Luciana da Fonseca

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.

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.

A síndrome do coração esquerdo hipoplásico não constitui fator de risco para operação de Fontan

Objective: To show the mortality rate of children undergoing to Fontan operation and determine whether the hypoplastic left heart syndrome (HLHS) is a risk factor for hospital mortality. Methods: From August 2001 to June 2008, 76 patients underwent Fontan operation and were divided into two groups: group A with 54 patients, 31 (40.7%) patients with tricuspid atresia and variants, six (7.8%) of double-inlet left ventricle, four (5.3%) and atrioventricular septal defect and total 13 (17.1%) of other complex congenital heart disease and group B all patients with HLHS a total of 22 (28.9%) patients. Results: Group A patients had a mean age of 6.47 years ± 4.83 and group B of 2.08 years ± 0.24 P <0.001, the average weight was 22.42 ± 11.04 against 12.99 ± 1.2 P = 0.016, the mean CPB time was 119.5 min versus 113.3 min P = 0.0, with a mean clamping time of 74.8 min and 73.5 min p = 0.75. The mean ICU stay was 4.1 days for group A versus 7.52 days for group B p = 0.0003. In total (group A + B) three patients died, with hospital mortality of 3.9%, and one patient with HLHS (4.54%) (P <0.001, 95% CI 0.001 to 0.228). Conclusion: Our study shows that despite higher morbidity in HLHS is not a risk factor for hospital mortality.

Atriosseptostomia por cateter balão guiada pela ecocardiografia em unidade de terapia intensiva neonatal

BACKGROUND The bedside two-dimensional echocardiography (2-D ECHO) has been successfully used to guide the balloon atrial septostomy, speeding up the procedure and preventing the risks of transportation to the hemodynamics laboratory. OBJECTIVE To assess the results of the bedside balloon atrial septostomy in cyanotic neonates. METHODS Between January/1997 and July/2008, 102 atrioseptostomies by balloon catheter guided by echocardiography were carried out and saturation levels, defect diameter, oxygen saturation, clinical-laboratory response and complications related to the procedure were evaluated. RESULTS Of 102 cases of bedside Rashkind septostomy, 98 met the inclusion criteria, with 90 neonates in Group A (Rashkind procedure in the preoperative phase) and 8 in Group B (procedure at the postoperative phase). There was a predominance of the male sex (75%), mean age was 8.3 ± 9.3 days and the mean weight was 3,100 ± 1,100 g; the transposition of the great arteries was the most frequent congenital heart disease (n = 74). When comparing the levels of saturation pre and post-procedure (65.9 ± 19.5% and 86 ± 9.7%) and the diameter of the interatrial septal defect pre and post-procedure (2.3 ± 1.0 mm and 5.5 ± 1.3 mm) there was a statistically significant difference (p < 0.001). When comparing the levels of saturation and the diameter of the interatrial septal defect between the group of survivors vs non-survivor, there was no statistically significant difference (p > 0.05). CONCLUSION The balloon atrial septostomy guided by the echocardiography reduces the risks by allowing the effective palliative procedure to be carried out promptly in cyanotic neonates, in addition to presenting lower hospital costs.

Aortic valve replacement with different types of prosthesis: are there differences in the outcomes during hospital phase?

OBJECTIVE To analyze intraoperative data and possible differences in clinical evolution during postoperative hospital phase for aortic valve replacement surgery using different types of prosthesis. METHODS Analysis of 60 patients divided into three groups. Valve replacement with bioprosthesis (20), mechanical prosthesis (20) and homologous valve (20). The mean age was 51.1, 60% were male and 40% female patients; 86.7 % were in NYHA II or III; 63.3% presented arterial hypertension and 18.3% had diabetes. Aetiology of valve disease was degenerative for 39%, rheumatic for 36% and endocarditis for 15%. RESULTS The hospital mortality was 5%; there were no differences in the incidence of septic or cardiogenic shock, acute renal failure, rhythms disorders during surgery or intensive care, neither for total time in intensive care and mechanical ventilation. However, there was statistical differences as regards the cardiopulmonary bypass total time (P=0.02) and the aortic clamping time (P<0.0001) unfavorable to homograft valve group. The ward admission time was greater for mechanical valve group (P=0.05) as well as for total admission time, but without statistical significance. It was observed that patients with preoperative hematocrit smaller than 38.1% used 2.73 units of blood components, and with postoperative hematocrit smaller than 32% used 1,79 units of blood components. Echocardiography control showed minimal evolutional differences. CONCLUSION The use of different types of prosthesis for this study does not cause differences in the results of postoperative hospital phase. The use of homograft valve is a feasible option with good clinical applicability.