Gustavo Roberto Hoppen

Revascularização cirúrgica do miocárdio em pacientes com stents coronários

Objective: To observe the surgical characteristics of patients operated on after percutaneous coronary interventions (PCI). Method: Fifty-six patients (41 M and 15 F), at the time of coronary artery bypass grafting (CABG), had already been submitted to coronary stenting procedures. In 101 PCI, 116 stents were implanted. At the time of the first PCI, 32 patients had three or more coronaries affected by severe stenosis. Six patients were treated with PCI for severe left coronary trunk stenosis. After the implantation of the first stent, 12 patients developed severe de novo lesions of the left coronary trunk. In 6 of these, stenosis developed within 6 months of stent implantation. Diabetes was present in 35.7% of the patients. In 22 patients (39.2%), at the time of CABG, the left ventricular function was reduced (p<0.001). During surgery, 160 grafts were implanted. Surgical studies included coronary and muscle biopsies. Results: Surgical observation showed more arteritis and inflammatory tissues adjacent to the stent when compared to other areas. Seventeen patients that could not have platelet antiaggregates withdrawn needed more blood transfusions. There were no hospital deaths. Conclusion: In patients operated on after stent implantation, facts like loss in LV function or de novo vascular lesions complicate surgical procedures and may impair longterm results. Due to endothelial dysfunction caused by stents, grafts may obstruct earlier. In addition the efficiency of clinical therapy may not be the same.

Coartação de aorta em crianças até um ano: análise de 20 anos de experiência

OBJECTIVE A review of experience with techniques of correction used, in the last 20 years, in children younger than one year old. METHODS In the period from 1978 to 1998, 148 patients (pt) with coarctation of the aorta (CoAo), under one year of age, with or without associated intracardiac defects, were submitted to surgery. Median age 50 days, 92 female pt (62.1%). The average weight was 4,367 +/- 1,897 gr. The average follow-up was 1,152 +/- 1,462 days. The population was divided in 3 groups: Group I, isolated CoAo: 74 pt (50%); Group II, CoAo and interventricular communication (IVC): 41 pt (27.7%) and Group III, CoAo with complex intracardiac malformations: 33 pt (22.3%). RESULTS The total mortality was of 43 patients (29%). In patients younger than 30 days, the mortality was 53%, p=0.009, DR=4.5, between 31 and 90 days, 14.7%, p=0.69, and over 91 days, 15%, p=0.004. The probability of actuarial survival of the whole population was 67% at 5 and 10 years. Thirty-six patients (24.3%) had recoarctation, from which 18 patients (50%) were younger than 30 days, DR=6.35. The incidence of recoarctation was with Waldhausen technique in 4 patients (10%) and with the classic termino-terminal technique in 19 patients (26%) p=0.03, and isthmusplastic operation in 6 patients (37.5%). The patients younger than 30 days showed a relative risk for recoarctation de DR=6.35. The probability of actuarial survival, free of coarctation repair, at 5 and 10 years was of 69% with Waldhausens technique and 63% with the classic termino-terminal technique. CONCLUSION Patients younger than 30 days showed increased mortality and recoarctation risk. Waldhausens technique in patients older than 30 days showed effective. The classic termino-terminal technique did not show to be a good option in all age ranges, being imperative to carry out more radical technical variations, such as the extended termino-terminal.

Infective endocarditis: surgical therapy

OBJECTIVE To assess the major causes of surgical morbidity and mortality in patients with infective endocarditis operated upon in a regional cardiology center. METHODS Thirty-four patients underwent surgical treatment for infective endocarditis. Their ages ranged from 20 to 68 years (mean of 40.6) and 79% were males. Their NYHA functional classes were as follows: IV - 19 (55.8%) patients; III - 12 (35.2%) patients; II - 3 (8.8%) patients. Blood cultures were positive in only 32% of the cases. Eight patients had already undergone previous cardiac surgery, whose major indication (82.3%) was heart failure refractory to clinical treatment. RESULTS Four (11.7%) patients died at the hospital. Follow-up was complete in 26 (86%) patients. Five (14.7%) patients died later, 12, 36, 48, 60, and 89 months after hospital discharge. Of the 21 patients being currently followed up, 1 is in NYHA functional class III, and 5 in NYHA functional class II. CONCLUSION A high degree of clinical suspicion, at an early diagnosis, and indication of surgical treatment prior to deterioration of left ventricular function and installation of generalized sepsis may improve prognosis.

Tratamento cirúrgico da endocardite infecciosa

The indication, surgical pathology and the results of surgical treatment of 28 patients operated on for infectious endocarditis between 1983 and 1994 are here evaluated. The clinical diagnosis was confirmed by echocardiography and cineangiography. Seventy-five percent of the patients were male and 25% female, with the mean age of 35.2 (14 to 67) years old. Ninety three percent were in functional class III or IV (N Y H A). Elapsed time between diagnosis and surgery was around 4 weeks (1-363 days). A positive hemoculture was present in 25% of the cases and the commonest bacteria found were streptococcus and staphilococcus. The aortic valve was the one usualy affected and vegetations was the usual finding. Surgical treatment consisted of valvuloplasty in 2 cases and valve replacement in 26. Complications were present in 39.28% of the cases, which resulted in the death of five of them (18%). We conclude that, although rare, the infectious endocarditis is a serious disease; if not prevented with adequate antibiotic prophilaxis or treated in due time, serious complications or even death might occur.

Unsupported valvuloplasty in children with congenital mitral valve anomalies. Late clinical results

OBJECTIVE To analyze late clinical evolution after surgical treatment of children, with reparative and reconstructive techniques without annular support. METHODS We evaluated 21 patients operated upon between 1975 and 1998. Age 4.67+/-3.44 years; 47.6% girls; mitral insufficiency 57.1% (12 cases), stenosis 28.6% (6 cases), and double lesion 14.3% (3 cases). The perfusion 43.10+/-9.50 min, and ischemia time were 29.40+/-10.50 min. The average clinical follow-up in mitral insufficiency was 41.52+/-53.61 months. In the stenosis group (4 patients) was 46.39+/-32.02 months, and in the double lesion group (3 patients), 39.41+/-37.5 months. The echocardiographic follow-up was in mitral insufficiency 37.17+/-39.51 months, stenosis 42.61+/-30.59 months, and in the double lesion 39.41+/-37.51 months. RESULTS Operative mortality was 9.5% (2 cases). No late deaths occurred. In the group with mitral insufficiency, 10 (83.3%) patients were asymptomatic (p=0.04). The majority with mild reflux (p=0.002). In the follow-up of the stenosis group, all were in functional class I (NYHA); and the mean transvalve gradient varied between 8 and 12 mmHg, average of 10.7 mmHg. In the double lesion group, 1 patient was reoperated at 43 months. No endocarditis or thromboembolism were reported. CONCLUSION Mitral stenosis repair has worse late results, related to the valve abnormalities and associated lesions. The correction of mitral insufficiency without annular support showed good long-term results.