José Pedro da Silva

Anomalia de Ebstein: resultados com a reconstrução cônica da valva tricúspide

OBJECTIVE: To assess the results of a technical modification of tricuspid valvuloplasty in Ebsteins anomaly. METHODS: From November 1993 to August 2002, 21 patients with Ebsteins anomaly of the tricuspid valve, with ages ranging from 20 months to 37 years (mean, 23 years), underwent a new technique of tricuspid valvuloplasty. This technique consisted of total or almost total detachment of the anterior tricuspid megaleaflet from the ventricular wall and valvular ring, transforming it into a cone, whose vertex remained fixed in the right ventricular tip, and the base was sutured to the tricuspid ring, after its plication, adjusting it to the size of the base of the cone (tricuspid ring), including the septal region. RESULTS: One (4.7%) patient with cardiomyopathy caused by chronic hypoxia died in the hospital due to low cardiac output. The mean follow-up lasted 4 years, and the recent echocardiograms showed good morphology of the right ventricle and tricuspid valve with mild or minimal insufficiency in 18 patients and moderate insufficiency in 2 patients. In 2 of the 3 patients with an anomalous bundle, it could be located and sectioned during surgery. No atrioventricular block occurred. CONCLUSION: The technique used was efficient in repairing tricuspid insufficiency and restoring right ventricular morphology, being applicable to all anatomic types of Ebsteins anomaly, except for Carpentier classification type D.

Síndrome do coração esquerdo hipoplásico: estratégia cirúrgica e comparação de resultados com técnicas de Norwood x Sano

Objectives: To report a surgical strategy for the Norwood procedure in hypoplastic left heart syndrome (HLHS) that enables short hypothermic circulatory arrest and aortic arch reconstruction using autologous pericardium. Additionally, the work compares the results of the modified BlalockTaussig (mBT) shunt and the right ventricle-to-pulmonary artery (RV-PA) conduit procedures as the source of pulmonary blood flow. Method: A retrospective study was performed of 78 newborns consecutively operated on between March 1999 and June 2006. One technique to reconstruct the neoaorta and two different techniques, to reestablish the pulmonary blood flow, were utilized - mBT shunts in the first 37 newborns and RV-PA conduits in the last 41. Cannulation of the ductus arteriosus for systemic perfusion was the main part of the surgical strategy used to reduce the hypothermic circulatory arrest time. Results: In-hospital survival for the entire cohort was 74.35%, or 67.57% for the mBT shunt and 80.49% for the RVPA conduit Groups (p=0.21). Hypothermic circulatory arrest times were 45.79 ± 1.99 minutes and 36.8 ± 1.52 minutes (p=0.0012), respectively. Mortality rates between first and second stages were 40% for the mBT shunt and 6.9% for the RV-PA conduit Groups (p=0.007). Late coarctation of the aorta occurred in five patients. A comparison of the actuarial survival curves (Kaplan-Meier) showed that the results were better with the VD-AP conduit (p=0.003). Conclusions: This surgical strategy resulted in a short circulatory arrest time, low mortality and a low incidence of aortic coarctation. Although the higher rate of survival in the first palliation stage with the RV-PA conduit was not significant, the lower interstage mortality and superior medium-term survival in the RV-AP Group were statistically advantageous.

Síndrome da hipoplasia do coração esquerdo: a influência da estratégia cirúrgica nos resultados

OBJECTIVES To report a surgical strategy for the Norwood procedure in the hypoplastic left heart syndrome (HLHS) that enables short hypothermic circulatory arrest time and aortic arch reconstruction with autologous pericardium patch, and to compare the results of the modified Blalock-Taussig (mBT) shunt with the right ventricle-to-pulmonary artery (RV-PA) conduit procedures as the source of pulmonary blood flow. METHODS Retrospective study of 71 newborns with HLHS consecutively operated between March, 1999 and February, 2006. One technique for reconstruction of the neoaorta and two different techniques for reestablishment of the pulmonary blood flow were used: the mBT shunt in the first 37 newborns and RV-PA conduit in the last 34. Cannulation of the ductus arteriosus for arterial perfusion was the main part of the surgical strategy to reduce the hypothermic circulatory arrest time. RESULTS In-hospital survival for the entire cohort was 74.64%, or 67.57% and 82.35% for the mBT shunt and RV-PA conduit groups, respectively (p=0.1808). Mortality rates between the first and second palliation stages were 40% and 4.4% for the mBT shunt and RV-PA conduit groups, respectively (p=0.0054). Hypothermic circulatory arrest times were 45.79+/-1.99 min and 36.62+/-1.62 min (p=0.0012), respectively. Late coarctation of the aorta occurred in five patients (7.2%). CONCLUSION This surgical strategy resulted in short circulatory arrest time, low mortality and favorable morphology of the neoaorta, with low incidence of late coarctation of the aorta. The higher rate of survival to first palliation stage with the RV-PA conduit was not significant, but interstage mortality was statistically lower when compared with the modified Blalock-Taussig shunt procedure.

Pulmonary root translocation in transposition of great arteries repair

Anterior pulmonary root translocation is used as a new approach for anatomic repair of transposition complexes with ventricular septal defect and pulmonary stenosis. It is performed to construct the right ventricle outflow tract, after patch diversion of left ventricle to aorta. Since 1994, 3 infants underwent this procedure. The preliminary results indicate some growth of the pulmonary root and suggest that this technique could diminish reoperations in this group of patients.

Ebstein's anomaly of the tricuspid valve: the cone repair.

Ebsteins anomaly is a cardiac malformation affecting the tricuspid valve and right ventricle with a wide range of anatomic and pathophysiologic presentations. The cone repair technique is described in detail, as applied to several types of this complex congenital heart disease. The importance of extensive mobilization of displaced and tethered tricuspid leaflets to permit a good leaflet-to-leaflet coaptation after the cone construction is highlighted. This technique was performed in 100 patients with a hospital mortality rate of 3.0%, good clinical outcome, and no need for tricuspid valve replacement. Echocardiograph results showed good anatomic and functional tricuspid valves at immediate and long-term postoperative follow-up.

Pulmonary root translocation in malposition of great arteries repair allows right ventricular outflow tract growth

OBJECTIVE Optimal surgical treatment of patients with transposition of the great arteries (TGA), ventricular septal defect (VSD), and pulmonary stenosis (PS) remains a matter of debate. This study evaluated the clinical outcome and right ventricle outflow tract performance in the long-term follow-up of patients subjected to pulmonary root translocation (PRT) as part of their surgical repair. METHODS From April 1994 to December 2010, we operated on 44 consecutive patients (median age, 11 months). All had malposition of the great arteries as follows: TGA with VSD and PS (n = 33); double-outlet right ventricle with subpulmonary VSD (n = 7); double-outlet right ventricle with atrioventricular septal defect (n = 1); and congenitally corrected TGA with VSD and PS (n = 3). The surgical technique consisted of PRT from the left ventricle to the right ventricle after construction of an intraventricular tunnel that diverted blood flow from the left ventricle to the aorta. RESULTS The mean follow-up time was 72 ± 52.1 months. There were 3 (6.8%) early deaths and 1 (2.3%) late death. Kaplan-Meier survival was 92.8% and reintervention-free survival was 82.9% at 12 years. Repeat echocardiographic data showed nonlinear growth of the pulmonary root and good performance of the valve at 10 years. Only 4 patients required reinterventions owing to right ventricular outflow tract problems. CONCLUSIONS PRT is a good surgical alternative for treatment of patients with TGA complexes, VSD, and PS, with acceptable operative risk, high long-term survivals, and few reinterventions. Most patients had adequate pulmonary root growth and performance.

Cardiogenic shock due to citomegalovirus myocarditis: successful clinical treatment

OBJECTIVE Cytomegalovirus (CMV) systemic disease and myocarditis in healthy persons is infrequently reported in the literature, although in increasing numbers in recent years. The importance of the recognition of the syndrome that usually has an initial picture of a mononucleosis like infection in an otherwise healthy person, is the available therapeutic agent, ganciclovir, that can cure the infectious disease. METHODS We analyzed the clinical result of pulsotherapy with steroids in a patient with CMV myocarditis after 7 days of etiological treatment, with ganciclovir, intravenous vasodilators, and the conventional treatment for congestive heart failure. RESULTS The clinical condition of the patient improved accordingly to the better function of the left ventricle, and the ganciclovir was kept for 21 days, most of it in an out patient basis. The patient was dismissed from the hospital, with normal myocardial function. CONCLUSION Potentially curable forms of myocarditis, like M pneumoniae and CMV, for example, can have an initial disproportionate aggression to the myocardium, by the acute inflammatory reaction, that can by itself make worse the damage to the LV function. In our opinion, the blockade of this process by pulsotherapy with steroids can help in the treatment of these patients. We understand that the different scenario of immunosuppressive treatments for the possible auto immunity of the more chronic forms of the presumably post viral cardiomyopathy has been in dispute in the literature, and has stolen the focus from the truly acute cases.

Heart retransplantation in children without the use of blood product.

This article reports a case of a cardiac retransplantation without the use of blood products, in a 6 year old, with severe dilated cardiomyopathy after chronic graft rejection and refractory to clinical treatment. To avoid a blood transfusion in this surgery a multidisciplinary approach was planned, which involved the use of preoperative erythropoietin, acute normovolemic hemodilution and intraoperative cell savage with autologous blood recovery system, as well as a meticulous hemostasis and reduced postoperative phlebotomy.

Operação de Glenn bidirecional no tratamento estagiado da síndrome de hipoplasia do coração esquerdo: resultados imediatos e tardios

OBJETIVO: Relatar os resultados imediatos e tardios da operacao de Glenn bidirecional como segundo estagio do tratamento da Sindrome de Hipoplasia do Coracao Esquerdo (SHCE) e descrever a tecnica de miniesternotomia utilizada. METODO: Entre marco de 1998 e fevereiro de 2004, 15 pacientes com operacao de Norwood previa foram submetidos eletivamente a derivacao cavopulmonar. As idades variaram de 2 a 6 meses (media 3,46 ± 0,83 meses), sendo seis pacientes do sexo masculino. Foram realizadas miniesternotomias em 11 (73,3%) casos. Para adequada oxigenacao sanguinea inicial foi associado enxerto sistemico-pulmonar de 3 mm em nove casos e manutencao do enxerto VD-TP em um caso. Acompanhamento clinico e ecocardiografico foi realizado em todos os pacientes. RESULTADOS: A sobrevida hospitalar foi de 86,6%, ocorrendo um obito por sangramento e outro por hipoxia. O ecocardiograma imediato mostrava fluxo pelo enxerto de PTFE nos dez pacientes em que foi utilizado, ocorrendo seu fechamento no controle tardio. Ocorreram dois (13,3%) obitos tardios, um por complicacao de traqueostomia e outro por meningite bacteriana. Sete pacientes aguardam o terceiro estagio, estando assintomaticos. Quatro foram submetidos ao terceiro estagio com sucesso. O ecocardiograma dos 11 pacientes sobreviventes tardios mostra boa funcao do ventriculo direito, sem insuficiencia tricuspide e bom fluxo pela anastomose cavo-pulmonar, num seguimento medio de 2 anos e 5 meses. CONCLUSOES: A operacao de Glenn na SHCE apresenta baixa mortalidade hospitalar, com resultados satisfatorios em longo prazo, podendo ser realizada atraves de miniesternotomia A associacao de fluxo sistemico-pulmonar acessorio em criancas de baixa idade parece melhorar a saturacao de oxigenio.

Therapeutic options to minimize allogeneic blood transfusions and their adverse effects in cardiac surgery: A systematic review

Introdution Allogeneic blood is an exhaustible therapeutic resource. New evidence indicates that blood consumption is excessive and that donations have decreased, resulting in reduced blood supplies worldwide. Blood transfusions are associated with increased morbidity and mortality, as well as higher hospital costs. This makes it necessary to seek out new treatment options. Such options exist but are still virtually unknown and are rarely utilized. Objective To gather and describe in a systematic, objective, and practical way all clinical and surgical strategies as effective therapeutic options to minimize or avoid allogeneic blood transfusions and their adverse effects in surgical cardiac patients. Methods A bibliographic search was conducted using the MeSH term “Blood Transfusion” and the terms “Cardiac Surgery” and “Blood Management.” Studies with titles not directly related to this research or that did not contain information related to it in their abstracts as well as older studies reporting on the same strategies were not included. Results Treating anemia and thrombocytopenia, suspending anticoagulants and antiplatelet agents, reducing routine phlebotomies, utilizing less traumatic surgical techniques with moderate hypothermia and hypotension, meticulous hemostasis, use of topical and systemic hemostatic agents, acute normovolemic hemodilution, cell salvage, anemia tolerance (supplementary oxygen and normothermia), as well as various other therapeutic options have proved to be effective strategies for reducing allogeneic blood transfusions. Conclusion There are a number of clinical and surgical strategies that can be used to optimize erythrocyte mass and coagulation status, minimize blood loss, and improve anemia tolerance. In order to decrease the consumption of blood components, diminish morbidity and mortality, and reduce hospital costs, these treatment strategies should be incorporated into medical practice worldwide.