Paulo Paredes Paulista

Risk factors associated with cardiac surgery during pregnancy

BACKGROUND This study is aimed at analyzing risk factors for fetal and maternal mortality in cardiac surgery during pregnancy. METHODS Seventy-four pregnant women underwent cardiac surgery and 58 (78.3%) were followed. The most frequent pathology was valve disease (93.2%). Mitral valve disease was the most prevalent (72.9%), and mitral commissurotomy or replacement was required in 78% of the cases. Most were in functional class III or IV and mean gestational age was 22 weeks. RESULTS There was functional class improvement after surgery (91% into class I or II), and 70.4% were restored to sinus rhythm. Twenty percent required reoperation. There were five maternal deaths (8.6%) and 11 fetal deaths (18.6%). Several aspects were considered as contributing risk factors for maternal mortality, such as the use of vasoactive drugs and other preoperative medications, age, kind of surgery, reoperation, and functional class. Functional class was the factor that predicted higher risk for maternal death. As to fetal mortality, several factors played a role, such as maternal age more than 35 years, functional class, reoperation, emergency surgery, type of myocardial protection, and anoxic time. CONCLUSIONS Cardiac surgery during pregnancy is associated with acceptable maternal and fetal mortality rates. These rates may be even lower if the factors mentioned above are maintained under control.

Resultados imediatos da cirurgia de revascularização miocárdica: comparação entre homens e mulheres

OBJETIVO: Avaliar a morbimortalidade de homens e mulheres submetidos a cirurgia de revascularizacao miocardica isolada e os fatores relacionados as diferencas eventualmente encontradas. METODOS: Analise comparativa de 2032 pacientes, 1402 (69%) homens e 630 (31%) mulheres submetidos consecutivamente a cirurgia, de janeiro 1999 a dezembro 2002. RESULTADOS: As mulheres apresentaram idade media mais elevada, maior numero de fatores de risco e taxas de angina instavel. Enxertos com arteria toracica interna foram mais frequentemente usados nos homens, 85,6% vs. 78,3%, p<0,001. Nao houve diferencas nas taxas de complicacoes pos operatorias, exceto as infeccoes, mais frequentes nas mulheres. A mortalidade hospitalar foi de 4,1% e 6,3%, para homens e mulheres respectivamente, p=0,026. Na analise multivariada o sexo feminino nao foi identificado como fator prognostico independente para obito, assim como o uso de enxertos com arteria toracica nao foi tambem isoladamente identificado como fator protetor, porem a interacao sexo-arteria toracica interna foi significativa; foram ainda selecionados, idade (OR 1,03; [IC] 95% 1,01 a 1,06; p=0,004), insuficiencia renal no pre-operatorio (OR 1.82; [IC] 95% 1,07 a 3,11; p=0,028) e cirurgia de urgencia/emergencia (OR 2,85; [IC] 95% 1,32 a 6,14; p=0,008). CONCLUSAO: O sexo feminino apresentou maior mortalidade operatoria porem nao se mostrou fator prognostico independente para obito; o uso de enxertos com arteria toracica mostrou-se protetor; pacientes mais idosos, com insuficiencia renal e em situacao emergencial apresentaram maiores indices de obito hospitalar.

A utilização de retalho composto de pele e tecido mamário na reparação de área cruenta resultante da deiscência de esternotomia em cirurgia cardíaca

OBJECTIVE: To describe a new technique for repairing recalcitrant wounds resulting from infection and dehiscence in sternotomy of cardiac surgery in 6 women, who had an extensive raw area in the sternal region and had undergone a previous reintervention with relapse. METHODS: The surgical technique used was based on a triangular flap composed of skin and breast tissue with a base in the inframammary crease, which was transposed to the raw area to provide coverage with vascularized tissue. RESULTS: The several treatments of the acute phase are discussed, as are the techniques for reconstructing dehiscences of the sternal region. CONCLUSION: That flap composed of skin and breast tissue fulfills the needs regarding the dimensions of tissue loss in the raw area, in addition to providing greater protection against infection to an area that, due to the dehiscence, remained exposed for a longer period.

Cirurgia da endocardite em valva aórtica: opção para tratamento de abscesso aórtico

BACKGROUND: Patients with infective endocarditis show a large diversity of anatomical presentations, which has been a complicating factor for the surgical treatment of this condition, especially in those who develop abscesses in the aortic ring or intracardiac fistulae. For this reason, surgeons have been developing tactical options to repair it. There is consensus around the fact that the removal of infected tissue promotes radical cleaning, and that the outcome of the treatment has been improved by the manufacture of biological glues which facilitate the closure of abscesses and by the creation of new valve replacements. OBJECTIVE:To demonstrate yet one more treatment option for aortic abscess for selected cases: a valved conduit placed in infra-coronary position. METHODS: We employed the technique in three patients: in two of them we employed a valved conduit with a mechanical prosthesis and in one of them a valved conduit with a biological prosthesis. Two patients needed associated procedures such as replacement of mitral valve in one of them and tricuspid valvoplasty in the other. All cases involved reoperation of prostheses in aortic position. RESULTS: The progression during surgery and in the early postoperative period was satisfactory and the three patients were discharged from the Intensive Care Unit and were sent to hospital rooms. One of the patients progressed to death during hospital stay due to severe comorbidities which were present in the preoperative period, and which related to esophageal varices and hepatic involvement. The other two progressed well in the late postoperative period. CONCLUSION: We believe that this option is yet one more alternative for the treatment of abscesses with great involvement of aortic ring structures and mitro-aortic continuity.

Aspergillus infection in the ascending aorta of a patient with aortic and mitral valve prostheses

We report the case of implantation of metallic mitral and aortic valve prostheses 6 months earlier, with subsequent multiple embolic episodes. The anatomicopathological examination of the thrombus of the third embolic episode was compatible with Aspergillus sp, which was treated with amphotericin B, followed by oral itraconazole. On the fourth embolism, vegetations were visualized in the ascending aorta on echocardiography and resonance imaging, and the patient underwent replacement of the aortic segment by a Haemashield tube and exploration of the aortic prosthesis, which was preserved, because no signs of endocarditis were found. Four months later, the patient died due to cardiogenic shock secondary to acute myocardial infarction caused by probable coronary embolism and partial dysfunction of the aortic prosthesis.

Modificação técnica na cirurgia da estenose aórtica supravalvar

A technical modification in the surgery of supravalvar aortic stenosis has been developed since October 1991 to December 1995, without using artificial grafts, but only healthy tissue of the ascending aorta thus permitting a suitable enlargement of the aortic root. The aim of this technique is to avoid complications of re-estenosis of aortic root in the late evolution of patientes submitted to surgical treatment of localized supravalvar aortic stenosis which was provoked by calcification and hardening of prosthetic material used for the enlargement of one or more Valsalva sinuses, with or whitout transversal section of the aorta. Ten patients underwent a surgery in this meantime, with clinical and hemodynamic diagnosis of localized supravalvar aortic stenosis. Their ages varied from 11 months to 38 years (mean = 13.2 years), the weight varied from 7.500 kg to 56 kg (mean = 29.1 kg), and the height varied from 72 cm to 1.68 m (mean = 1.5 m). Six of these patients were male. Three of them were asymptomatic; 4 had dyspnea, 2 were tired at efforts, 2 had palpitations, 1 had paresthesia in the lower limbs, and 1 cyanosis at crying; 6 of them bore Williams syndrome. The systolic gradient between free cavity of left ventricle and aorta varied from 50 to 100 mmHg (mean = 73.5).The patients were operated on with extracorporeal circulation, moderate hypothermia, crystalloid cardioplegia in the 7 first cases and bloody cardioplegia in the 3 last ones. The ascending aorta was widely dissected till the supra-aortic vessels. After the aorta total transection and the resection of the stenosis f ibrotic tissue, longitudinal incisions were performed at the edge of the aortic proximal portion till the bottom of the Valsalva sinuses. Next to it, longitudinal incisions were performed in the distal portion, in the regions corresponding to the comissural points, in such a way that each stretching of the distal aorta may widen a bottom of Valsalva sinus, in this way obtaining an aortic root with an anatomic aspect and regular sizes. Presently, no death has occurred in a post-operative period from 3 months to 4 years and 5 months. All the patients are asymptomatic, having a satisfactory evolution, checked by Doppler Echocardiogram, Magnetic Nuclear Ressonance and Hemodynamic study. These results allow us to conclude that this technique is suitable to the surgical correction of the localized supravalvar aortic stenosis, by the point of not using artificial grafts and accomplishing the aorta suture in a sinusoidal line, avoiding reestenosis.

Surgical treatment of partial anomalous pulmonary venous connection to the superior vena cava

OBJECTIVE Surgical treatment of anomalous pulmonary venous connection to the superior vena cava, associated with sinus venous atrial septal defect, is well established and correlates with low mortality and morbidity. In order to reduce the incidence of stenosis or occlusion of the right superior vena cava, especially when associated with the presence of left superior vena cava, the right atrial appendage was used to enlarge the right superior vena cava, after the diversion of the anomalous pulmonary veins for the left atrium. METHODS Between June 1986 and September 2008, 95 consecutive patients were operated with anomalous drainage in the superior right vena cava and high right atrium. Ages ranged from 6 months to 68 years and females predominated with 50 cases. RESULTS There was no death in the immediate or late post operative care. The sinus cardiac rhythm was preserved in all cases and there was no complications in the late follow up. CONCLUSION This paper demonstrates the applicability of the technique described, with favorable results on mortality, rhythm disturbances and complications in the right superior vena cava.

Incidência de trombo intracardíaco e de tromboembolismo nos três primeiros meses após o implante de bioprótese valvar

OBJETIVO: Avaliar a incidencia de trombo intracardiaco e de tromboembolismo nos tres primeiros meses apos a troca valvar por bioprotese e identificar fatores de risco para a formacao de trombo. METODO:Incluidos 184 pacientes, entre 15 e 75 anos de idade, submetidos a implante de bioprotese e realizados ecocardiogramas transtoracico e transesofagico (ETE) na fase hospitalar, media 8,4±3 dias, e tres meses apos, media 97,4±21,7 dias. RESULTADOS: Incidencia de trombo foi significativamente mais elevada nos pacientes com protese em posicao mitral ou mitroaortica (21,0%) do que em posicao aortica (2,8%), p<0,001. A analise de regressao logistica multivariada identificou a protese em posicao mitral ou mitroaortica como a unica variavel independente para a formacao de trombo. No seguimento de tres meses o ETE evidenciou trombo em 35 (20,7%) dos 169 pacientes com evolucao ecocardiografica, 31,7% nos mitrais e 3,1% nos aorticos, p<0,001. No 3o mes a analise de regressao logistica multivariada tambem identificou a protese em posicao mitral ou mitroaortica como a unica variavel independente para a formacao de trombo. Durante os tres meses de seguimento, tres (1,6%) pacientes faleceram e oito (4,3%) apresentaram fenomeno embolico, todos para territorio cerebral. CONCLUSAO: A incidencia de trombo nos tres primeiros meses, apos o implante da bioprotese foi 14,1% nos 10 primeiros dias e 20,7% em tres meses; a protese em posicao mitral ou mitroaortica foi identificada como fator de risco para a formacao de trombo; a incidencia de fenomenos embolicos diagnosticados clinicamente foi inferior a proporcao de trombo atrial documentado pelo ecocardiograma.

Variáveis Doppler-ecocardiográficas e o tipo de cirurgia a ser realizada na regurgitação valvar mitral reumática

OBJECTIVE: To identify the Doppler echocardiographic variables associated with the type of surgery performed in rheumatic mitral valve regurgitation and to determine the relation between those variables and the medium-term results of valvuloplasty. METHODS: Doppler echocardiographic variables were assessed in 68 patients with severe rheumatic mitral valve regurgitation on the day preceding surgery. The patients were divided, according to the surgery performed, into 2 groups: 1) valvuloplasty group; and 2) valve replacement group. The valvuloplasty group also underwent Doppler echocardiography before hospital discharge and 6 months after that. The Doppler echocardiographic variables of the preoperative period were assessed considering the type of surgery performed and the degree of regurgitation detected 6 months later. RESULTS: The groups did not differ in regard to their demographic characteristics and ventricular function. The valve replacement group had a smaller mitral area (P=0.001). In univariate analysis, the variables related to valve replacement were as follows: restricted mobility of the anterior (P=0.01) and posterior (P=0.01) leaflets; calcification of the anterior leaflet (P=0.01); and fusion of the chordae tendineae (P=0.018). Restricted mobility of the anterior leaflet and area remained as independent determining factors of the prosthetic implantation after multivariate analysis. Of the 7 patients with mitral regurgitation greater than mild detected 6 months after valvuloplasty, 6 had, before surgery, restricted mobility of the anterior leaflet and 4 had fusion of the chordae tendineae. CONCLUSION: The chance of valve replacement is 3.8 times greater when restricted mobility of the mitral valve anterior leaflet exists and 2.2 times greater for each 0.5 cm2 reduction in the mitral valve area. Restricted mobility of the anterior leaflet and fusion of the chordae tendineae are associated with regurgitation greater than mild, observed 6 months after valvuloplasty.

New approach in partial cavopulmonary connection.

The development of pulmonary arteriovenous fistulas after bidirectional cavopulmonary operations, such as the bidirectional Glenn shunt and Kawashimas procedure, has raised concern. Development of these fistulas, which are more frequent than initially thought, can represent a limiting factor in the late outcome of these patients and may even limit the indication for these types of surgery. Whether the fistulas can be reversed by transforming the surgical procedures has yet to be established. In the hope of avoiding this kind of complication, thought to be caused by the lack of passage of a hypothetical hepatic factor through the pulmonary circulation, we have developed an inverted type of bidirectional cavopulmonary connection in which the blood coming from the liver perfuses immediately both lungs. This is made possible by shunting via an intra-atrial tunnel the blood from the superior caval vein directly to the left atrium, and the blood from the inferior caval vein to the right branch of the pulmonary trunk (keeping its bifurcation intact). We describe findings in two patients undergoing successful surgery with this technique. Serial follow-up with contrast echocardiography did not show evidence of arteriovenous pulmonary fistulas. Despite our numbers being small, and the time of follow-up being limited, we believe that it is important to document these and similar cases.