Roberto T. Takeda

Ressincronização cardíaca e terapia celular: existe terapia associativa?

Nos ultimos anos, a terapia de ressincronizacao cardiaca tem sido uma conduta bem definida para pacientes com insuficiencia cardiaca (IC), classe funcional III ou IV, que nao tiveram resposta a otimizacao terapeutica. Estudos ja mostraram esta eficacia, mas um grupo bem definido de miocardiopatias dilatadas com areas de fibrose nao tem tido o mesmo sucesso (30%-40%). Por isto decidimos associar a estes pacientes o implante de celulas-tronco. A partir de 04/2005 iniciamos estes implantes em pacientes (pcs.) com IC, classe funcional III/IV, otmizados e fracao de ejecao <35% com dissincronia ventricular. Total de 25 pacientes (16 homens), idade entre 30-80anos (media de 58) e 44% de etiologia chagasica (11 pcs). Ressincronizacao e terapia celular foram por via epicardica (12 pcs) e endocardica (13 pcs) e a selecao celular pela filtracao por Ficoll e 3.0x108 de celulas infundidas CD34 + (5,0 x 106) e CD 133 + (2,5 x 106). Apos 24 meses de evolucao observamos que 84,8% destes pcs permaneceram vivos e a mortalidade (15,2%) nao estava relacionada ao procedimento. A sobrevida dos portadores de marcapasso foi maior (52,4%) e os chagasicos tiveram uma pior sobrevida, mas com teste de long-rank de 0,218 e 0,626, respectivamente. Nos casos de pcs com ressincronizador isoladamente, os resultados nao parecem ser tao bons,e nos optamos pela associacao de celulas-tronco como uma alternativa segura e adequada para estes graves pcs com insuficiencia cardiaca e miocardiopatia dilatada.

Tratamento cirúrgico da insuficiência mitral em crianças: dez anos de técnicas reparadoras

From April 1979 through January 1989, 71 patients with mitral insufficiency were surgically treated, 53 of them (74,6%) submitted to valvuloplasty. From this group 21 patients had associated mitral estenosis. Rheumatic fever was the major cause of the mitral lesions (79,2%). All patients, but 3, were situated in funcional class III and IV (NYHA). Anuloplasty (Carpentier ring and Gregori-IMC) were made associated to plastic procedures at the leaflet and the subvalvar set. In the postoperative period, we observed: no hospital mortality; early postoperative evolution was better in patients subjected to surgery in the period from 84 through 89, in comparison to the anterior period (79-83); reoperation index very acceptable at the late postoperative (5,7%); satisfactory clinical and hemodynamic late evolution; better evolution in the group of patients in the functional class postoperative II and III; better evolution in the group of patients with mitral insufficiency without associated stenosis.

Secção da aorta descendente por traumatismo fechado do tórax: tratamento cirúrgico com sucesso

E descrito caso de seccao da aorta toracica descendente, apos a emergencia da arteria subclavia esquerda decorrente de trauma fechado do torax. O diagnostico precoce e o rapido tratamento cirurgico foram fundamentais para a excelente evolucao pos-operatoria. O emprego de circulacao extracorporea atrio esquerdo-femoral para a interposicao de tubo de Dacron restabelecendo o fluxo arterial, foi fundamental para a prevencao de paraplegia por lesao da medula espinhal ja levemente isquemica.

Dúvidas na indicação cirúrgica da cerclagem do tronco pulmonar

From February 1979 to March 1986, 50 patients were submitted to pulmonary artery banding in order to control congestive heart failure and to prevent pulmonary vascular disease. Twenty-three patients were male and 17 were female. The mean age was 6 months (20 days to 17 months). The preoperative diagnosis were: ventricular septal defect (22), atrioventricular canal (6), double outlet right ventricle (2), tricuspid atresia (2), transposition of the great arteries (3), truncus arteriosus (2), single ventricle (1) and complexes pathologies (2). The pulmonary banding was carried out under control of the pulmonary artery pressure. Two patients (5 per cent) died on the immediate postoperative period: one patient in atrioventricular block and another in sepsis. One patient died of pneumonia on the late postoperative period. The remaining patients had a satisfactory evolution, increasing 400g of weight monthly. Thirteen patients were submitted to hemodynamic studies on the postoperative period (mean 21 months). Important reduction in pulmonary pressures and flows were then observed, including in five cases with A-V canal. Thirteen patients were reoperated on to correct their underlying defects one year after the banding. Then, one patient died in the immediate postoperative phase and another on the late phase. One of the six patients with A-V canal died on the immediate postoperative period and the others were reoperated for correction of the defects, with good results.