Fabio Said Sallum

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.

Avaliação inicial de homoenxertos em posição pulmonar em crianças e adolescentes

Objective: Heart valve homografts - fresh or cryopreserved - are a good valvular substitute in infants and teenagers as they need no anticoagulation, have a higher resistance to infection and present a good hemodynamic performance. The objective of this report was to evaluate the initial postoperative results on pediatric subjects after homograft implant in pulmonary position. Methods: Fourteen homografts were implanted in pulmonary position from September, 1995 to December, 1997. Four of them were fresh (28.6%) and ten were cryopreserved (71.4%). Subjects ranged in age from 10 months to 17 years with 9 (64%) males and 5 (36%) females . The subjects were divided into two groups, as follows: A - aortic valve disease (Ross operation) and B - congenital heart disease. The diameter of the homografts ranged from 16 to 26 mm. The cardiopulmonary-bypass time ranged from 74 to 303 minutes and the aortic-occlusion time between 49 to 160 minutos. Results: A hospital death occurred. All the survivors were clinically, radiologically, electrocardiographycally and echocardiographycally monitored. There were 13 NYHA I patients and one NYHA II patients. The most common complications were low output syndrome, pericardial effusion and EKG abnormalities. All these ocurred in two patient but with a favorable outcome. Stenosis of the right ventricular outflow track was observed early on in two subjects with gradients of 44 and 23 mmHg. One of the pulmonary homografts was submitted to a successful balloon valvuloplasty due to a severe stenosis. The rheumatic patients are still receiving antibiotic therapy and without recurrence of the disease. Conclusion: Evaluation of the hemodynamics of the homografts, in pulmonary position, was satisfactory. One of the subjects has presented marked stenosis but, after a balloon valvuloplasty, his gradient decreased. Another patient has kept his preoperative NYHA classification. We believe was not correlated with the homograft (coagulation disorder). Its our belief that fresh and cryopreserved homografts are a satisfactory solution for the correction of congenital or acquired valve disease in infants and adolescents.

Operação de Ross: a intervenção ideal para pacientes aórticos jovens?

Background: Aortic valve prosthesis with adequate hemodynamic performance should allow more complete left ventricular mass regression and return left ventricular function back to normal. This possibly affects long term prognosis after aortic valve replacement. Objective: Assessment of hemodynamic performance of the pulmonary autograft in the aortic position and the regression of left ventricular mass after the Ross procedure. Material and Methods: Between May/95 and Mar/96, 45 patients with mean age of 27.1 years were submitted to a Ross procedure. Doppler echocardiography and cardiac catheterization were performed on all patients before hospital discharge to analyze the hemodynamic performance of the auto and homografts employed, as well as to evaluate left ventricular mass and function. Fourteen patients with follow-up longer than six months were sumitted to dobutamine stress echocardiography to study hemodynamic performance of the auto and homografts at during exercise. Results: Hospital mortality was 6%. After a mean follow-up of 12.8 months (1-23), there was one late sudden death. No valve related event was noted during this period. Immediate and late hemodynamic performance of the pulmonary autografts were normal with average mean gradients of 1.8 ± 0.6 mmHg and average maximum instantaneous gradients of 2.9 ± 0.9 mmHg. Valvular insufficiency was almost null. Even during exercise, gradients did not increase significantly with average mean gradients of 4.3 ± 2.5 mmHg and average maximum gradients of 10.4 ± 6.1 mmHg. Homografts used for right ventricular reconstruction exhibited excellent immediate hemodynamic performance. However, at late follow-up an increase in flow velocities was noted with an average of mean gradients of 10 ± 7.1 mmHg at rest and 26 ± 13.3 mmHg at exercise. Left ventricular mass index dropped from 168 ± 46 g/m2 preoperatively to 115 ± 32 g/m2 six months after the operation. Left ventricular function was normal at rest and during exercise in the marjority of patients. Conclusions: Given the normal hemodynamic performance of the autografts, the important decrease in left ventricular mass and the normal left ventricular function late postoperatively, the Ross procedure is considered the operation of choice for young patients who need aortic valve replacement.

Dysfunction of the pulmonary homograft used in the reconstruction of the right ventricle exit tract

BACKGROUND The pulmonary homograft has been used as an option in the correction of congenital cardiopathy with obstruction of the right ventricle exit tract. The long term results, however, are little satisfactory. OBJECTIVE Identify the risk factors associated to the dysfunction and the pulmonary homograft failure. METHODS Study with children submitted to the enlargement of the exit tract of the right ventricle with pulmonary homograft. The clinical, surgical, evolutional and morphological aspects of the prosthesis variables were analyzed as risk factors. RESULTS The final sample of 75 patients with median age at the surgery of 22 months, varying from 1-157 months, presented 13 patients (17.0%) who developed dysfunction of the homograft, characterized by stenosis or severe pulmonary insufficiency. The occurrence time between the homograft implant and the detection of the dysfunction was of 45 ± 20 months. When the size of the homograft was smaller than 21 mm and the Z score of the pulmonary valva is lower than zero, or higher than three, the risk factors were considered for the dysfunction occurrence. CONCLUSION The pulmonary homograft smaller than 21 mm and the inadequate pulmonary valva for the age and weight of the patient are determining factors for the prosthesis dysfunction.FUNDAMENTO: O homoenxerto pulmonar tem sido utilizado como uma opcao na correcao de cardiopatia congenita com obstrucao da via de saida do ventriculo direito. Os resultados em longo prazo, no entanto, mostram-se pouco satisfatorios. OBJETIVO: Identificar os fatores de risco associados a disfuncao e a falencia do homoenxerto pulmonar. METODOS: Estudo em criancas submetidas a ampliacao da via de saida do ventriculo direito com homoenxerto pulmonar. As variaveis clinicas, cirurgicas, evolutivas e de aspectos morfologicos da protese foram analisadas como fatores de risco. RESULTADOS: A amostra final de 75 pacientes com idade mediana na cirurgia de 22 meses, variando de 1-157 meses, apresentou 13 pacientes (17,0%) que desenvolveram disfuncao do homoenxerto, caracterizado por estenose ou insuficiencia pulmonar grave. O tempo de ocorrencia entre o implante do homoenxerto e a deteccao da disfuncao foi de 45 ± 20 meses. Quando o tamanho do homoenxerto foi menor de 21 mm e o escore Z da valva pulmonar foi menor do que zero, ou maior do que tres, foram considerados fatores de risco para a ocorrencia de disfuncao. CONCLUSAO: O homoenxerto pulmonar de tamanho menor do que 21 mm e a valva pulmonar inadequada para idade e peso do paciente sao fatores determinantes para disfuncao da protese.

Hospital mortality in surgery for reconstruction outflow right ventricle with pulmonary homograft

BACKGROUND Hospital mortality for surgical reconstruction of the outflow of the right ventricle with pulmonary homograft is variable. OBJECTIVES To identify risk factors associated with hospital mortality and clinical profile of patients. METHODS Children underwent reconstruction of the outflow tract of right ventricle with pulmonary homograft. Analyzed as risk factors for the clinical, surgical and morphological aspects of the prosthesis. RESULTS Ninety-two patients operated on between 1998 and 2005 presented mainly pulmonary atresia with ventricular septal defect and tetralogy of Fallot. Forty patients were treated in the first month of life. He needed 38 surgeries to Blalock Taussig due to clinical severity. The median age at surgery for total correction was 22 months, ranging from 1 to 157 months. Size pulmonary homograft ranging from 12 to 26 mm and length of bypass was 132 +/- 37 minutes. After surgery there were seventeen deaths (18% cases) on average 10.5 +/- 7.5 days. The predominant cause was multiple organ failure. In the univariate analysis between the types of heart disease, they found in favor of age at surgery, size of homograft, pulmonary valve Z value, CPB time, maintaining the integrity of the homograft and pulmonary tree change. There was no statistical difference in hospital mortality between the variables and the type of heart disease. CONCLUSION The congenital obstructive right requires surgical care in the first days of life. The total correction surgery has a risk rate of 18% but there was no association with any variable studied.

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.

Seguimento de 8 anos de prótese aórtica Medtronic-Hall: influência da anticoagulação oral na ocorrência de embolias

One hundred and sixty five survivors of isolated Medtronic-Hall aortic prosthesis operated on from September 1979 to September 1987 were studied. Ages varied from 14 to 68 years (m = 35.2) and 129 patients were male, 36 female. Preoperative diagnosis were 70 aortic insuficiency, 37 aortic stenosis and 39 double lesions. There were additionally 8 prosthetic dysfunctions, 8 acute infective endocarditis and 3 interventricular septal defects plus aortic insufficiency. One hundred and sixty three patients were followed (98.72), 9 of them being lost during the observation period. There were 45 late deaths, 59% SE 10.9% being the actuarial survival probality in 8 years. Twenty one patients suffered 26 embolic episodes, 69.8 SE 11.7% the probability of freedom from embolism and 39.7% SE 10.4% the chance of survival free from embolism. The rate of embolism episodes was 3,5% per patients/year in the entire series, 6 of them being lethal. In relation to the use of oral anticoagulation patients were divided into three sub-groups. Sub-group A included 144 patients, with a linearized incidence of 3.2% episodes per patients/year. Sub-group B included 21 patients who used anticoagulants after surgery, with an incidence of 1.9% per patients/year. Sub-group C comprised 9 patients who were put on anticoagulants after the occurence of an embolic episode. This sub-group presented 8.1 episodes per patients/year. It is concluded that it was not possible to doccument the influence of anticoagulation in the conditions prevailing during the observation of this series. After the occurence of one embolic episode the institution of oral anticoagulation was not effective in decreasing chance of its reccurence.

Disfunção do homoenxerto pulmonar utilizado na reconstrução do trato de saída do ventrículo direito

BACKGROUND The pulmonary homograft has been used as an option in the correction of congenital cardiopathy with obstruction of the right ventricle exit tract. The long term results, however, are little satisfactory. OBJECTIVE Identify the risk factors associated to the dysfunction and the pulmonary homograft failure. METHODS Study with children submitted to the enlargement of the exit tract of the right ventricle with pulmonary homograft. The clinical, surgical, evolutional and morphological aspects of the prosthesis variables were analyzed as risk factors. RESULTS The final sample of 75 patients with median age at the surgery of 22 months, varying from 1-157 months, presented 13 patients (17.0%) who developed dysfunction of the homograft, characterized by stenosis or severe pulmonary insufficiency. The occurrence time between the homograft implant and the detection of the dysfunction was of 45 ± 20 months. When the size of the homograft was smaller than 21 mm and the Z score of the pulmonary valva is lower than zero, or higher than three, the risk factors were considered for the dysfunction occurrence. CONCLUSION The pulmonary homograft smaller than 21 mm and the inadequate pulmonary valva for the age and weight of the patient are determining factors for the prosthesis dysfunction.FUNDAMENTO: O homoenxerto pulmonar tem sido utilizado como uma opcao na correcao de cardiopatia congenita com obstrucao da via de saida do ventriculo direito. Os resultados em longo prazo, no entanto, mostram-se pouco satisfatorios. OBJETIVO: Identificar os fatores de risco associados a disfuncao e a falencia do homoenxerto pulmonar. METODOS: Estudo em criancas submetidas a ampliacao da via de saida do ventriculo direito com homoenxerto pulmonar. As variaveis clinicas, cirurgicas, evolutivas e de aspectos morfologicos da protese foram analisadas como fatores de risco. RESULTADOS: A amostra final de 75 pacientes com idade mediana na cirurgia de 22 meses, variando de 1-157 meses, apresentou 13 pacientes (17,0%) que desenvolveram disfuncao do homoenxerto, caracterizado por estenose ou insuficiencia pulmonar grave. O tempo de ocorrencia entre o implante do homoenxerto e a deteccao da disfuncao foi de 45 ± 20 meses. Quando o tamanho do homoenxerto foi menor de 21 mm e o escore Z da valva pulmonar foi menor do que zero, ou maior do que tres, foram considerados fatores de risco para a ocorrencia de disfuncao. CONCLUSAO: O homoenxerto pulmonar de tamanho menor do que 21 mm e a valva pulmonar inadequada para idade e peso do paciente sao fatores determinantes para disfuncao da protese.

Disfunción del homoinjerto pulmonar utilizado en la reconstrucción del tracto de salida del ventrículo derecho

BACKGROUND The pulmonary homograft has been used as an option in the correction of congenital cardiopathy with obstruction of the right ventricle exit tract. The long term results, however, are little satisfactory. OBJECTIVE Identify the risk factors associated to the dysfunction and the pulmonary homograft failure. METHODS Study with children submitted to the enlargement of the exit tract of the right ventricle with pulmonary homograft. The clinical, surgical, evolutional and morphological aspects of the prosthesis variables were analyzed as risk factors. RESULTS The final sample of 75 patients with median age at the surgery of 22 months, varying from 1-157 months, presented 13 patients (17.0%) who developed dysfunction of the homograft, characterized by stenosis or severe pulmonary insufficiency. The occurrence time between the homograft implant and the detection of the dysfunction was of 45 ± 20 months. When the size of the homograft was smaller than 21 mm and the Z score of the pulmonary valva is lower than zero, or higher than three, the risk factors were considered for the dysfunction occurrence. CONCLUSION The pulmonary homograft smaller than 21 mm and the inadequate pulmonary valva for the age and weight of the patient are determining factors for the prosthesis dysfunction.FUNDAMENTO: O homoenxerto pulmonar tem sido utilizado como uma opcao na correcao de cardiopatia congenita com obstrucao da via de saida do ventriculo direito. Os resultados em longo prazo, no entanto, mostram-se pouco satisfatorios. OBJETIVO: Identificar os fatores de risco associados a disfuncao e a falencia do homoenxerto pulmonar. METODOS: Estudo em criancas submetidas a ampliacao da via de saida do ventriculo direito com homoenxerto pulmonar. As variaveis clinicas, cirurgicas, evolutivas e de aspectos morfologicos da protese foram analisadas como fatores de risco. RESULTADOS: A amostra final de 75 pacientes com idade mediana na cirurgia de 22 meses, variando de 1-157 meses, apresentou 13 pacientes (17,0%) que desenvolveram disfuncao do homoenxerto, caracterizado por estenose ou insuficiencia pulmonar grave. O tempo de ocorrencia entre o implante do homoenxerto e a deteccao da disfuncao foi de 45 ± 20 meses. Quando o tamanho do homoenxerto foi menor de 21 mm e o escore Z da valva pulmonar foi menor do que zero, ou maior do que tres, foram considerados fatores de risco para a ocorrencia de disfuncao. CONCLUSAO: O homoenxerto pulmonar de tamanho menor do que 21 mm e a valva pulmonar inadequada para idade e peso do paciente sao fatores determinantes para disfuncao da protese.