Pedro R Salerno

Vacuum-assisted venous drainage in cardiopulmonary bypass and need of blood transfusion: experience of service

OBJECTIVE To report the experience with the vacuum-assisted venous drainage (VAVD) technique in cardiopulmonary bypass (CPBP) and blood transfusion need. METHODS A retrospective study was made about data from 111 patients who were operated, using VAVD between October 2006 and February 2008, at the Esperança Hospital, Recife, Pernambuco. The necessity of blood transfusion was verified on the single group of patients who underwent VAVD, comparing with sex, age and weigh, before the beginning of the CPBP and during the surgery, using Chi-square test and t-student test. RESULTS Before the beginning of the CPBP only 10% of patients had need for blood transfusion and 12% during the surgery. It was observed that 17% of women received blood transfusion versus 4.7% of men before the beginning of CPBP (P=0.51), and 38% of women versus 9% of men during the surgery (P<0.001). The weight of patients who received blood transfusion were lower both before the beginning of the CPBP as during the surgery (P=0.049 e P=0.001, respectively). CONCLUSION The VAVD technique has been used safely and satisfactorily, optimizing venous drainage during CPBP, in the hospital that conducted the study. However, prospective and comparative investigations between conventional drainage and VAVD are needed to better clarify this relation with blood transfusion.

Tratamento da fibrilação atrial com ablação por ultrassom, durante correção cirúrgica de doença valvar cardíaca

Objective: This study aims to evaluate the surgical treatment of atrial fibrillation with ultrasound ablation concomitant to mitral surgery in PROCAPE’s patients with permanent atrial fibrillation. Methods: From March 2008 through January 2009 a prospective study was performed at the Pernambuco Cardiology Emergency Facility on 44 consecutive patients with a permanent atrial fibrillation and concomitant cardiac valvular surgery indication, from March 2008 through January 2009 at Pernambuco Cardiology Emergency Facility Twenty two patients underwent right atrium epicardial ultrasonic ablation and left atrium endocardial ultrasonic ablation performed concomitant with the valve procedure. The other 22 patients, the concurrent controls were submitted to valve procedure without ultrasonic ablation. Patients with serious diseases such as coronary and others were excluded of the research. Results: It was observed 90% restoration to sinus rhythm immediately after surgery in patients submitted to treatment of atrial fibrillation with ultrasound ablation simultaneous a mitral surgery. The evolution in late post operation showed that the maintenance of sinus rhythm drops although it was still 27% higher in the group which received ablation compared with the control group. 86.40% of the patients who received ablation had improved in functional class; they also have fewer complications than patients in the control group. Conclusion: The results showed that the patients who received treatment for atrial fibrillation simultaneously with valvar surgery had advantages related to the control group.

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.

Fechamento de canal arterial por minitoracotomia: técnica e resultados

OBJECTIVE:The purpose of this study was to describe a new technique for closure of patent ductus arteriosus (PDA) by minithoracotomy (2.5 a 3.0 cm) and clipping the PDA with titanium clips. MATERIAL AND METHODS: From November 1996 to December 1997, 15 children with PDA underwent surgical closure. The mean age at the time of operation was 2.7 years, mean weight was 13.9 kg. The procedure was through a left minithoracotomy at the 4o intercostal space. The ductus was identified, dissected and isolated. Interruption of ductal flow was performed by direct clipping with two clips. The chest was closed without a chest drain. Unless the patient was ventilator dependent before the closure, the child usually was extubated in the operating room. RESULTS: Color doppler echocardiography demonstrated total occlusion of the ductus in all patients. All 15 patients were discharged from the hospital on the 4o postoperative day (mean). CONCLUSION: We conclude that surgical closure of patent ductus arteriosus with minitoracotomy, without chest tube drainage can be accomplished safely and with low incidence of complications.

Correção cirúrgica dos tumores primários do coração

Fifty two patients with primary cardiac tumors were operated on at the Instituto Dante Pazzanese de Cardiologia between 1962 and 1991. Among the benign neoplasms, 43 were myxomas; the only two malignant tumors were rhabdomyosarcomas. The mean age of the patients was 41 years (range 15 days to 68 years); 33 patients were females and 19 males; 52.6% had congestive heart failure, 18% had chest pain or palpitation and 16% taquiarrhythmias. Complete resection was carried out in 50 patients. The two patients with malignant tumors had only been submitted to biopsy. All patients survived operation, although 3 died in the early postoperative period. One patient with myxoma presented recurrence three years after the innitial surgery and was reoperated on. The follow up data of 20 patients are available, all in NYHA functional class I. Longterm results were excellent in this group.

Técnica e resultados da endarterectomia de artéria coronária

A abordagem cirurgica da doenca coronaria sofreu grandes modificacoes nos ultimos anos. Devido a possibilidade de angioplastia, os doentes encaminhados para cirurgia sao aqueles com doenca ateromatosa difusa grave e/ou com arterias ocluidas, geralmente responsavel por uma area de musculo viavel. Assim sendo, a endarterectomia de coronaria e um recurso tecnico que viabiliza a abordagem destes vasos. Em nosso Servico, no Hospital do Coracao, foram submetidos para cirurgia de revascularizacao do miocardio (RM) com endarterectomia, no periodo de janeiro de 88 a dezembro de 92,110 pacientes(pts.). O sexo masculino predominou, com 99 (90%) pts. Encontramos com funcao ventricular normal 33 (30%), deficit moderado 71 (64,5%) e severo 6 (5,4%). Doze (10,9%) pts. eram reintervencao para nova RM. Dividimos em 2 grupos quanto ao numero de endarterectomias realizadas. Grupo A com uma endarterectomia 104 (94,5%) pts. e Grupo B com mais de uma endarterectomia 6 (5,4%) pts. No Grupo A a coronaria esquerda (CE) foi abordada em 38 (36,5%) pts. e a coronaria direita (CD) 66 (63,4%) pts. No Grupo B com mais de uma endarterectomia a CE foi abordada 8 vezes e a CD outras 4. Em todos os casos o cirurgiao removeu a endoarteria com a placa ateromatosa, com sucesso. A ocorrencia de infarto trans-operatorio na regiao da arteria endarterectomizada foi de 7 (6,3%) pts. e em regioes nao relacionadas com as arterias manipuladas foi de 3 (2,7) pts. Em 9 (8,1 %) pts. foi realizado procedimento associado, como: aneurismectomia do ventriculo esquerdo 5 (4,5%) pts., troca de valva aortica 1 (0,9%) e ventriculotomia para retirada de trombo em 3 (2,7%). As complicacoes mais frequentes foram: arritmias 26 (23,6%) pts., insuficiencia renal aguda 10 (9%) pts., sindrome de baixo debito (SBD) 4 (3,6%) pts. Ocorreram 5 (4,5%) obitos, tendo como causa mais frequente a SBD. Quatro (3,8%) pts., do Grupo A e 1 (16,6%) do Grupo B. Com esses resultados, verificamos que a endarterectomia e um procedimento que, utilizado criteriosamente, possibilita uma RM completa e com resultados consistentes.

The behavior of Troponin I and CKMB mass in children who underwent surgical correction of congenital heart malformations

OBJECTIVE: To analyze the behavior of troponin (TROP I) and CKMB mass (CKMBm) in regards to the addition of magnesium in cardioplegic solutions; and also the influence of per-operative factors. METHOD: A total of 28 children with ages ranging from 3 to 108 months were studied. The mean weight was 11.8 kg. Eighteen were male. The patients were divided into two groups. Sixteen children in group I (GI) and 12 in group II (GII). The patients in GI received cold blood cardioplegic solution with magnesium (12 mEq/L) and potassium chloride (20 mEq/L) at 20 mL/kg. The patients in GII received the same solution without magnesium. Six blood samples were collected for serum analysis of the concentration of TROP I and CKMBm. The blood samples were collected before clamping the aorta and at 1, 6, 24, 48 and 72 hours after aorta clamping termination. RESULTS: There were no statistical differences in the TROP I and CKMBm levels between the two groups. Among the per-operative factors cyanosis influenced the TROP I and CKMBm levels. Additionally, the aorta clamping time influenced the TROP I levels. CONCLUSIONS: The addition of magnesium in the cardioplegic solution was not associated with different levels of TROP I and CKMBm. Cyanosis and aorta clamping time interfered with peak TROP I levels.

O papel do cirurgião nas valvopatias reumáticas tratadas com valvoplastia percutânea

No Instituto Dante Pazzanese de Cardiologia, as valvoplastias percutâneas para as valvas mitral e aortica tiveram inicio em agosto de 1987. Foram realizados 37 procedimentos, sendo 26 para a mitral (VMP) e 1 para a aortica (VAP). Nas 26 VMP, obteve-se sucesso 14 vezes, tendo 4 complicacoes. Em 3 pacientes, o sucesso nao foi total, sendo que uma paciente com insuficiencia mitral recusou cirurgia, outro foi operado e o terceiro esta assintomatico, mas nao houve melhora da area valvar e das pressoes, e deve ser reestudado para posterior avaliacao. Os 9 pacientes restantes foram operados, sendo realizadas 6 comissurotomias e papilarotomias e 3 substituicoes valvares. A indicacao cirurgica se deu por tamponamento cardiaco em 1 caso, rotura de musculo papilar com consequente insuficiencia em outro, 1 caso de baixo debito, puncao da aorta em 4 casos e nao passagem do cateter para o atrio esquerdo em 2 com suspeita de tamponamento nao confirmada. O paciente submetido a VAP obteve melhora imediata do gradiente, mas faleceu 1 mes apos, em insuficiencia cardiaca. As valvoplastias percutâneas tem apresentado uma alternativa no tratamento das lesoes valvares e sao uma opcao, principalmente para casos de valvas nao calcificadas e com o aparelho subvalvar nao comprometido. Devem ser lembradas nos casos em que a cirurgia e de alto risco, como em idosos, pneumopatas e nefropatas.

Novo sistema de cardioplegia sangüínea em cirurgia de cardiopatia congênita

The purpose of this study is to present a simple Delivery System of Blood Cardioplegia for myocardial preservation during congenital cardiac operation. We prospectively analysed 71 patients (pts) with 10/12 kg of body mean weight, 34 were female and mean age was 2/1 years. From the arterial line, passing through a mini heat exchanger, blood at 8 C is aspirated to a 50 cc syringe, which is conected to a 10 cc syringe with a KCL + decimal solucion using 2 stopcocks. The mixture originates a cold blood with 15 mEq/l of KCL + that is infused into the aortic root, according to the pts weight (10 cc/kg). In all pts cardiac arrest was obtained. The mean extracorporeal circulation time and crossclamping was 87.2 and 60.7 min. All pts recovered sinus rhythm with good ventricular function. Thirteen patients died, 6 with respiratory failure, 3 with low cardiac output, 2 with dysrhythmias, 1 with renal failure and 1 with hematologic disorder; the other 58 patients left the hospital with no complications. In conclusion, this method showed good results with efficient myocardial preservation and low morbi-mortality

Tratamento cirúrgico da embolia pulmonar maciça aguda

Between January 1984 and December 1992, 8 patients with acute massive pulmonary embolism (PE) underwent pulmonary embolectomy under cardiopulmonary bypass. The age ranged from 36 to 70 years (average 56.6 years). There were 6 men and 2 women. A causative factor for pulmonary embolism was found in 6 (95%): myocardium revascularization in 3, abdominal lipoaspiration in 2 and hemorrhoidectomy in 1. All patients where severely hypoxic with mean arterial PO2 of 55%. The diagnosis of PE was established by pulmonary angiogram in 6 (75%) and surgery in 2. Hospital mortality was 50% (4 patients), two of them had previous cardiac arrest, 1 patient died of acute respiratory distress syndrome, 1 of neurologic complication, 1 of pulmonary infection and 1 of myocardial failure. Among the survival patients, 3 are without symptoms and 1 complains of discrete exertional dyspnea (NYHA class II). This study demonstrates that: 1) the mortality rate was higher in patients with previous cardiac arrest; 2) the time between diagnosis and surgery was a predictive factor; 3) the high mortality rate reflects the gravity of the situation; 4) the long term results in surviving patients have been favorable.