Marco Antônio Volpe

Mitral valve repair with a malleable bovine pericardium ring

OBJECTIVE To describe a surgical procedure utilizing a malleable bovine pericardium ring in mitral valve repair and clinical and Doppler echocardiographic results. METHODS Thirty-two (25 female and 7 male) patients, aged between 9 and 66 (M=36.4+/-17.2) years, were studied over a 16-month period, with 100% follow-up. In 23 (72%) of the patients, the mitral approach was the only one applied; 9 patients underwent associated operations. The technique applied consisted of measuring the perimeter of the anterior leaflet and implanting, according to this measurement, a flexible bovine pericardium prosthesis for reinforcement and conformation of the posterior mitral annulus, reducing it to the perimeter of the anterior leaflet with adjustment of the valve apparatus. RESULTS The patient survival ratio was 93.8%, with 2 (6.2%) fatal outcomes, one from unknown causes, the other due to left ventricular failure. Only one reoperation was performed. On Doppler echocardiography, 88% of the patients had functional recovery of the mitral valve (50% without and 38% with mild insufficiency and no hemodynamic repercussions). Of four (12%) of the remaining patients, 6% had moderate and 6% had accented insufficiency. Twenty-eight percent of class II patients and 72% of class III patients passed into classes I (65%), II (32%), and III (3%), according to NYHA classification criteria. CONCLUSION Being flexible, the bovine pericardium ring fit perfectly into the valve annulus, taking into account its geometry and contractility. Valve repair was shown to be reproducible, demonstrating significant advantages during patient evolution, which did not require anticoagulation measures.

Geli Putty®: a new alternative on sternal hemostasis in cardiac surgery

We present a gelatin that fills the medullary of sternum providing effective hemostasis plus protection for each sternal end.

Tratamento cirúrgico das valvopatias: Parte 3

Este trabalho, subdividido em tres partes, apresentou breve historico da cirurgia cardiaca, com enfase a cirurgia valvar e substitutos valvulares, empregados com sucesso na decada de 60, inicialmente com proteses mecânicas, seguidas pelas heterologas apos a introducao do glutaraldeido para preservacao dos tecidos biologicos. As indicacoes basicas para operar lesoes valvares consistem em alivio dos sintomas, prevencao das complicacoes e da mortalidade. Foram descritos, tambem, na primeira parte da publicacao, aspectos da indicacao cirurgica, com enfase em estenose e insuficiencia das valvas mitral, aortica, tricuspide e pulmonar, endocardite infecciosa ativa e da conduta pre-operatoria, alem da caracterizacao das diferentes proteses valvulares cardiacas mecânicas e biologicas existentes no mercado e suas complicacoes mais frequentes. O tratamento cirurgico das valvopatias, incluindo tecnica operatoria para troca de valvas mitral, aortica, tricuspide e pulmonar, condutas anestesica e pos-operatoria e reoperacoes foram abordados na segunda parte da publicacao. O trabalho foi concluido considerando as situacoes especiais, como tratamento cirurgico na endocardite em valvas mitral, tricuspide e aortica, cuja incidencia e maior que na mitral e a causa mais comum de insuficiencia aortica aguda. O desenvolvimento da endocardite tem fisiopatologia diferente quando comparado as proteses e valvas naturais, com morbi-mortalidade maior que a observada nas valvas nativas. Existem fatores que aumentam o risco de endocardite em valva nativa, raca negra, proteses mecânicas, sexo masculino e longo tempo de circulacao extracorporea. A interacao clinico-cirurgica parece influenciar de forma decisiva na obtencao de melhores resultados para essa lesao. Finalmente, foi registrada a nossa experiencia com proteses biologicas em posicao mitral e aortica com 11 e 10 anos de seguimento, respectivamente. O indice de sobrevida na troca mitral foi semelhante entre jovens e adultos (74%) para mitral e 67% para aortica. As complicacoes tardias fatais relacionadas a bioprotese na posicao mitral foram rotura, endocardite, vazamento paravalvular, tromboembolismo e, principalmente, calcificacao, com frequencia de 1,0 evento %/paciente-ano, com 95% dos pacientes livres dessas complicacoes. Na posicao aortica, destacaram-se tromboembolismo e, principalmente, endocardite, totalizando 1,6 eventos %/paciente-ano, com 92,6% dos pacientes livres dessas complicacoes. As complicacoes tardias nao fatais apresentaram-se com frequencias de 2,9 (mitral) e 1,1 eventos %/paciente-ano (aortica), com destaque para endocardite e calcificacao para mitral e endocardite e acidente vascular cerebral para aortica, com 55,2% (mitral) e 85,7% (aortica) dos pacientes livres dessas complicacoes. Pela alta incidencia de calcificacao, principalmente entre pacientes jovens submetidos ao implante de bioproteses em geral, realizou-se um estudo abordando diferentes faixas etarias, com proteses de pericardio bovino em posicao mitral. Os resultados justificam o uso dessa bioprotese mesmo em pacientes jovens, contrariando autores que nao recomendam o uso desse tipo de enxerto em pacientes com ate 30 anos. Concluiu-se que a protese de pericardio bovino, quando rigorosamente preparada, apresenta, alem de bom desempenho hemodinâmico, evolucao tardia satisfatoria. E importante considerar que a reuniao permanente da literatura e fundamental para que a comunidade mantenha-se informada das vantagens e desvantagens de cada modelo de protese disponivel.

Heart Injury with Projectile Lodged Inside the Heart

Penetrating heart injuries present high mortality rates. Increasing rates of urban violence have contributed to a significant rise in the number of heart injuries by firearm projectiles. Such injuries are associated with the highest mortality rates among penetrating cardiac injuries and may involve one or more cardiac chambers. We present the case of a police officer who, in an approach to five robbers, suffered a transfixed cardiac injury by firearm with the projectile having been lodged inside the right ventricle. This patient was successfully operated, 65 days after the injury, at our institution.

Valvopathies: surgical treatment. Part 1

Este assunto, de amplo aspecto, sera abordado em tres partes. O presente trabalho trata-se do historico, indicacao cirurgica, conduta pre-operatoria e proteses valvulares cardiacas. Os demais capitulos discutirao sobre tecnica operatoria, reoperacoes e situacoes especiais, como o tratamento cirurgico na endocardite e experiencias com valvula de pericardio bovino.

Tratamento cirúrgico das lesões da aorta torácica utilizando parada circulatória total hipotérmica com perfusão cerebral retrógrada

From September 1991 to February 1992, nine patients presenting thoracic aorta pathologies were submitted to surgery using deep hypothermic total circulatory arrest with retrograde cerebral perfusion. Six patients were male and three female, with ages ranging from 45 to 80 years. Four had type A dissection, three had true aorta aneurysm, one had true aneurysm associated with type A dissection and one had anulusaorta ectasia associated with type B dissection. A cava-cava-femoral cardiopulmonary bypass was established with deep hypothermia and total circulatory arrest. Retrograde blood cardioplegia was used for myocardial preservation. During total circulatory arrest retrograde cerebral perfusion was made using arterial line cannulated to the superior vena cava with a flow of 250 to 300 ml/min the central venous pressure monitored at the arm ranged between 30 and 40 cmH2O. Surgical repair was achieved using bovine pericardial tube and patch associated to the biological glue. Duration of cardiopulmonary bypass ranged from 75 to 169 min, total circulatory arrest from 32 to 79 min and retrograde cerebral perfusion from 32 to 79 min. There was no mortality associated to surgery or to immediate postoperative period. There was only one late death, due to septcemia. All other patients are on follow-up. The results show that total circulatory arrest with retrograde cerebral perfusion protects the brain more effectively than conventional total circulatory arrest during surgical treatment of thoracic aorta pathologies that require total circulatory arrest.