Leonardo Andrade Mulinari

Cirurgia cardíaca no idoso

BACKGROUND: Because of the increase in the life expectancy of the Brazilian population, elderly patients are being increasingly referred to cardiac surgery. MATERIAL AND METHODS: Seventy-five patients, 70 years of age or older, who underwent cardiac surgery in the HC-UFPR, between 1995 and 1999 were studied. The purpose of this study was to analyze early and long-term results. Ages from 70 to 88 years, with 34 females (46.7%) and 41 males (53.3%). Symptoms included angina (81.3%), dyspnea (42.6%) and syncope (16%). There was 57.3% of patients in NYHA class I, 17.3% in class II, 18.6% in class III and 6.6% in class IV. The main risk factors listed were high blood pressure (61.3%), smoke (48%), diabetes mellitus (28%) and 9.3% had already had cardiac operations. Surgical procedures included 50 coronary artery bypass grafts - CABG (66.6%), 9 aortic valve replacements (12%), 5 aortic operations (6.6%), 4 CABG + valve replacement (5.2%) and other procedures (7%). The main postoperative complications were cardiovascular - ventricular arrhythmias (22.6%), supraventricular arrhythmias (21.3%), low cardiac output (16%) - infections (16%) and pulmonary problems (9.3%). The median stay in the ICU was 5 days. RESULTS: Sixty-five (78.4%) survivors had complete follow-up. The mean follow-up time was 20.7 months and long-term survival was 92%. Only one of the late deaths was cardiac related. CONCLUSION: Although this subgroup is associated with chronic diseases compromising other organs, advances in cardiac surgery and intensive care have made possible an intervention with safety and low morbidity and mortality.

Evaluation of the biological behavior of decellularized pulmonary homografts: an experimental sheep model

INTRODUCTION The cryopreserved homograft is a good valve substitute due attributes like excellent hemodynamics, low incidence of thromboembolic events, infection resistance and good mid-term durability. However, progressive homograft degeneration and fibrocalcification may occur, particularly in the childhood and young adults. Their antigenicity triggers an immunological reaction that plays an important role in their degeneration and failure. The decellularization process was proposed to decrease this antigenicity. By the action of detergents and enzymes, this process removes all cellular components from the homograft matrix, diminishing immunogenicity and probably delaying its degeneration. OBJECTIVE The objective of this experimental and descriptive study is to evaluate the biological and functional behavior of decellularized pulmonary homografts (Decell-H), treated by a sodium dodecil sulfate solution (0.1%), developed in our University (Pontifícia Universidade Católica do Paraná). For the characterization of Decell-H performance, parameters like recellularization, calcification, and echocardiographic data will be analyzed. METHODS Eight juvenile sheep were submitted to the implantation of the Decell-H sutured into orthotopic position, through a left thoracotomy and with cardiopulmonary bypass support. They were followed-up clinically and by periodical echocardiograms until the explantation, which were performed in different time for every two sheep: seven, 30, 90 and 180 postoperative days. For histological analysis we used Hematoxilin-eosin, Movat and Alizarin-Red staining. RESULTS The sheep reached their follow-up period in a good clinical state. There was no valve regurgitation or stenonis by the echocardiogram. The animals submitted to the explantation in 90 and 180 days had a significant somatic growth and these Decell-H(s) had a diameter increase, without central valve insufficiency. Histologically, all homografts preserved their extra-cellular matrix organization and were progressively recellularized, without calcification. CONCLUSION In this experimental model, the Decell-H behaved as an excellent valve substitute.

Plástica da valva mitral com emprego do anel de Gregori-Braile: análise de 66 pacientes

The complications of valvular prosthesis has led us to preserve the mitral valve. Objective: This paper analyses mitral reconstruction in 66 patients (pts.) where the ring of Gregori-Braile was used, in the period between October 1989 and October 1995. Casuistic and Methods: 45 (74.1%) were male and the mean age was 32.9 years. Rheumatic disease was present in 49 pts. and mitral insufficiency in 38 pts. (57.5%). The follow-up was 2.560 pts./mounth (mean 38.8 months) in 64 pts. (96.9%). The method used to evaluate the patients were as follows: clinical symptoms in FC (NYHAC), systolic mitral murmur and Doppler-echocardiographic study in the pre and post-operative period. The mitral techniques were: ring implantation, mobilization of leaflets and chordae tendinae and restriction of valve mobility. Shortening of the chordae was used in 44 pts. (66.6%). Associated procedures were: reduction of the LA (8 pts.), aortic valve replacement (3 pts.) and Cox procedure in 3 pts. One patient died (1.5%) in early PO from pulmonar thromboembolism. Results: The PO functional class improved. In the pre-op 41 pts. (62.1%) were in FC III and 23 pts. in FCIV (34.8%). In the PO, 53 pts (80.3%) were in FC I and 8 pts. (12.1%) in FC II. The mitral murmur was absent or + intensity in 92.4% in PO. The FC and murmur improved significantly (p < 0.001). The Doppler-echocardiographic study showed: mean left ventricular diastolic diameter was 5.96 cm in the pre-op and 5.33 cm in the PO (p < 0.001); mean LA dimension was 5.67 cm (pre-op) and 4.65 cm in the PO (p < 0.001); mean aortic diameter was 2.97 cm in the pre-op and 3.13 cm in PO (p < 0.01); the mean shortening was 35.38% in pre-op and 34.12% in PO (not significantly). The mean valve area was 1.7 cm2 in the pre-op period and 2.43 cm2 in PO (p < 0.003) and the mean gradient pressure in the pre-op and PO period was 11.10 mmHg and 5.58 mmHg (p < 0.003), respectively. In the late PO, 3 pts. died (4.5%). After 72 months, the survival was 95.5%, 96% free from reoperation and 98.4% free from thromboembolism. Conclusions: Mitral reconstruction is a safe procedure, the improvement in functional class was statistically significant, and the procedure should be done whenever possible to correct the mixed lesion and mitral insufficiency.

Bilateral carotid endarterectomy combined with myocardial revascularization during the same surgical act

The best surgical approach for the treatment of patients with severe cerebral artery disease and simultaneous serious coronary artery disease still remains controversial. In this report we present a case of a 72-year-old female patient admitted to the hospital with unstable angina. Triple coronary artery obstructive disease and severe bilateral carotid artery stenosis were diagnosed. A combined, simultaneous surgical procedure was performed. After total circulatory by-pass with a membrane oxygenator, the patients body temperature was lowered to 32 degrees C. During the cool-down period, three proximal anastomoses of segments of autologous saphenous veins were performed in the ascending aorta. Immediately afterwards, bilateral carotid endarterectomy was performed, followed by three distal anastomoses to coronary arteries. The patient showed a satisfactory post-operative outcome. It was concluded that the combination of moderate hypothermia, hemodilution with appropriate hemodynamic control, as used in this patient, was an effective method of cerebral protection. The simultaneous approach of carotid endarterectomy and coronary artery by-pass surgery should be seen as a safe option for the treatment of this type of patient.

Efeitos da correção cirúrgica de estenose mitral sobre o ritmo cardíaco

Objetivo: Determinar a frequencia de reversao de fibrilacao atrial (FA) ao ritmo sinusal (SA) em pacientes com estenose mitral (EM) submetidos a tratamento cirurgico e identificar provaveis fatores favoraveis ou desfavoraveis a este evento. Casuistica e Metodos: Estudo de caso-controle, envolvendo 53 pacientes com EM, sem acometimento de outras valvas, submetidos a correcao cirurgica. A populacao estudada apresentou as seguintes caracteristicas: mulheres: 71,7%; idade media: 42,4 anos; classe funcional III: 67,9%; area mitral media: 0,92 cm2; atrio esquerdo medio: 56,0 mm; ritmo antes da operacao: SA: 51,0% e FA: 49,0%. Os pacientes foram divididos em dois grupos de acordo com o ritmo apresentado no periodo pos-operatorio tardio: grupo I, formado pelos pacientes que, apos a operacao, apresentavam ritmo SA e grupo II, constituido por aqueles que, no pos-operatorio, estavam em FA. Resultados: Dez (18,9%) pacientes (em relacao ao total; 38,5% em relacao aqueles com FA) apresentavam FA no periodo pre-operatorio e sofreram reversao para o ritmo SA no pos-operatorio e em 2 pacientes (3,8% em relacao ao total; 7,4% em relacao aqueles em ritmo SA) houve degeneracao do ritmo SA para FA. Houve diferenca estatisticamente significativa (p < 0,05) entre os dois grupos apenas em relacao a variavel idade (p = 0,0456). Conclusoes: A operacao de correcao de EM apresenta resultados insatisfatorios em relacao a reversao da FA para ritmo SA, sugerindo a necessidade de associacao de outro procedimento cirurgico para restaurar o ritmo normal. Varios estudos tentaram identificar os fatores predisponentes a permanencia e ao desenvolvimento de FA apos a operacao, porem foram obtidos resultados contraditorios. No presente estudo, a unica variavel que apresentou associacao com a FA foi a idade avancada.

Emprego e avaliação em médio prazo da cúspide de homoenxerto decelularizado na correção da tetralogia de Fallot

OBJECTIVE To describe the technique of implantation and to show the echocardiographic follow-up of the decellularized cusps allografts used in patients with tetralogy of fallot. METHODS Fifteen patients underwent this implantation between March 2005 and August 2007 and they were clinically followed-up. An echocardiogram was performed to evaluate the morphofunctional result of the allografts. RESULTS The mean follow-up was 12.7 months (1-25 months). The echocardiography results showed that pulmonary insufficiency was mild in nine (60%) patients, moderate in three (20%) patients, and severe in three (20%) patients. The results also showed that the systolic right ventricle function was normal in 13 (86.7%) and that there was mild dysfunction in two (13.3%). Eleven (73.4%) patients did not present any gradient in the right ventricular outflow tract and four (26.6%) presented mild stenosis. The mobility of the cusps were normal in all cases and there was no thickness larger than 1.5 mm. There was no calcification; 14 patients (93.3%) presented Z score between -1 and 0,7 and one patient presented dilated pulmonary annulus with a Z score of + 2.5. CONCLUSION In midium-term follow-up, the decellularized allograft seemed to be a good option for right ventricle outflow tract enlargement in patients underwent tetralogy of Fallot.

Erosão esternal por aneurisma da aorta. Qual o melhor acesso

E descrito o caso de um paciente que apresentava erosao esternal ocasionada por aneurisma da aorta ascendente e hemi-arco aortico proximal. A via de acesso foi toracotomia bilateral uma vez que a erosao era na parte alta do esterno, empregando-se hipotermia profunda e parada circulatoria total. Foi interposto enxerto de pericardio bovino para correcao da aorta ascendente e hemi-arco aortico proximal e outro enxerto entre o tronco braquicefalico e a parede lateral do enxerto de pericardio bovino. A arteria descendente anterior foi revascularizada por haver oclusao do ostio da arteria coronaria esquerda. Apos 3 anos da operacao o paciente esta assintomatico.

Emprego do anel de Gregori na posição invertida para o tratamento da insuficiência tricúspide: experiência inicial

Purpose: To analyse the technique and results for correction of functional tricuspid insufficiency with Gregoris ring in the inverted position. Material and Methods: Between July 1991 and November 1997, 11 patients were operated on and the mean age was 37 years. The assessment of the patients was made by clinical symptoms (NYHA-FC) classification and echocardiography study. The ring was implanted in tricuspid position and the retilineal part of the ring was sutured with interruped stitches in the annulus of the anterior leaflet. The reason behind this technique was to reduce the natural ring that is dilated in that region. Eight patients was in functional class (FC) III or IV (72.7%) in the pre-operative period and atrial fibrilation (AF) was presented in 6 patients (54.5%). The mean right ventricular diameter was 34 mm (normal value is up to 26mm). Results: There was no early or late mortality. The associated procedures were: mitral valve replacement in 5 patients; closure of ASD in 2; aortic valve replacement plus mitral valve repair in 1; isolated mitral valve repair in 1; ressection of bilateral endomyocardial fibrosis (EMF) in 1 and myocardial revascularization in 1. Follow-up was possible in 10 patients (91%). Nine patients (89%) were in FC I or II. The patient in FC III presented residual mitral valve insufficiency post-correction of EMF. Three patients were in AF and 7 in sinus rythm and none in total A-V block. None of the patients were reoperated. The mean right ventricular diameter was 24.6 mm (p < 0.001). Conclusions: 1) The technique is safe and reproducible; 2) clinical improvement was evident; 3) reduction of the right ventricular cavity was statistically significant; 4) considering the excellent results of this technique, it can be employed, routinely.

Electrophysiological Study in Ebstein's Anomaly With no Evidence of Accessory Pathway

Ebsteins anomaly (EA) is characterized by low implantation of the tricuspid valve, and corresponds to less than 1% of all congenital heart defects1-3. It is often associated with other malformations, such as ventricular septal defect, and Wolff-Parkinson-White syndrome often accompanies. Its clinical manifestation depends on the severity of the anatomical changes, and the indications for surgery have been well established4,5. When anomalous pathways are associated with EA, in one third of the cases the electrocardiographic pattern can differ from the classic one (short PR interval and presence of delta wave), because of slow intra-atrial conduction or anomalous pathway of long and slow conduction6. Arrhythmias are usually present in up to 80% of the patients7, with prevalence of anomalous atrioventricular pathways ranging from 0 to 44%1-3. Despite the universal acceptance of electrophysiological study (EPS) in symptomatic patients or in those with apparent accessory pathway on the electrocardiogram (ECG), data on asymptomatic patients with no electrocardiographic evidence of pre-excitation are scarce in the literature. Because of postoperative implications (difficult access to certain left atrial areas after surgical repair, risk of tachyarrhythmias in the intra- and postoperative periods, and likelihood of intraoperative elimination of accessory pathway), we report a case in which preoperative EPS was performed in a patient with EA and no classical evidence of tachyarrhythmias.

A dívida com a saúde da nação: o caso das cardiopatias congênitas

1. President of the Brazilian Society of Cardiovascular Surgery, Sao Paulo, SP, Brazil. Accepting the quality of healthcare provided to Brazilians has become untenable, not only to the population as a whole, but especially to patients and their loved ones as well as doctors and other related professionals. The situation becomes worse when it compromises children with congenital heart diseases, stripping them of their basic rights to proper care and the chance of remaining alive. The article by Pinto Jr. about the difficulties of caring for children with congenital heart diseases, published in this issue of the Brazilian Journal of Cardiovascular Surgery, is particularly timely as it does a great job of showcasing part of the reality faced by all of us in our daily routine [1]. Epidemiological data show a painful reality, in which 65% of the 23000 children diagnosed with congenital heart disease needing surgical treatment born annually in Brazil do not have access to the procedures requested. The largest discrepancies are found in the North and Northeast of the country (93.5% and 77.4%, respectively); the smallest, in the South and MidWest (46.4% and 57.4%, respectively). These children grow up with the natural progression of the disease. Consequently, they face high mortality rates and restrictions in their quality of life, both preventable considering more than 70% of them could be cured if treated appropriately. Resources dedicated to the treatment of congenital heart diseases are insufficient and, most of the time, are re-allocated to other departments whose productivity results are more visible thereby impressing authorities [2,3]. With a growing concern about this omission, the Brazilian Society of Cardiovascular Surgery (BSCVS) has made every effort to find solutions for this deficit. A group of specialists was gathered to tackle the problem by formulating several proposals for a definitive solution, which were then referred to the Brazilian Society of Cardiology (BSC) to be discussed.1. President of the Brazilian Society of Cardiovascular Surgery, São Paulo, SP, Brazil. Accepting the quality of healthcare provided to Brazilians has become untenable, not only to the population as a whole, but especially to patients and their loved ones as well as doctors and other related professionals. The situation becomes worse when it compromises children with congenital heart diseases, stripping them of their basic rights to proper care and the chance of remaining alive. The article by Pinto Jr. about the difficulties of caring for children with congenital heart diseases, published in this issue of the Brazilian Journal of Cardiovascular Surgery, is particularly timely as it does a great job of showcasing part of the reality faced by all of us in our daily routine [1]. Epidemiological data show a painful reality, in which 65% of the 23000 children diagnosed with congenital heart disease needing surgical treatment born annually in Brazil do not have access to the procedures requested. The largest discrepancies are found in the North and Northeast of the country (93.5% and 77.4%, respectively); the smallest, in the South and MidWest (46.4% and 57.4%, respectively). These children grow up with the natural progression of the disease. Consequently, they face high mortality rates and restrictions in their quality of life, both preventable considering more than 70% of them could be cured if treated appropriately. Resources dedicated to the treatment of congenital heart diseases are insufficient and, most of the time, are re-allocated to other departments whose productivity results are more visible thereby impressing authorities [2,3]. With a growing concern about this omission, the Brazilian Society of Cardiovascular Surgery (BSCVS) has made every effort to find solutions for this deficit. A group of specialists was gathered to tackle the problem by formulating several proposals for a definitive solution, which were then referred to the Brazilian Society of Cardiology (BSC) to be discussed.