Eduardo Sérgio Bastos

One-stage management of infected sternotomy wounds using bilateral pectoralis major myocutaneous advancement flap

OBJECTIVE To assess the results of single-stage treatment of infected sternotomy wounds using bilateral pectorals major myocutaneous advancement flaps. METHODS Between January 2000 and July 2007, 1972 heart surgeries with median transesternal thoracotomy were performed. Thirteen (0.65%) patients presented wound infections and dehiscence after sternotomy. To treat those patients we adopted exclusively single-stage management, drainage, early intervention and immediate wounds closure using bilateral pectoralis major myocutaneous advancement flaps to the medium line of the sternum. Two patients with superficial wounds infection and other two who underwent torsion adjustment of the steel wire were not included in this study. RESULTS There was one death in the 30-day postoperative period. There was no intraoperative death. Four patients needed additional surgical intervention to drain residual seroma or local infection. There was total resolution of the sternal infection in 12 patients. CONCLUSION The authors recommend the single-stage early management of sternotomy infected wounds with debridement, drainage and immediate closure of the wound using bilateral pectoralis major myocutaneous advancement flaps to the medium line of the sternum. The procedure is effective and may contribute to decrease the morbidity.

Myocardial revascularization surgery using composite Y-graft of the left internal thoracic artery: blood flow analysis

OBJECTIVE: To assess the left internal thoracic artery (LITA) flow pattern, when it was used to supply the left anterior descending artery (LADA) and another branch from the left coronary artery system (LCAS). METHODS: In the following study, the left internal thoracic artery flow was investigated by echocardiography Doppler, at rest and under dobutamine stress, in two twenty-patient groups. Group A consisted of patients who received only a pedicled LITA graft to the LADA. Group B consisted of patients who received a pedicled LITA graft associated with a vein graft to supply the LADA and another artery from the LCAS. The angiographic study showed graft patency in all patients from both groups. The following parameters were used: systolic flow (SF), diastolic flow, total flow, total flow in stress/total flow at rest ratio (TFS/TFR), systolic peak velocities (SPV), diastolic peak velocities and systolic peak velocity/diastolic peak velocity ratio. RESULTS: All analysed parameters were considered statistically significant, except SF, TFS/TFR and SPV. CONCLUSIONS: We concluded that in the same conditions and methodology, the LITA flow in the composite graft (group B) is higher than in the free graft (group A), which shows the great flow adaptability of LITA to respond to flow demand.

Molecular evaluation of the great vessels of patients with bicuspid aortic valve disease

OBJETIVO: A valva aortica bicuspide (VAB) esta associada a maior prevalencia de ectasia anulo-aortica, aneurisma e disseccao da aorta ascendente. Este estudo investigou a quantidade de fibrilina-1 e elastina nos grandes vasos de portadores de VAB. METODO:Amostras de tecidos foram colhidas da aorta ascendente e tronco da arteria pulmonar de 22 portadores de VAB e 16 portadores de valva aortica tricuspide (VAT) submetidos a cirurgia cardiaca, incluindo seis portadores de valva aortica normal, provenientes do programa de transplante. Imunofluorescencia indireta e analise computadorizada de imagens foram utilizadas para quantificacao das proteinas na camada media dos vasos, expressas como densidade optica integrada media (DOI). RESULTADOS: Na aorta, a DOI especifica para fibrilina-1 foi 15 ± 8 no grupo bicuspide e 24 ± 7 no grupo tricuspide (p=0,001). Na arteria pulmonar, a DOI especifica para fibrilina-1 foi 18 ± 10 no grupo bicuspide e 25 ± 9 no grupo tricuspide (p=0,07). A DOI especifica para elastina na aorta foi 34 ± 13 no grupo bicuspide e 36 ± 19 no grupo tricuspide (p=0,31). Na arteria pulmonar, a DOI para elastina foi 30 ± 12 no grupo bicuspide e 29 ± 14 no grupo tricuspide (p=0,34). CONCLUSOES: Os portadores de VAB apresentaram menor quantidade de fibrilina-1, mas nao elastina, na aorta ascendente e arteria pulmonar que os portadores de VAT normal ou doente. Estes achados podem explicar a maior incidencia de dilatacao e disseccao da aorta ascendente em portadores desta ma-formacao da valva aortica.

Valva aórtica bicúspide: fundamentos teóricos e clínicos para substituição simultânea da aorta ascendente

Bicuspid aortic valve (BAV) is associated with annuloaortic ectasia, dissection and ascending aortic aneurysm. The high incidence of this congenital malformation and aortic disease suggests a close correlation between the two phenomena. Abnormalities in different phases of cell migration of the neural crest might be responsible for the occurrence of abnormalities in the aortic valve, media layer of the ascending aorta and vessels of the aortic arch. Previous studies have shown that patients with normal BAV or slight dysfunction may present with dilation of the aortic root. The hemodynamic changes caused by BAV without stenosis or insufficiency seem to be an insufficient explanation for these findings. Several mechanisms have been proposed to explain the molecular and hystological aspects of this disease. We found a reduced fibrillin-1 content in both ascending aorta and pulmonary trunk as a possible cause. Histologically, the ascending aorta can present cystic medial necrosis and elastic fragmentation, similar to Marfans disease. Some authors concluded that many patients, mainly those with aortic regurgitation, should have the aortic valve and the ascending aorta replaced at the same procedure, even if a mild dilatation (45 mm) is present in patients with BAV if life expectancy is anticipated to be greater than 10 years to prevent further aneurysms or ruptures.Bicuspid aortic valve (BAV) is associated with annuloaortic ectasia, dissection and ascending aortic aneurysm. The high incidence of this congenital malformation and aortic disease suggests a close correlation between the two phenomena. Abnormalities in different phases of cell migration of the neural crest might be responsible for the occurrence of abnormalities in the aortic valve, media layer of the ascending aorta and vessels of the aortic arch. Previous studies have shown that patients with normal BAV or slight dysfunction may present with dilation of the aortic root. The hemodynamic changes caused by BAV without stenosis or insufficiency seem to be an insufficient explanation for these findings. Several mechanisms have been proposed to explain the molecular and hystological aspects of this disease. We found a reduced fibrillin-1 content in both ascending aorta and pulmonary trunk as a possible cause. Histologically, the

Plastia valvar mitral na doença cardíaca reumática e degeneração mixomatosa: estudo comparativo

The differential pressure/pressure transmitter of the present invention detects overpressures by using pre-loading diaphragms. The differential pressure/pressure transmitter of the present invention is provided with a high pressure-side diaphragm assembly 24 having a high pressure-side process diaphragm 34, which transfers high pressure from a process to the high pressure-side transfer oil, and a high pressure-side pre-loading diaphragm 32. The differential pressure/pressure transmitter is also provided with a low pressure-side diaphragm assembly 25 having a low pressure-side process diaphragm 38 and a low pressure-side pre-loading diaphragm 36. A differential pressure sensor assembly is provided to detect the pressure difference between the high pressure-side transfer oil from the high pressure-side diaphragm assembly and the above low pressure-side transfer oil from the low pressure-side diaphragm assembly.

Surgical treatment of mitral valve insufficiency by valve repair

OBJECTIVE: To analyze the short term results of mitral valve repair in a consecutive series of mitral insufficiency patients from different ethiologies. METHODS: A retrospective study was made of 86 patients with mitral insufficiency operated on between May 1992 and May 2001 for mitral valve repair. Mitral insufficiency was severe in 77 patients and moderate in 9. The functional class of the patients was I in 4, II in 48, III in 29 and IV in 5 patients. The etiology was rheumatic in 47 (54.6%) cases. RESULTS: Mitral valve repair was performed by only one procedure on the mitral valve in 6 patients, two procedures in 29, and three or more procedures in 51 (59.3%) patients. Mitral annuloplasty was performedin 81 patients, with the Braile posterior pericardial ring being the mostcommonly used (87.2%). Hospital mortality was 3.5%. There was improvement in the funcional class in 79 (91.8%) patients. Mitral valve function was normal in 80 (93%) patients and moderate mitral insufficiency occurred in 6 patients. CONCLUSION: Mitral valve repair can be performed with low mortality (3.5%) and high probability of valve function recovery (93%). It should be the procedure of choice in patients with mitral insufficiency.

Circulação extracorpórea com desvio veno-arterial e baixa pressão parcial de oxigênio

PURPOSE: This study is divided into 2 parts, an experimental study to establish a technique of extracorporeal circulation with low oxygen partial pressure and a clinical study to show the feasibility in humans. MATERIAL AND METHODS: Experimental surgery with extracorporeal circulation was performed in 20 dogs divided into 2 groups of ten. In group I, cannulation was done first in the superior vena cava, then in the inferior vena cava, keeping normal heartbeat and breathing, controlled by a respirator and pure oxygen. After passing through a heat exchanger, the blood of each vena cava was injected in the femoral artery. Blood samples from the aorta were taken above the diaphragm in every 30 minutes to check gasometric values. In group II, the right atrium was drained and half of the blood injected in the pulmonary artery with another pump and picked up through the left ventricle to the reservoir that also works as a heat exchanger. The mixed blood (50% arterial and 50% venous) was re-injected by another pump in the arterial circulation. The heart was maintained fibrillating and the breathing controlled by the respirator. In the clinical study, 40 patients were divided into 2 groups of 20 each. In group A the patients were bypassed in the conventional manner, that is, compressed air and oxygen in the oxigenator with high arterial pO2. In group B, pure oxygen was used in the membrane oxigenator and venous-arterial shunt, performed between 40% to 50%. RESULTS: In both groups, from a physiologic point of view there was shunting of 50% of venous blood to the arterial circulation and arterial blood flow was maintained high (around 100 ml\kg\min). It was observed that the arterial pO2 in both groups remained between 50 and 100 mmHg and venous saturation between 50 and 70%. All animals woke up at end of the experiment. In the clinical study, the arterial pO2 was a low 60 mmHg. Comparison of the clinical results showed there was no mortality difference between both groups, but in the group B, with the low pO2 and venous-arterial shunt, the post-operative bleeding was significantly smaller, having been used three times less blood and no need to use the blender.

Fatores determinantes da letalidade após cirurgia para endocardite infecciosa

The factors leading to high postoperative mortality in active infectious endocarditis (IE) are poorly defined. We studied patients operated at an University Hospital between March 1978 and April 1992. We hipothesized that the summation of potential adverse factors would strongly increase mortality after surgery. We studied 39 patients (28 men), age range 13-70 years (mean±SD =32±16) operated during active IE (time from onset 52+48 days). Predisposing factor: rheumatic valvar disease in 14 cases, intravenous drug use in 5. Affected valves: aortic in 14, mitral in 10, tricuspid in 8, multiple structures in 7. In most cases, S aureus (12) or Streptoccocus sp (10) was isolated in blood cultures. Surgery was indicated in most patients because of heart failure (30), multiple embolic complications (17) or treatment failure (14). The possible adverse influence of specific demographic characteristics, clinical features and surgical variables was assessed by the Student t test or the %2 test. Also, multple regression analysis was performed in order to identify independent adverse factors for increased mortality. Positive correlations were further investigated with the X2 test to assess whether an increasing number of adverse factors could identify a special subset of patients with markedly elevated death risk. Fourteen patients (36%) died after surgery. Emergency surgery (p = 0.001), the presence of coma 6 hours after surgery (p = 0.0015) and S. aureus infection (p = 0.023) were all associated with increased mortality. The presence of neurological complications was correlated with a high mortality (54% vs. 27%). However this increase was of dubious statistical significance (p = 0.097). Multiple regression analysis confirmed S. aureus and emergency surgery as independent adverse factors for increased mortality. When put together, an increasing number of adverse factors was highly predictive of a fatal outcome, even after exclusion of that evaluated after surgery (level of consciousness). Patients with two or three adverse factors had a very high mortality rate (>76.9%). Mortality following surgery for active IE is increased in patients operated on an emergency basis especially if the infection is caused by S. aureus. The presence of neurological complications may also be associated with worse outcome. Early consideration of surgery should reduce the high mortality in patients with active IE.

Pericardium closure after heart operations: a safety option?

OBJECTIVES Primary pericardium closure may reduce the risk of cardiac injury during chest re opening, especially the right ventricle, aorta and coronary bypass grafts. Nevertheless, concern about adverse hemodynamic effects prevents most heart surgeons of closuring the pericardium. METHODS We evaluated 48 patients undergoing open heart surgery consecutively which the pericardium was closed in 30 patients (group A) and 18 patients, as a control group (group B) in which the pericardium was left open. All patients underwent posteroanterior and lateral chest roentgenograms before surgery and one week postoperatively. Postoperative evaluation also included echocardiograms, ECG and postoperative enzyme analysis. RESULTS There were no deaths or any complications in both groups (acute myocardial infarction, stroke, bleeding or cardiac tamponate). It was observed statistically differences between both groups especially in echocardiogram parameters and cardiothoracic ratio without clinical impact. CONCLUSION Pericardium closure is a simple method to facilitate resternotomy during subsequent re operative procedures. However, cardiac surgeons should be aware of the transient deterioration in hemodynamics associated with it, even thought there was no clinical significance in this study.

Revascularização do miocárdio em origem anômala da artéria coronária direita: relato de caso

A 21-year-old man with angina-like chest pain and syncope related to ischemic ECG changes due to an anomalous origin of the right coronary artery. The patient was submitted to surgical correction with myocardial revascularization with internal thoracic artery. A literature review of this rare congenital heart disease is presented.A 21-year-old man with angina-like chest pain and syncope related to ischemic ECG changes due to an anomalous origin of the right coronary artery. The patient was submitted to surgical correction with myocardial revascularization with internal thoracic artery. A literature review of this rare congenital heart disease is presented.