are functionally well without postoperative events. Late echocardiographic control showed persistence of the good immediate results. Conclusions: The immediate and short-term results of mitral valve replacement with mitral homografts are satisfactory, demonstrating the feasibility of the technique. Longer follow-up periods are necessary to determine durability of this graft and to eventually expand its indications.

Experiência cirúrgica inicial com a operação de Ross (auto-enxerto pulmonar)

BACKGROUND: After the excelent long term results reported with the Ross operation, its use increased worldwide. OBJECTIVE: Report our initial surgical experience with this procedure. METHODS: From may/95 trough february/96, 24 patients (mean age 28.3 years) were submitted to Ross procedure with the root replacement method. Reconstrution of the right ventricular outflow tract was achieved by 17 pulmonary and 7 aortic homografts stored in nutrient-antibiotic media. All patients were submitted to angiographic and echocardiographic Doppler flow studies at the immediate postoperative period to assess ventricular function and hemodynamic performance of the homografts. Three patients with follow-up longer than 6 months had a second ecocardiographic study. RESULTS: Hospital mortality was 4%. All hospital survivors were discharged in synus rhytm and with no diastolic murmur of aortic insufficiency. Hemodynamic performance of the autografts was excellent with low peak systolic gradients (4.0 ± 1.3 mmHg by echocardiography and 2.8 ± 1.2 mmHg by cardiac catheterism). Twenty-one patients had none or trivial autograft insufficiency and two presented with mild insufficiency. None had moderate or severe regurgitation. Peak systolic gradients in the homografts were also low (3.0 ± 0.9 mmHg by echocardiography and 4,3 ± 1,4 mmHg by catheterism) and only two had mild insufficiency. There was a significant reduction in left ventricular mass in the early postoperative period. After a mean follow-up of 5,1 months (1-9 months) all patients were in NYHA functional class I and free of events. Three patients with followup periods longerthan 6 months had asecond echocardiogram which showed normal left ventricular function and mass and adequate performance of the auto and homografts. CONCLUSION: The Ross operation can be done with low operative mortality and good short term results. We believe it will be widely employed by others in our country.