Leonardo Secchin Canale

Simplified frozen elephant trunk repair for acute DeBakey type i dissection

OBJECTIVE The study objective was to describe a novel technique and assess the safety and feasibility of this initial experience for performing a modified frozen elephant trunk extended repair of acute dissection. METHODS From June 2009 to February 2012, 17 patients with DeBakey type I acute aortic dissections underwent emergency surgery using a new approach for extended repair of the ascending arch and proximal descending aorta with a hybrid technique. Fourteen patients were male (82%) with a mean age of 61.4 ± 17.5 years. Some 8 of 17 (47%) presented with malperfusion, and the mean time from symptom onset to operating room was 12.8 ± 3.7 hours. Two patients had root replacement with a stentless bioprosthesis, 1 patient had aortic valve replacement, 13 patients had the valve resuspended, and 1 patient had the native valve reimplanted as a David procedure. A single, commercially available descending thoracic stent graft (26-37 mm TAG, WL Gore and Associates, Flagstaff, Ariz) was delivered antegrade directly into the open descending aorta, trimmed proximally, and sutured into the arch of each patient. The left subclavian artery was covered in 8 of 17 patients (47%). Data were from a prospectively collected database. Follow-up computed tomography was performed at discharge, 3 months, and annually, and assessed with 3-dimensional reconstruction. RESULTS There were no perioperative deaths, and all patients are still alive at intermediate follow-up. There were 2 strokes without residual deficit, and 2 patients had paraparesis postoperatively with recovery before discharge. Two patients required temporary tracheostomy for respiratory failure, and 3 patients required temporary hemodialysis. The mean length of stay was 20 ± 12 days, 10 of which were in the intensive care unit. At imaging follow-up, the proximal aortic repair was stable in all patients, and the false lumen was thrombosed in the treated segment in 87.5% of patients. CONCLUSIONS A novel simplified frozen elephant trunk hybrid technique for acute type I dissections allows for safe and effective extended aortic repair with false lumen thrombosis and aortic remodeling of the treated segment. Long-term outcomes of this technique warrant further investigation.

Cardiac tamponade caused by central venous catheter in two newborns

Cardiac tamponade secondary to the use of central venous catheter is a rare complication; however, it is potentially reversible when it is caught in time. We report two cases of cardiac tamponade that was diagnosed using a transthoracic echocardiography, followed by urgent pericardiocentesis and surgical pericardial drainage as a complication from umbilical venous catheterization. In one case, the tip of the catheter was properly placed, and in the other case, it was not. In both cases, a hyperosmolar solution was being injected. Although it may be an uncommon situation, it should be always considered as a possibility in a newborn who develops cardiogenic shock without an apparent cause.Cardiac tamponade secondary to the use of central venous catheter is a rare complication; however, it is potentially reversible when it is caught in time. We report two cases of cardiac tamponade that was diagnosed using a transthoracic echocardiography, followed by urgent pericardiocentesis and surgical pericardial drainage as a complication from umbilical venous catheterization. In one case, the tip of the catheter was properly placed, and in the other case, it was not. In both cases, a hyperosmolar solution was being injected. Although it may be an uncommon situation, it should be always considered as a possibility in a newborn who develops cardiogenic shock without an apparent cause.

Tratamento cirúrgico de fibrilação atrial utilizando ablação com radiofrequência bipolar em doença mitral reumática

OBJECTIVE: To analyze the effectiveness of surgical treatment of atrial fibrillation (AF) using bipolar radiofrequency ablation during mitral valve procedures of rheumatic etiology in heart surgery. METHODS: We retrospectively reviewed medical registries of 53 patients submitted to atrial ablation with bipolar radiofrequency energy during mitral valve surgery. Thirty four (64%) patients were women and the age varied from 27 to 72 years old (average: 49.3 ± 10.7 years). Aortic and/or tricuspid procedures were also present in 36 (68%) patients. Average time of reported atrial fibrillation was 41 months (from 3 to 192 months). Type of AF was classified as: paroxysmal in 8 patients, persistent in 3, permanent in 42. Left atrium had an average size of 52.9 ± 8.5 mm. The surgeries in these series were: 47 mitral valve replacements and 6 mitral valve repairs. Eletrocardiografic follow up was 83% complete in 14 months. Data from 24h Holter were explored. RESULTS: Seven (13%) perioperative deaths were observed and survival after 14 months was 87%. Observed heart rhythm after 1 year of surgery was sinus rhythm in 25 (66%) patients, AF in 7 (18%), flutter in 7 (13%), junctional in 1 (3%). CONCLUSION: Bipolar radiofrequency ablation in patients submitted to mitral valve surgery of rheumatic etiology is effective in converting to sinus rhythm in 68% of patients after 14 months.

Mid-to-long term follow-up after surgical repair of atrioventricular septal defect with common atrioventricular junction and ventricular shunting associated with tetralogy of Fallot.

OBJECTIVES Our aim is to describe our surgical approach in dealing with patients having atrioventricular septal defect with common atrioventricular junction and ventricular shunting associated with tetralogy of Fallot over the last 8 years, and to present our results in mid-to-long term follow-up. METHODS Between November 1995 and January 2004, we performed surgical correction in 8 consecutive children with atrioventricular septal defect, common atrioventricular junction, interventricular shunting, and associated tetralogy of Fallot. The age at surgical correction varied from 8 months to 20 years, with a mean of 45 months, and standard deviation of 74 months. A palliative systemic-to-pulmonary shunt had previously been performed in 3 patients. Follow-up ranged from 57 to 135 months, with a mean of 93.5 months, and standard deviation of 32 months. We used a two-patch technique to repair of the atrioventricular septal defect, and a pericardial transjunctional patch for relief of the obstruction in the right ventricular outflow tract. RESULTS There were no deaths, nor reoperations either in the postoperative period or during follow-up. All patients are asymptomatic, or in the second class created by the New York Heart Association. The mean period of cardiopulmonary by-pass was 136 minutes, and the mean stay in hospital was 11.8 days. At the last examination, pulmonary valvar insufficiency was considered severe in 2 patients, and moderate in another 2. No patient developed more than a trace of regurgitation across the reconstituted left atrioventricular valve. CONCLUSIONS The two-patch technique, associated with ventriculotomy and a transjunctional pulmonary patch is safe and efficient when correcting atrioventricular septal defect associated with tetralogy of Fallot, resulting in good mid-to-long term clinical outcomes.

Uso da radiofrequência bipolar para o tratamento da fibrilação atrial durante cirurgia cardíaca

FUNDAMENTO: O tratamento da fibrilacao atrial com dispositivo de ablacao de tecidos por radiofrequencia bipolar em concomitância a cirurgia cardiaca tem se mostrado metodo eficaz no tratamento desta arritmia. OBJETIVO: Descrever a experiencia inicial do Instituto Nacional de Cardiologia no tratamento cirurgico da fibrilacao atrial com uso de dispositivo de radiofrequencia bipolar em pacientes submetidos a cirurgia cardiaca, relatando o resultado de acompanhamento pos-operatorio de um ano. METODOS: Entre janeiro de 2008 e marco de 2009, 47 pacientes (36 mulheres) consecutivos, com idade media de 53,7 ± 10,6 anos, apresentando fibrilacao atrial por um periodo medio de 34,6 meses (3 a 192 meses) foram submetidos a ablacao cirurgica desta arritmia, por radiofrequencia bipolar, durante o procedimento que motivou a indicacao da cirurgia. Oito apresentavam fibrilacao atrial intermitente e 39, continua. Oitenta e um por cento foram submetidos a cirurgia valvar como procedimento principal. Esta e uma analise retrospectiva, observacional, com avaliacao de um ano de pos-operatorio das variaveis clinicas e de Holter 24 h. RESULTADOS: Dos 47 pacientes, 40 sobreviveram um ano. Desses, 33 foram submetidos a Holter 24 h, em um intervalo medio de 401 dias apos a cirurgia. Encontrou-se a seguinte distribuicao de ritmos: 24 (73%) sinusal, 5 (15%) fibrilacao atrial, tres (9%) Flutter atrial e um (3%) ritmo juncional. Foram observados dois acidentes vasculares encefalicos, sendo um associado a arritmia supraventricular. CONCLUSAO: A ablacao cirurgica de fibrilacao atrial com dispositivo de radiofrequencia bipolar concomitante a cirurgia cardiaca e metodo eficaz para o tratamento desta arritmia.BACKGROUND Atrial fibrillation with tissue ablation device through bipolar radiofrequency in conjunction with cardiac surgery has proven to be an effective method to treat this arrhythmia. OBJECTIVE Describe the initial experience of the Instituto Nacional de Cardiologia in the surgical treatment of atrial fibrillation using bipolar radiofrequency device in patients undergoing cardiac surgery, reporting the results of postoperative follow-up of one year. METHODS Between January 2008 and March 2009, 47 consecutive patients (36 women), with mean age of 53.7 ± 10.6 years, with atrial fibrillation for a mean period of 34.6 months (3-192 months) underwent surgical ablation of this arrhythmia, through bipolar radiofrequency during the procedure which led to the indication of surgery. Eight of them showed intermittent atrial fibrillation and 39, continued. Eighty-one percent underwent valve surgery as the main procedure. This is a one-year postoperative retrospective, observational evaluation of clinical variables and 24-h Holter. RESULTS Out of the 47 patients, 40 survived one year. Out of these, 33 underwent 24 h Holter, at an average interval of 401 days after the surgery. The following rhythm distribution was found: 24 (73.0%) sinus, five (15.0%) atrial fibrillation, three (9.0%) atrial Flutter and one (3.0%) junctional rhythm. Two cerebrovascular accidents were observed, one of which was associated with supraventricular arrhythmia. CONCLUSION Surgical ablation of atrial fibrillation with bipolar radiofrequency device concomitant with cardiac surgery is an effective method for treating this arrhythmia.

Assistência circulatória com oxigenação por membrana extracorpórea (ECMO) no adulto: um conceito falido ou esquecido?

FUNDAMENTO: A oxigenacao por membrana extracorporea (ECMO) em recem-nascidos e criancas tem resultados excelentes. A experiencia em adultos e mais modesta e os resultados imediatos sao inferiores. Entretanto, a sobrevida em cinco anos de pacientes que sobrevivem a esse metodo e bastante promissora. Nao ha relato na literatura brasileira de experiencias com esse sistema nesse contexto. OBJETIVO: Relatar a experiencia com o uso da oxigenacao por membrana extracorporea no adulto que se apresenta em choque cardiogenico agudo e refratario. METODOS: Analise retrospectiva de prontuarios medicos de pacientes submetidos a implante do sistema de oxigenacao por membrana extracorporea para a assistencia circulatoria no choque cardiogenico agudo e refratario. RESULTADOS: Onze pacientes (63,5 anos; 45,5% homens) foram considerados para analise no periodo de 2005 a 2007. O tempo medio de suporte circulatorio foi de 77 horas (10-240h) e cinco pacientes estavam vivos em 30 dias (45,5%). Dois pacientes foram subsequentemente submetidos a implante de assistencia circulatoria prolongada apos um periodo de ressuscitacao em ECMO, um dos quais foi submetido ao transplante cardiaco. As causas de morte durante a assistencia com ECMO (seis pacientes) incluiram falencia multiorgânica (66,6%) ou sangramento refratario (33,4%). CONCLUSAO: O sistema ECMO e uma opcao de assistencia circulatoria temporaria para pacientes adultos com falencia cardiaca aguda refrataria, podendo ser utilizado como ponte para a recuperacao ou com o intuito de selecionar candidatos a assistencia circulatoria prolongada (ponte para a ponte).

Surgical treatment of right atrial myxoma complicated with pulmonary embolism

Myxomas are the most common type of cardiac benign tumors and most of them are located in the left atrium, followed by the right atrium. Myxomas in the right atrium may rarely embolize to the pulmonary arterial vasculature. Here, we present a case report of a patient with right atrial myxoma and massive embolism to the pulmonary arteries treated surgically with right atrial mass removal and pulmonary embolectomy. The right atrium mass presented with prolapse through the tricuspid valve causing a stenotic physiology. The left pulmonary artery was completed occluded and the right pulmonary artery was partially obstructed. Surgical tactics included a brief hypothermic circulatory arrest. The patient had an uneventful recovery and was asymptomatic after 6 months of follow-up.

Dissecting intramyocardial hematoma after robotic mitral valve repair.

We report the first case of a dissecting intramyocardial hematoma discovered intraoperatively after robotic mitral valve repair, potential etiologies relevant to robotic surgery, and its successful management.

Toracotomia minimamente invasiva (miopreservadora) para ligadura do canal arterial em prematuros

OBJECTIVES To analyze the feasibility, the safety, and the primary outcomes of a minimally invasive thoracotomy for the occlusion of ligamentum arteriosum (ductus arteriosus) in preterm infants. METHODS Between October 1991 and June 2003, 273 preterm infants and very low birth weight preterm infants were submitted to a surgical occlusion of the ligamentum arteriosum (ductus arteriosus) through muscle-sparing thoracotomy under general anesthesia in the neonatal ICU. Pre-operative demographic data, mortality outcomes, and adverse events were retrospectively analyzed through medical records consultation. RESULTS There were no deaths related to surgery, and 234 (86%) patients were discharged from hospital. Thirty-nine deaths have occurred between the 1st and the 51st days. The cause of death was sepsis (14 patients); intracranial bleeding (11 patients); and necrotizing enterocolitis (9 patients). All causes were related to prematurity. In five patients the cause of death was not established or could not be found in the medical records. The most frequent adverse events related to the surgery were: pneumothorax: 3.3% (9 patients), bleeding: 1.4% (4 patients). CONCLUSIONS The minimally invasive thoracotomy technique for the occlusion of the ligamentum arteriosum (ductus arteriosus) when performed in preterm infants and very low birth weight infants is feasible, safe, efficient, related to low morbidity, and not dependent of hospital resources.OBJECTIVES: To analyze the feasibility, the safety, and the primary outcomes of a minimally invasive thoracotomy for the occlusion of ligamentum arteriosum (ductus arteriosus) in preterm infants. METHODS: Between October 1991 and June 2003, 273 preterm infants and very low birth weight preterm infants were submitted to a surgical occlusion of the ligamentum arteriosum (ductus arteriosus) through muscle-sparing thoracotomy under general anesthesia in the neonatal ICU. Pre-operative demographic data, mortality outcomes, and adverse events were retrospectively analyzed through medical records consultation. RESULTS:There were no deaths related to surgery, and 234 (86%) patients were discharged from hospital. Thirty-nine deaths have occurred between the 1st and the 51st days. The cause of death was sepsis (14 patients); intracranial bleeding (11 patients); and necrotizing enterocolitis (9 patients). All causes were related to prematurity. In five patients the cause of death was not established or could not be found in the medical records. The most frequent adverse events related to the surgery were: pneumothorax: 3.3% (9 patients), bleeding: 1.4% (4 patients). CONCLUSIONS: The minimally invasive thoracotomy technique for the occlusion of the ligamentum arteriosum (ductus arteriosus) when performed in preterm infants and very low birth weight infants is feasible, safe, efficient, related to low morbidity, and not dependent of hospital resources.

Current State of Robotically Assisted Coronary Artery Bypass Surgery

The development of robotic technology for surgical purposes involves the convergence of several different technologies. From the use of telemanipulation in hazardous situations such as radiation handling and deep sea exploration to advances in microelectronics, computing and virtual reality techniques, all these areas of knowledge gave important contributions to our current status of development. Despite the fact that the first operations ever carried out robotically were heart surgery procedures, cardiac surgeons were more resistant to this new concept of minimally invasive therapy. In part because of the more difficult procedures in the cardiac realm, and in part due to the lack of tradition in laparoscopic surgery, the truth is that the cardiac surgical community was very slow and resistant in adopting this new technology. Still many brilliant surgeons paved the way and developed tactics and new approaches to old problems utilizing this robotic system.